Coronary Anomaly Preventing Transcatheter Closure of an Atrial Septal Defect

Abstract

A 4-year-old asymptomatic girl presented for elective transcatheter closure of her ostium secundum atrial septal defect (ASD). Her examination revealed a fixed split second heart sound with a 2/6 systolic ejection murmur at the left upper sternal border and a right ventricular lift. Transthoracic echocardiogram demonstrated a 15-mm secundum ASD with a mildly dilated right ventricle. The left coronary artery (LCA) could not be readily identified on the study. The patient was referred for percutaneous device closure when a preprocedural transesophageal echocardiogram revealed a moderatesized secundum ASD with left to right shunting, moderate right ventricle dilation, and an anomalous origin of the LCA from the right sinus of Valsalva was identified ( Figure 1A). The origin and distribution of the right coronary artery was normal. Cardiac catheterization revealed a Qp:Qs ratio of 2:1. Aortography confirmed the anomalous origin of the LCA from the right sinus of Valsalva with a course posterior to the aorta ( Figure 2A).With balloon sizing using the stop flow technique, the ASD measured 12 mm in diameter. A 12-mm Amplatzer septal occluder was then positioned but not released in the defect and was evaluated by transesophageal echocardiogram. The Amplatzer septal occluder was well seated but concern arose secondary to the device's proximity to the anomalous LCA as it coursed posterior and adjacent to the atrial septum ( Figure 1B). A repeat aortography revealed systolic compression of the LCA ( Figure 2B and online-only Data Supplement Video). No electrocardiogram abnormalities suggesting ischemia or hemodynamic changes occurred. The device was successfully removed and a repeat aortogram demonstrated no further distortion of the LCA ( Figure 2C). The patient recovered well and has been recommended for surgical ASD closure.In the current era, there exist very few contraindications to transcatheter closure of secundum ASDs 1 and very few periand postprocedural complications.2 Known device-related complications of percutaneous ASD closure, particularly with the Amplatzer septal occluder, include worsening of aortic regurgitation and cardiac erosion.3 Additionally, little information is available regarding the presence of coronary artery anomalies in patients undergoing ASD device closure. To our knowledge, this is the first reported case providing

False positive retroaortic left circumflex coronary artery in a patient with atrial septal defect

“…In the majority, it is possible to demonstrate the anomaly by TTE. Nevertheless, clarifying the presence or absence of the anomaly using TEE or coronary angiography is almost always preferred . We conclude that a prominent pericardial inferior aortic recess of transverse sinus, in some cases like ours, can mimic retroaortic coronary artery but this should be distinguished by the absence of color flow in the presumed coronary artery.…”

“…Nevertheless, clarifying the presence or absence of the anomaly using TEE or coronary angiography is almost always preferred. [3][4][5] We conclude that a prominent pericardial inferior aortic recess of transverse sinus, in some cases like ours, can mimic retroaortic coronary artery but this should be distinguished by the absence of color flow in the presumed coronary artery. An awareness of this possibility is imperative to avoid spurious diagnosis of retroaortic coronary artery denying patient a chance of nonsurgical closure of ASD.…”

“…Imaging plane of TEE in short‐axis aortic view transacts the inferior aortic recess of transverse sinus and, therefore, can produce an appearance typical of retroaortic coronary artery. This distinction is extremely important as a retroaortic course of coronary artery, owing to the risk of compression by the device, is a relative contraindication to device closure of ASD . In the majority, it is possible to demonstrate the anomaly by TTE.…”

“…This distinction is extremely important as a retroaortic course of coronary artery, owing to the risk of compression by the device, is a relative contraindication to device closure of ASD. 3,4 In the majority, it is possible to demonstrate the anomaly by TTE. Nevertheless, clarifying the presence or absence of the anomaly using TEE or coronary angiography is almost always preferred.…”

Interventional ASD II closure in the presence of an abnormally localized left main coronary artery

“…The coexistence of this anomaly with a secundum atrial septal defect is rare. To close the ASD under this condition [1,2], surgery is the most common procedure. The alternative catheter-interventional closure is rarely performed, because a partly or even complete compression of the LCA may occur as the occluder may rest at or on the aortic wall and therefore also on the LCA [3].…”