Speed-up the Diagnosis and Evaluation of anoMalous Coronary ARTery From the Aorta (SMART)

SMART: Speed-up the Diagnosis and Evaluation of anoMalous Coronary ARTery From the Aorta.

Anomalous aortic origin of the coronary arteries (AAOCA) is a rare congenital disease and one of the leading causes of sudden cardiac deaths (SCD) in young athletes but also has a lethal presentation in adult age with myocardial infarction, even if not related to obstructive coronary arteries. Unfortunately, diagnostic imaging techniques, invasive assessment, and provocative stress tests have shown low sensitivity and specificity in detecting inducible ischemia, and a multimodality assessment is then necessary.

Innovative tools have been developed in the medical field using computer-based simulation, 3-dimensional reconstruction, machine learning, and artificial intelligence (AI). With the application of such new technologies, we aim to fill the gap of knowledge and the diagnostic limitation regarding risk stratification for most subjects with AAOCA.

This work seeks to enhance, fasten, and personalize the clinical diagnosis of AAOCA by integrating anatomical measurements, clinical data, and biomechanical patient-specific features. The SMART study will set a system to automatically segment and classify coronary arteries with AAOCA from computerized tomography angiography (CTA) by artificial intelligence (AI). Segmentation will feed a 3D model of the aortic root and coronary artery for biomechanical assessment through finite element analysis (FEA). This will allow us to assess the location of possible coronary artery compression under an effort condition. These in-silico results, the anatomical features measured by AI, and the clinical data will be integrated into a risk model to estimate the hazard risk of adverse events such as SCD or myocardial infarction. This workflow will be framed in an IT system to allow a web-based remote diagnostic service.

Thanks to the proposed multidisciplinary approach, SMART aims to overcome the current diagnostic limitations related to the reduced ability of functional stress tests to detect ischemia. Potentially helping in patient-specific risk stratification, SMART is also thought to provide a way to get a first diagnostic indication about AAOCA being accessible from any hospital, fostering the diffusion of peripheral territorial support to the diagnosis and treatment of such rare disease.

Study Overview

• Status: Recruiting
• Conditions: Myocardial Ischemia; Sudden Cardiac Death; Anomalous Coronary Artery Origin; Anomalous Coronary Artery Arising From the Opposite Sinus; Anomalous Coronary Artery With Aortic Origin and Course Between the Great Arteries; Anomalous Aortic Origin of the Coronary Artery (AAOCA); Myocardial Ischemia, Angina Pectoris; AAOCA; ACAOS; Coronary Anomaly
• Intervention / Treatment: Diagnostic test: Autonomic response in AAOCA

Detailed Description

The project aims to create a web-based platform that allows the uploading Computed Tomography Angiography (CTA) images, particularly cardio CTA, with contrast medium in anonymized form.

The CTA images will be processed by a neural network developed by the project, which will be able to segment CTA automatically, identify the presence or not of the anomalous coronary origin, and retrieve geometrical measurements of the anatomy of interest. The anatomical and geometrical measurements, automatically made by artificial intelligence, will be integrated with clinical data and computational simulations (Finite Element Structural Analysis) to understand the potential site of dynamic coronary compression under simulated stress conditions.

The final output of the platform will be a report that will integrate clinical data and geometrical and anatomical information to estimate the hazard risk of sudden cardiac deaths or major adverse ischemic events.

• Study Type: Interventional
• Enrollment (Estimated): 38
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Italy
  • Italia
    • San Donato Milanese, Italia, Italy, 20097
      • Recruiting
      • IRCCS Policlinico San Donato
      • Contact: Mauro Lo Rito; Phone Number: 02 52774511; Email: mauro.lorito@grupposandonato.it

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Adult and pediatric patients (age > 6 years) with anomalous coronary origin from the aorta (AAOCA).
• Patients in spontaneous sinus rhythm.
• Signed informed consent.

Exclusion Criteria:

• Patients with acute and chronic inflammatory conditions such as chronic liver disease, chronic kidney failure (creatinine > 1.5 mg/dl), and thyroid disorders.
• Patients with arrhythmias, absence of sinus rhythm.
• Contraindications to autonomic testing.
• Patients with a known allergy to materials in recording devices.
• Female patients who are pregnant.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Diagnostic
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: Prospective study; The prospective phase aims to validate the entire model developed during the retrospective phase and to evaluate the role of autonomic response in subjects with Anomalous Aortic Origin of a Coronary Artery (AAOCA). The prospective recruitment of the cohort of AAOCA patients for autonomic assessment and validation will span the entire duration of the study. Our objective is to recruit 38 patients with AAOCA to obtain consistent and uniform data from at least 32 participants. Patients in this cohort will undergo an active standing test to elicit an autonomic response, and the results will be compared with reference normal values. During this examination, the following data will be collected: continuous ECG, non-invasive blood pressure, and respiratory measurements in both supine and prone positions.

Diagnostic test: Autonomic response in AAOCA; Autonomic regulation sub-analysis: Autonomic control will be evaluated in a population prospectively recruited. Thirty-eight subjects with Anomalous Aortic Origin of a Coronary Artery (AAOCA) will undergo an active standing test. For this prospective sample, demographic and clinical data, as well as DICOM images from previously conducted diagnostic CT angiographies (CTAs) for AAOCA, will also be collected. These data will be utilized to assess the final functionality of the online platform before its public launch. The patients will be subjected to the active standing test to elicit an autonomic response, with results compared to reference normal values. During this examination, the following data will be collected: continuous ECG, non-invasive blood pressure, and respiratory measurements in both supine and prone positions.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Analysis of Autonomic Test Data	Beat-to-beat series will be extracted from recorded signals to derive indices related to autonomic, cardiovascular, cerebrovascular, and peripheral microcirculation control during REST and STAND phases. The cardiac period will be defined as the interval between consecutive R peaks (RR- msec) in the ECG, with systolic (SAP - mmHg) and diastolic blood pressure (DAP - mmHg) calculated as the maximum and minimum pressures between these peaks. Random sequences of 250 beats will be selected from each recording and manually verified for corrections. Ectopic beats will be adjusted using cubic spline interpolation. Indices of cardiovascular control will be derived from time-domain variability measures, and spectral density will be estimated using a parametric autoregressive approach. Analyses will be conducted using software developed in Matlab and C++.	two years

Collaborators and Investigators

• Sponsor: IRCCS Policlinico S. Donato
• Collaborators: University of Pavia; University of Naples; The Mediterranean Institute for Transplantation and Advanced Specialized Therapies

Study record dates

Study Major Dates

• Study Start (Actual): September 12, 2024
• Primary Completion (Estimated): August 1, 2026
• Study Completion (Estimated): February 1, 2027

Study Registration Dates

• First Submitted: October 17, 2024
• First Submitted That Met QC Criteria: November 22, 2024
• First Posted (Actual): November 26, 2024

Study Record Updates

• Last Update Posted (Actual): April 15, 2026
• Last Update Submitted That Met QC Criteria: April 10, 2026
• Last Verified: March 1, 2026

More Information

Terms related to this study

• Keywords: CT; AAOCA; IMAGE SEGMENTATION; ACAOS
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Vascular Diseases; Cardiovascular Diseases; Pathologic Processes; Heart Diseases; Death; Heart Arrest; Death, Sudden; Chest Pain; Pathological Conditions, Signs and Symptoms; Signs and Symptoms; Myocardial Ischemia; Death, Sudden, Cardiac; Angina Pectoris
• Other Study ID Numbers: PNRR-MCNT2-2023-12378301; MCNT2-2023-12378301 (Other Grant/Funding Number: Italian Ministery of Health)

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No