Multimodality Imaging in Anomalous Aortic Origin of the Coronary Arteries: Lessons From 4 Athlete Cases

Background: Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital anomaly linked to increased risk of myocardial ischemia and sudden cardiac death, especially among athletes subjected to extreme physiological stress. The diagnostic and therapeutic strategies in highly active individuals remain challenging and represent important knowledge gaps. Case Summary: We present 4 cases of elite athletes with AAOCA with a variety of characteristics and detail their clinical evaluation, imaging and functional assessment, risk stratification, treatment decisions, and longitudinal follow-up. Discussion: There are limited prospective data regarding the management of AAOCA in athletes. Autopsy studies have identified young age (<35 years), high exercise levels, and myocardial fibrosis as risk factors for sudden cardiac death. Moreover, the European Society of Cardiology on adult congenital heart disease recommends including age, level of exercise, and presence of high-risk anomaly features in risk assessment. This series highlights the complexities of managing AAOCA in athletes, and emphasizes the necessity for multimodality imaging in a context of multidisciplinary, individualized decision-making. Take-Home Messages: A multimodality imaging approach is essential for early recognition, risk stratification, and clinical decision-making in AAOCA. Treatment decisions should be based on symptoms, presence of high-risk features, and inducible ischemia using complementary imaging modalities, with personalized recommendations supported by a multidisciplinary sports cardiology team.