Comparison of 64‐Slice EKG‐Gated Computed Tomographic Angiography, Transthoracic Echocardiography, and Transesophageal Echocardiography for Detection and Complete Characterization of Anomalous Coronary Arteries in Infants with Comorbid Congenital Cardiac Malformations

Abstract

Background and Objective: Computed tomographic angiography (CTA) offers several benefits over echocardiography in the detection of CAAs (coronary artery anomalies). These include higher spatial resolution, operator independency, non‐invasiveness, and the availability of reconstructive techniques to track the entire arterial course.1,4,9 Accordingly, standard clinical practice (per ACC/AHA guidelines for adults with CAAs) for adults with suspected CAAs includes use of CTA as a first‐line imaging modality.6 Currently, there is no evidence favoring either CTA, transthoracic echocardiography (TTE), or transesophageal echocardiography (TEE) for initial imaging of infants with suspected CAAs. Therefore, the aims of this retrospective study include investigating the efficacy of CTA, TTE, and TEE in the detection and complete characterization of CAAs. Methods: Imaging and surgical data for 27 patients who presented for evaluation of congenital heart disease between 2006 and 2011 were evaluated. Patients had a mean age of 2.2 ± 0.7 months at initial evaluation and had undergone EKG‐gated 64‐slice cardiac CTA with 3D reconstruction in addition to multiple TTE and TEE studies. Performance metrics (including sensitivity, specificity, positive predictive value, negative predictive value, and accuracy) of each modality in CAA detection were computed. Concordance between each modality and surgical/conventional angiographic diagnosis in the characterization of anatomy along the origin, course, and termination of anomalous coronary arteries was evaluated. The rate of limitations of each modality in the imaging and interpretation of coronary anatomy was also reported. Results: Using surgical/angiographic diagnosis as the gold standard, CTA produced a sensitivity, specificity, and accuracy of 80%, 50%, and 74%, respectively. TTE produced a sensitivity, specificity, and accuracy of 20%, 50%, and 26%, respectively. TEE produced a sensitivity, specificity, and accuracy of 27%, 100%, and 42%, respectively. CTA outperformed TTE and TEE at characterizing anatomy at the origin and course of an anomalous coronary artery. At characterizing anatomy at the termination of an anomalous coronary artery, CTA outperformed TEE but did not significantly outperform TTE. CTA had a higher rate of documented limitations to imaging/interpretation compared to TTE and TEE but a lower rate when compared to conventional angiography. Conclusion and Impact: CTA is a rapid, non‐invasive, operator‐independent imaging modality that offers high resolution, 3‐dimensional imaging of CAAs in infants. The results of this study indicate that CTA is the most sensitive and accurate modality for detection of CAAs in infants and is optimal for characterizing anatomy along the entire length of an anomalous coronary artery. As such, CTA may be the optimal modality for first‐line coronary artery imaging in infants with suspected anomalous coronary artery anatomy who have a high pretest probability for having a CAA.