Anomalous Retro-Aortic Left Circumflex Artery Identified During Transcatheter Patent Foramen Ovale Closure: Procedural Implications.

BACKGROUND: Coronary artery anomalies are uncommon; certain origin and courses may be more vulnerable to compression by septal occluder devices and warrant careful evaluation. CASE SUMMARY: A 43-year-old man with recurrent transient ischemic attacks and embolic stroke was referred for transcatheter patent foramen ovale (PFO) closure. Coronary angiography demonstrated absence of the left main coronary artery with an anomalous origin of the left circumflex artery from the right coronary artery. Transesophageal echocardiography confirmed a retro-aortic anomalous coronary sign. After device deployment but before the release, repeat right coronary artery angiography confirmed preserved TIMI III flow in the anomalous left circumflex artery without evidence of compression. DISCUSSION: Recognition of coronary anomalies before PFO closure is essential. When a retro-aortic coronary course is present, coronary flow should be reassessed before final device release to exclude mechanical compression. TAKE-HOME MESSAGE: Comprehensive coronary assessment is critical during PFO closure when anomalous coronary anatomy is present.