Evaluation of coronary artery disease in congenital heart disease and pediatrics utilizing adenosine stress perfusion

Introduction

The diagnosis of CAD utilizing adenosine stress perfusion is well described in adults. CAD in children is rare but can occur in the setting of congenital and acquired heart disease. Adults with CHD, a growing patient population, are at risk for CAD. A review of the medical literature revealed one previous study involving 4 patients in which adenosine stress perfusion was used for evaluating CAD in these populations.

Purpose

To evaluate the safety and feasibility of adenosine stress perfusion in the assessment of coronary artery disease (CAD) in congenital heart disease (CHD) and pediatrics.

Methods

A retrospective chart review was performed on consecutive patients with a diagnosis of CHD or age < 18yo in which adenosine stress perfusion was attempted. SSFP cine and delayed enhancement CMR (DE-CMR) were performed in a standard manner. Adenosine stress perfusion was performed with the administration of 140ug/kg/min of adenosine for 2-4 minutes and 0.1mmol/kg of gadolinium using a standard adult protocol. Patients with abnormal DE-CMR in a pattern consistent with coronary artery distribution were considered to have myocardial infarction (MI). A stress perfusion defect larger than the infarct on DE-CMR was indicative of inducible ischemia.

Results

32 studies were attempted in 30 patients (mean 31 years, 12 < 18 years). 97% of the studies were completed safely and with images of diagnostic quality. Stress perfusion was discontinued in a patient with Ebstein’s anomaly and atrial flutter who had increased ventricular rates with adenosine. General anesthesia was used in 3 studies. Diagnoses and symptoms are listed in Tables 1 and 2. 35% of studies had evidence of CAD. 26% had DE-CMR evidence of MI. 16% had evidence of inducible ischemia on stress perfusion. 8 patients had a cardiac catheterization, and there was agreement with CMR in 6. A patient with repaired anomalous right coronary artery from the pulmonary artery had abnormal stress perfusion but normal catheterization. A patient with repaired anomalous left coronary artery from the pulmonary artery had a CMR in the post-operative period with evidence of infarct and inducible ischemia but no stenosis on catheterization. A CMR result negative for CAD resulted in no further workup in 18/20 (90%). A finding of CAD on CMR resulted in continued workup or intervention in 9/11 (82%).

Table 1 Diagnoses

Table 2 Presenting Symptom

Conclusion

CMR with adenosine stress perfusion can be safely performed in CHD and pediatrics. CMR can be used to evaluate CAD and influence outcomes in these populations.