Anomalous coronary artery originating from the opposite sinus of Valsalva (ACAOS), fractional flow reserve‐ and intravascular ultrasound‐guided management in adult patients

Objectives To describe the use of fractional flow reserve (FFR) and intravascular ultrasound (IVUS) in the evaluation of patients with anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS). Background ACAOS of the right and left coronary are rare, but may lead to symptoms and impose a risk for sudden cardiac death, depending on several anatomical features. Assessment and risk estimation is challenging in (nonathlete) adults, especially if they present without symptoms or with atypical complaints. Methods The team retrospectively studied 30 consecutive patients with ACAOS with interarterial course, who received IVUS‐ and FFR‐guided treatment at our institution between October 2010 and September 2017. Results FFR was abnormal in only seven patients. IVUS showed the typical slit‐like anatomy of the orifice in 23 patients. Based on FFR and/or IVUS results, in conjunction with the clinical presentation, clinical decision was made. A decision for intervention was made if at least two out of three entities were abnormal. Intervention implied unroofing of the coronary artery (n = 10) or coronary artery bypass grafting (n = 1). In all other patients a conservative strategy was followed. No adverse events occurred in the total population after a median of 37 (0–62) months of follow‐up. Conclusions Conservative treatment may be justifiable in adult patients with ACAOS in the presence of normal FFR and nonsuspicious symptoms, despite the presence of an interarterial course and/or slitlike orifice on IVUS. We recommend the use of FFR and IVUS in the standard work‐up for adult patients with ACAOS and propose the use of a flowchart to aid in decision‐making.