Date of Award
Doctor of Philosophy (PhD)
LaDisa, John F.
Frommelt, Peter C.
Anomalous aortic origin of a coronary artery (AAOCA) is a condition where a coronary artery arises from the opposite aortic sinus, often with acute angle of origin (AO). AAOCA is associated with ischemia.1 This is especially concerning when the anomalous coronary artery takes an intramural course within the aortic wall, creating the potential for distortion or compression. Unroofing surgery replaces a restrictive ostium and intramural segment with a large ostium from the appropriate sinus and aims to create a less acute AO. Although these anatomical features may alter coronary artery blood flow patterns, hemodynamic indices such as time averaged wall shear stress (TAWSS), oscillatory shear index (OSI) and fractional flow reserve (FFR) that impact a patient’s future risk for ischemia and morbidity 2–6 remain largely unexplored. We hypothesized that morphology of the anomalous coronary artery has a significant impact on local hemodynamics of AAOCA and aimed to 1) characterize hemodynamic alterations in AAOCA by patient-specific simulation of patients pre-operative and post-unroofing using advanced coronary artery boundary conditions, 2) assess the impact of AO on the severity of hemodynamic alterations, and 3) characterize the hemodynamic effect of proximal narrowing of the anomalous artery and hyperemic resistance of the downstream vasculature (HMR) on FFR. Findings from Aim 1 suggested that different flow patterns exist natively between right and left coronary arteries, a reduction in TAWSS is observed post-unroofing, and that unroofing may normalize TAWSS but with variance related to the AO. Data from Aim 2 indicated that AO alters TAWSS and OSI in simulations run from a patient-specific model with virtually rotated AOs. The arterial wall experienced lower TAWSS for more acute AO near the ostium. Distal to the ostium, arterial wall experienced higher TAWSS for more acute AO. Findings from Aim 3 showed that for a given narrowing, higher HMR resulted in higher FFR thereby mimicking the interaction of the upstream and downstream micro-vasculature resistance to regulate FFR for the first time using computational models of AAOCA. Virtual manipulation of the anomalous artery provided a direct comparison for the effect of the anatomic high-risk features. Collectively, these results serve as the foundation for larger studies of AAOCA that could correlate hemodynamics with outcomes for risk stratification and surgical evaluation.
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