A Critical Re-evaluation of Current Management Strategies for AAORCA with an Interarterial Course

Background: Anomalous aortic origin of the right coronary artery (AAORCA) with an interarterial course is a rare congenital anomaly that can cause dynamic compression, myocardial ischemia, and sudden cardiac death (SCD). Current clinical guidelines rely heavily on symptom assessment and non-invasive functional testing (e.g., exercise stress testing) to guide surgical decision-making. However, the reliability of these strategies in predicting clinically significant ischemia remains controversial, particularly given the dynamic nature of the obstruction. Methods: This patient-led project critically reviews the published literature, clinical case reports, and contemporary guidelines to evaluate five key areas: (1) the role of stress testing, (2) the adequacy of current surgical criteria, (3) the clinical weight assigned to patient symptoms, (4) challenges in recognition and management, and (5) future directions for guideline re-evaluation. Results: The review demonstrates that conventional exercise stress testing has low sensitivity for detecting inducible ischemia in AAORCA and that a negative result does not reliably exclude clinically significant risk. High-risk anatomical features—particularly an interarterial and intramural course accompanied by ostial or proximal luminal narrowing—are frequently discordant with functional findings and patient symptoms. Asymptomatic patients may still demonstrate inducible ischemia, while symptomatic patients may have negative functional tests, creating a substantial clinical "gray zone." Current surgical criteria may place disproportionate weight on demonstrable ischemia rather than on the anatomical potential for dynamic coronary compromise. Conclusion: The evidence supports a shift from a predominantly test-dependent model toward an integrated, anatomy-led, multimodality risk-stratification approach. A negative conventional functional test should not automatically override high-risk coronary anatomy. High-risk anatomical features should carry greater weight in clinical decision-making, particularly in young and physically active patients, to reduce the risk of false reassurance and improve the identification of patients who may benefit from surgical intervention. Prospective multicenter studies are required to validate this proposed framework.