Dobutamine stress cardiac MRI is safe and feasible in pediatric patients with anomalous aortic origin of a coronary artery (AAOCA)

https://doi.org/10.1016/j.ijcard.2021.04.031Get rights and content

Highlights

  • Dobutamine stress CMR has excellent performance in adults with ischemic heart disease.

  • DSCMR with first pass perfusion is safe and feasible in pediatric patients with AAOCA.

  • DSCMR results guide management of AAOCA using shared decision making with families.

  • Most DSCMR after AAOCA surgery were negative and allowed for return to activities.

Abstract

Background

Risk stratification in anomalous aortic origin of a coronary artery (AAOCA) is challenged by the lack of a reliable method to detect myocardial ischemia. We prospectively studied the safety and feasibility of Dobutamine stress-cardiac magnetic resonance (DSCMR), a test with excellent performance in adults, in pediatric patients with AAOCA.

Methods

Consecutive DSCMR from 06/2014–12/2019 in patients≤20 years old with AAOCA were included. Hemodynamic response and major/minor events were recorded. Image quality and spatial/temporal resolution were evaluated. Rest and stress first-pass perfusion and wall motion abnormalities (WMA) were assessed. Inter-observer agreement was assessed using kappa coefficient.

Results

A total of 224 DSCMR were performed in 182 patients with AAOCA at a median age of 14 years (IQR 12, 16) and median weight of 58.0 kg (IQR 43.3, 73.0). Examinations were completed in 221/224 (98.9%), all studies were diagnostic. Heart rate and blood pressure increased significantly from baseline (p < 0.001). No patient had major events and 28 (12.5%) had minor events. Inducible hypoperfusion was noted in 31/221 (14%), associated with WMA in 13/31 (42%). Inter-observer agreement for inducible hypoperfusion was very good (Κ = 0.87). Asymptomatic patients with inducible hypoperfusion are considered high-risk and those with a negative test are of standard risk.

Conclusions

DSCMR is feasible in pediatric patients with AAOCA to assess for inducible hypoperfusion and WMA. It can be performed safely with low incidence of major/minor events. Thus, DSCMR is potentially a valuable test for detection of myocardial ischemia and helpful in the management of this patient population.

Introduction

Current practice guidelines attest to the lack of a reliable tool to risk stratify young athletes with anomalous aortic origin of a coronary artery (AAOCA) because the recommended tests (exercise stress test, stress echocardiography, and nuclear perfusion imaging) have low negative predictive value in detecting myocardial ischemia [1,2]. Dobutamine stress-cardiac magnetic resonance imaging (DSCMR) has excellent performance in adults with suspected or known ischemic heart disease, and shown to be predictive of major cardiovascular events [3,4]. DSCMR has been reported in pediatric patients, but data are sparse in AAOCA [5]. Pathophysiologic events in a demand ischemia cascade demonstrated that reversible ischemia precedes changes in wall motion abnormalities (WMA) [6,7]. Hence, the addition of first-pass perfusion (FPP) to wall motion assessment improves the sensitivity of DSCMR [8,9]. We aimed to prospectively determine the feasibility and safety of DSCMR in detecting inducible ischemia and WMA in pediatric patients with AAOCA and describe the utility of the test results in the decision-making process in a multidisciplinary approach.

Section snippets

Study population

All patients ≤20 years old with AAOCA were prospectively enrolled in the Coronary Artery Anomalies Program and managed following a standardized clinical algorithm (Fig. S1). Patients with consecutive DSCMR examinations from June 2014 to December 2019 were included in this study. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a priori approval by the institution's human research committee and informed consent was obtained from each

Results

The data underlying this article will be shared on reasonable request to the corresponding authors.

From June 2014 to December 2019, 224 consecutive DSCMR examinations were performed in 182 patients (112 males, 61.5%) with AAOCA at a median age of 14 years (IQR 12, 16) and median weight of 58.0 kg (IQR 43.3, 73.0). The study was performed in 31 (14%) pediatric patients with anomalous aortic origin of a left coronary artery (AAOLCA), 20 (9%) intraseptal AAOLCA, and 173 (77%) anomalous aortic

Discussion

To the best of our knowledge, this is the first study to describe the use of DSCMR in the assessment of myocardial perfusion, wall motion, and myocardial viability in a large cohort of pediatric patients with AAOCA. We demonstrated feasibility and safety with DSCMR and this strategy has been helpful at our institution in risk stratification and decision-making of these challenging patients at presentation, follow-up, and post-intervention assessment [[16], [17], [18], [19], [20]]. Inducible

Study limitations

DSCMR's role to detect myocardial ischemia in pediatric patients with AAOCA needs to be validated, as does its clinical impact and long-term outcome data. The high rate of abnormal DSCMR in our study could be subjected to referral bias. Despite a heart rate ≥ 150 bpm and RPP ≥20 × 103 bpm·mm Hg were observed in many patients at maximal dobutamine dose, the study was limited by the lack of an evidence-based target hemodynamic response in the assessment of FPP on DSCMR in this population.

Conclusions

Our study demonstrates that DSCMR is feasible in pediatric patients with AAOCA, given the high completion rate, significant hemodynamic response, and good interobserver agreement. It can be performed safely with a low incidence of major or minor events and informed our management of this challenging population. DSCMR may be a valuable test for assessment of myocardial perfusion in this patient population. Further longitudinal studies are necessary to determine the implications of these findings

Funding

The authors did not receive financial support from any organization for the submitted work.

Authors' contributions

Tam T Doanω,‡,δ,ϕ, Silvana Molossi ω,‡,§,ϕ, Shagun Sachdeva‡,δ, James C Wilkinson‡,δ, Robert W Loar‡,δ, Justin D Weigand‡,δ, Tobias R Schlingmannδ, Dana L Reaves-O'Neal, Amol S Pednekar§,⁎,δ, Prakash Masand§,*, Cory V Noelω,‡,§,*. ω Conception and design of project.

‡ Data Acquisition.

§ Collaboration in the design, implementation and use of the DS-CMR in the study population.

* CMR sequence design and optimization.

δ Collaboration in data interpretation and analysis.

ϕ Manuscript draft and

Conflicts of interest

The authors declare that they have no conflict of interest.

Acknowledgements

The authors appreciate all the patients and families for their participation in this project and all the staff in the Division of Cardiac Imaging, Section of Cardiology and Section of Radiology at Texas Children's Hospital, Baylor College of Medicine for their continued support to make this work possible.

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    This work was done at Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA. Oral abstract was presented at the Society for Cardiovascular Magnetic Resonance Scientific Sessions 2020 in Orlando, FL, USA.

    1

    Silvana Molossi and Cory V. Noel the senior authors of this article.

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