Paolo Angelini's Legacy in the Study of and Treatment for Anomalous Coronary Arteries

Abbreviations and Acronyms

AAOCA

anomalous aortic origin of coronary arteries

R-AAOCA

right coronary artery arising from the left

To the Editor

The news of Paolo Angelini's passing on July 29, 2023, at the age of 81¹ was received with profound sadness. It also was seemingly met with a synchronous homage in Gaudino et al's² state-of-the-art review on anomalous aortic origin of coronary arteries (AAOCAs), which extensively quotes Dr Angelini's life works. Dr Angelini was a contemporary of Andreas Grüntzig and had worked with him in Zurich to refine the procedure of coronary angioplasty.¹ The interarterial course is now considered to be benign, thanks to Dr Angelini demonstrating that the mechanism of ischemia is via ostial stenosis and aortic intramural compression. He presented a stenting series of 42 patients with right coronary arteries arising from the left coronary cusp (R-AAOCA), of whom 30 had more than 5 years of follow-up with no deaths and a lower-than-expected in-stent restenosis rate of 13%.¹ His publication of these results was followed 3 years later by an equivalent surgical series that included 30 patients with R-AAOCA, of whom 17% developed early aortic regurgitation, 2% had supravalvular aortic stenosis, 4% had recurrent ostial coronary artery stenoses, and 6% needed repeat surgery.³ Meanwhile, stenting techniques continue to improve, and in-stent restenosis is simple to treat percutaneously with the aid of high-resolution intracoronary imaging, greater general availability of atherectomy and debulking devices, and the recently proven efficacy of the drug-coated balloon for in-stent restenosis. These techniques have removed the need for restenting. Clearly, Dr Angelini was ahead of the curve; he correctly observed that for R-AAOCA, if there is no concomitant cardiac abnormality or widespread atherosclerosis, stenting can safely be performed with a durable outcome. In contrast, undertaking a major open-heart operation for a single coronary artery involving aortic transection appears to be excessive and is associated with significant surgical morbidity³ as opposed to the more traditional “3-or-more” surgical coronary arterial bypass grafting, which improves long-term survival in addition to alleviating symptoms. Finally, thanks to Dr Angelini, ischemic testing with a formal coronary physiology study that involves dobutamine fractional flow reserve, including vasospasm testing with acetylcholine (if indicated), is routinely performed to guide the management of AAOCA.