CJC Open - (2022) 1e2

Images in Cardiology

Percutaneous Patent Foramen Ovale Closure in a PatientWith Anomalous Aortic Origin of the Left Coronary Artery
Shiro Miura, MD, MSc,a Takehiro Yamashita, MD, PhD,a Hideaki Kanazawa, MD, PhD,b
Hidehiko Hara, MD, PhD,c and Jonathan M. Tobis, MDda

Department of Cardiology, Hokkaido Ohno Memorial Hospital, Sapporo, Japanbcd

Department of Cardiology, Keio University School of Medicine, Tokyo, Japan

Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan

Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, California, USA

The anomalous aortic origin of the coronary artery is a rarecongenital disease that occurs in approximately 0.7% of thegeneral population, often causing sudden death with a highrisk of anatomic features, such as a slit-like ostium or aninterarterial or intramural course.1 A left coronary artery(LCA) arising from the nonadjacent sinus is one of the rarest
forms of anomalous aortic origin of the coronary artery. Its
prognosis and management are controversial despite reports
on adverse outcomes.1 Patent foramen ovale (PFO) is aremnant of fetal circulation in approximately 20%-25% of theadult population, and it increases the risk of an embolic strokeof undetermined source.2 Therapeutic options include medical therapy, surgical closure, and percutaneous transcatheter
closure in patients with embolic stroke of undeterminedsource. We present a challenging case with this anomaly as asigniﬁcant concern for successful percutaneous PFO closure.
A 55-year-old woman presented with sudden onset of
apraxia, diagnosed by neurologists as PFO-related stroke.
Transesophageal echocardiography (TEE) demonstrated amacroscopic PFO with right-to-left shunting at rest andconcomitant high-risk features3 (Videos 1 and 2, view
video online). Three-dimensional coronary computed tomography angiography (3D-CCTA; Fig. 1A, left) revealed ananomalous aortic origin of the LCA from the nonadjacentsinus and the artery to the sinus node branching from the left
circumﬂex coronary artery, posing a potential risk of interference with an implanted device. A percutaneous PFO
closure could cause a left main trunk obstruction, and pacemaker implantation might be needed with the artery to theReceived for publication March 7, 2022. Accepted May 31, 2022.
Ethics Statement: The research reported adheres to relevant ethicalguidelines.
Corresponding author: Dr Shiro Miura, Department of Cardiology,
Hokkaido Ohno Memorial Hospital, 2-1-16-1 Miyanosawa, Nishi-ku, Sapporo 063-0052, Japan. Tel.: þ81(0)11-665-0020; fax: þ81-(0)11-665-0242.
E-mail: s.miura@ohno-kinen.or.jp
See page 2 for disclosure information.

Novel Teaching Points Anomalous aortic origin of the LCA from a nonadjacent sinus might cause serious interference with animplanted PFO device.
 3D-CCTA can help in establishing the diagnosis ofanomalous aortic origin of the LCA and planning thePFO closure procedure.

sinus node seriously involved. The 3D-CCTA images suggested that a 35-mm device would interfere with the LCAostium, but that a 25-mm device would not (Fig. 1B, left).
Because the patient was asymptomatic, with no evidence of
myocardial ischemia and few high-risk anatomic features,1 theanomalous aortic origin of the LCA was considered a low-levelindication for surgical repair.
After careful discussion with our cardiovascular team, thepatient opted for a percutaneous PFO closure using multiimaging guidance instead of surgical closure. During the procedure, the LCA ostium was closely monitored using TEE andintravascular ultrasound, and the artery to the sinus node wasvisualized through frequent selective coronary angiography(Fig. 1C). Based on the waist diameter (7.1-mm) of a 24-mmsized balloon, a 25-mm Amplatzer PFO Occluder (AbbottVascular, Abbott Park, IL; 18 mm for the left atrial disc) wasimplanted successfully, with no interference with the LCAostium, and with the artery to the sinus node safely patent. At 1
week postimplantation, 3D-CCTA (Fig. 1A [right] and B[right]) revealed that the LCA ostium and the device wereadequately separated, and that the artery to the sinus nodepartially passed through both discs without serious compression. The patient was asymptomatic, and no residual shunting
was seen on the TEE at the 6-month follow-up.
Percutaneous PFO closure in patients with an anomalous
aortic origin of the LCA from a nonadjacent sinus might carry

https://doi.org/10.1016/j.cjco.2022.05.008
2589-790X/Ó 2022 The Authors. Published by Elsevier Inc. on behalf of the Canadian Cardiovascular Society. This is an open access article under the CC BY-NCND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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Figure 1. Computed tomography-based and ﬂuoroscopic illustrations of percutaneous patent foramen ovale (PFO) closure. (A) Oblique axial and (B)volume-rendered images of coronary computed tomography angiography (left) before and (right) after the 25-mm Amplatzer PFO Occluder (APO)
implantation, highlighting the anatomic relationship among the (red arrow) left coronary artery (LCA) ostium, (blue arrow) the artery to the sinus
node, (yellow arrow) PFO, and (green arrow) the implanted device. (C) Coronary angiogram (left) before and (right) after device implantation with(middle) the balloon sizing. H, head; IVUS, intravascular ultrasound; L, left; NAS, nonadjacent sinus; P, posterior.

a unique risk of coronary artery involvement with an
implanted device and often requires careful monitoring during
the procedure. We emphasized the usefulness of pre- andpost-procedural CCTA in performing the percutaneous PFO
closure, which would be superior to TEE regarding theanatomic assessment of all cardiac structures. However, procedural monitoring would be unfeasible with CCTA as alimitation.
Funding Sources
The authors have no funding sources to declare.
Disclosures
The authors have no conﬂicts of interest to disclose.

References
1. Bravo-Jaimes K, Balan P, Garcia-Sayan E. Controversies on the cusp:
anomalous origin of the left coronary artery from the non-coronary cusp.
Cureus 2020;12:e7993.
2. Collado FMS, Poulin MF, Murphy JJ, Jneid H, Kavinsky CJ. Patentforamen ovale closure for stroke prevention and other disorders. J Am
Heart Assoc 2018;7:e007146.
3. Davison P, Clift PF, Steeds RP. The role of echocardiography in diagnosis,
monitoring closure and post-procedural assessment of patent foramen
ovale. Eur J Echocardiogr 2010;11:i27-34.

Supplementary MaterialTo access the supplementary material accompanying thisarticle, visit CJC Open at https://www.cjcopen.ca/ and athttps://doi.org/10.1016/j.cjco.2022.05.008.