Multimodal Imaging in Anomalous Aortic Origin of the Coronary Arteries: Contemporary Approaches to Risk Stratification

Multimodal cardiac imaging has fundamentally reshaped the evaluation of anomalous aortic origin of the coronary artery, yet risk stratification remains challenging because anatomy, symptoms, and physiological demands vary widely across patients. This review summarizes contemporary anomalous aortic origin of the coronary artery classification and emphasizes anatomic features associated with higher risk, including interarterial and intramural courses, adverse ostial morphology, and compression related to the intercoronary pillar or myocardial bridges, which contribute to both fixed and dynamic ischemia. The complementary roles of echocardiography, coronary CT angiography with CT-derived fractional flow reserve, nuclear myocardial perfusion imaging, cardiac magnetic resonance, and hybrid anatomic–functional imaging are discussed, with attention to the specific clinical contexts in which each modality is most informative. Finally, we discuss the Vanderbilt management approach that integrates age, symptoms, detailed anatomic assessment, and functional testing to guide observation, exercise recommendations, invasive evaluation, and surgical intervention, with particular focus on individualized counseling and safe return-to-play decisions in young and athletic patients.