Dobutamine stress cardiac magnetic resonance role in patients with anomalous aortic origin of coronary arteries

Abstract Aims: Anomalous Aortic Origin of Coronary Arteries (AAOCA) is associated with myocardial ischaemia and sudden cardiac death, particularly in young athletes. Although inducible myocardial ischaemia investigation is generally recommended, there is no clear indication of the most appropriate stress test, as the ECG exercise stress test presents low diagnostic accuracy. Dobutamine-stress cardiac magnetic resonance (dsCMR) has been proposed as a promising diagnostic tool, but its application has been limited to paediatric populations. This study aimed to evaluate the presence of inducible myocardial ischaemia assessed by dsCMR in AAOCA patients, regardless of age, and to identify factors associated with inducible myocardial ischaemia. Methods and results: In this single-centre observational study, 100 AAOCA patients who underwent dsCMR were enrolled from 2015 to 2024. dsCMR resulted positive in 14 cases, all showing perfusion abnormalities, with only one presenting segmental wall motion abnormalities. dsCMR was found to be safe without major adverse events. Factors significantly associated with inducible ischaemia included intramural course, the presence of ischaemic late gadolinium enhancement (LGE), and a history of acute coronary syndrome (ACS). Nine patients (9%) showed small areas of ischaemic LGE within the AAOCA territory, and they were older with a higher incidence of arterial hypertension, smoking habits and previous ACS episodes. Conclusion: dsCMR is a reliable test for the evaluation of myocardial ischaemia in AAOCA, especially for those with intramural course, ischaemic LGE, and previous ACS episodes. Although rare, older patients may have a myocardial ischaemic scar without alteration of ventricular function. Keywords: anomalous aortic origin of a coronary artery; cardiovascular imaging; dobutamine stress cardiac magnetic resonance; inducible myocardial ischaemia.