Advanced Cardiac Imaging Techniques for Detection of Myocardial Ischemia in Children with Coronary Artery Abnormalities.

introductionCoronary artery disease in children arises from a diverse group of non-atherosclerotic conditions that may result in myocardial ischemia, ventricular dysfunction, and sudden cardiac death. Important etiologies include post-inflammatory vasculopathy following Kawasaki disease, transplant-related cardiac allograft vasculopathy, congenital coronary anomalies such as anomalous aortic origin of a coronary artery, and complications after coronary reimplantation during congenital heart surgery. The detection of myocardial ischemia in children is uniquely challenging, as symptoms are frequently absent or atypical, and traditional screening tools such as resting electrocardiography and transthoracic echocardiography lack sufficient sensitivity.

methodsA narrative review was performed of the literature on non-invasive myocardial ischemia evaluation in pediatric patients with acquired and congenital coronary artery disease, focusing on Kawasaki disease, congenital coronary anomalies, cardiac allograft vasculopathy, and postoperative conditions involving coronary artery manipulation. PubMed and Google Scholar were searched and supplemented by reference lists and guideline documents. Original studies, reviews, consensus statements, and society guidelines were qualitatively synthesized by disease category and imaging modality, with emphasis on diagnostic performance, clinical applications, safety considerations, limitations, and evidence gaps.

resultsMultimodality imaging plays a central role in the evaluation of pediatric coronary pathology. Stress echocardiography provides a widely available, radiation-free method for detecting inducible regional wall motion abnormalities but requires specialized expertise. Stress perfusion cardiac magnetic resonance imaging offers comprehensive assessment of ventricular function, myocardial perfusion, and scar tissue without ionizing radiation and is increasingly incorporated into surveillance strategies. Nuclear perfusion imaging remains a well-established technique but is used less frequently due to radiation exposure and modest specificity in some populations. Coronary computed tomography angiography provides high-resolution anatomic characterization of coronary origin, course, and luminal patency and is particularly valuable in congenital coronary anomalies and postsurgical coronary assessment.

conclusionsOptimal evaluation of pediatric coronary disease requires the integration of anatomic and functional imaging tailored to the underlying pathology and patient characteristics. Despite advances in multimodality imaging, pediatric-specific data remain limited, and many diagnostic thresholds are extrapolated from adult populations. Further multicenter studies are needed to refine risk stratification and establish evidence-based surveillance strategies for children at risk of myocardial ischemia.