Abstract
Coronary artery anomalies represent a series of congenital heart diseases characterized by the abnormal circulation of coronary arteries. Of particular interest is the anomalous aortic origin of coronary arteries (AAOCA), an underdiagnosed but potentially fatal anomaly, specifically relevant in young adult athletes. During the last decades, knowledge of the pathophysiology of AAOCA-related ischemic mechanisms has increased, and major risk conditions have been discovered. Unfortunately, a universally shared approach is still lacking, and clinicians often follow the policy of their own centers. Most of the population with AAOCA is asymptomatic or complains of minor symptoms but is among them that there is much more uncertainty about the correct strategy to perform a risk stratification process, and consequently for providing indications on exercise restriction or surgery. This review focuses on the diagnostic approach to coronary anomalies and discusses the diagnostic workflow in these patients. Finally, we perform an in-depth analysis of novel angiographic invasive functional methods and how they contribute to AAOCA in selected cases.