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Background With the emergence of coronary computed tomography (CT) angiography, anomalous aortic origin of a coronary artery (ANOCOR) is more frequently diagnosed. Fractional flow reserve derived from CT (FFRCT) is a noninvasive functional test providing anatomical and functional evaluation of the overall coronary tree. These unique features of anatomical and functional evaluation derived from CT could help for the management of patients with ANOCOR. We aimed to retrospectively evaluate the physiological and clinical impact of FFRCT analysis in the ANOCOR registry population. Methods and Results The ANOCOR registry included patients with ANOCOR detected during invasive coronary angiography or coronary CT angiography between January 2010 and January 2013, with a planned 5‐year follow‐up. We retrospectively performed FFRCT analysis in patients with coronary CT angiography of adequate quality. Follow‐up was performed with a clinical composite end point (cardiac death, myocardial infarction, and unplanned revascularization). We obtained successful FFRCT analyses and 5‐year clinical follow‐up in 54 patients (average age, 60±13 years). Thirty‐eight (70%) patients had conservative treatment, and 16 (30%) patients had coronary revascularization after coronary CT angiography. The presence of an ANOCOR course was associated with a moderate reduction of FFRCT value from 1.0 at the ostium to 0.90±0.10 downstream the ectopic course and 0.82±0.11 distally. No significant difference in FFRCT values was identified between at‐risk and not at‐risk ANOCOR. After a 5‐year follow‐up, only one unplanned percutaneous revascularization was reported. Conclusions The presence of ANOCOR was associated with a moderate hemodynamic decrease of FFRCT values and associated with a low risk of cardiovascular events after a 5‐year follow‐up in this middle‐aged population.

Few patients with an anomalous aortic origin of a coronary artery (AAOCA) require a correction of this congenital anomaly. Current recommendations offer surgical repair as a first line therapy to prevent a sudden cardiac death as a main objective. However, these guidelines are focused on children and not based on randomized controlled studies. Furthermore, decision-making should be different in an adult population less exposed to the risk of sudden cardiac death. Current practices showed reluctance to offer a surgical treatment for right AAOCA associated with ischemic symptoms or myocardial ischemia. Our aim in this review is to expose the rationale for percutaneous coronary intervention in right AAOCA with interarterial course and to present the published results.

A 77-year-old man was referred for treatment of a secundum type atrial septal defect (ASD). Transthoracic echocardiography and transesophageal echocardiography showed a 20-mm atrial ASD (Figure [A]) with important enlargement of the right ventricle. A 24-mm ASD Ultrasept II (Cardia Inc, Eagan, MN) closure device was successfully implanted (Figure [B]) after the first attempt with no residual shunt. The Ultrasept II device was loaded and deployed in a similar manner to Amplatzer devices. The nickel-titanium frame of the Ultrasept II device has 2 discs covered with a polyvinyl alcohol (PVA) membrane ( . In follow-up at 8 months the patient was well. Thereafter, a routine transthoracic echocardiography was performed at 3 months of all patients (n=9) implanted with the ASD Ultrasept II device in our institution. One other similar case was diagnosed: a 41-year-old woman referred for treatment of an ASD associated with moderate enlargement of the right ventricle. Transesophageal echocardiography showed a 19-mm defect associated with thin margins. A 32-mm ASD Ultrasept II closure device was implanted successfully with no residual shunt. One-week and one-month echocardiographic followup were unremarkable. A routine transthoracic echocardiography performed at 3 months revealed a recurrent significant left-to-right shunt. Transesophageal echocardiography, intraoperative, and explanted images were similar to those described as in the first case. Surgical device removal and Gore-Tex patch repair were performed with an uneventful follow-up at 6 months. DiscussionTwo early malfunctions of the PVA membrane were observed in a series of 9 consecutive patients treated with ASD Ultrasept II closure device in our institution. Implantation of a second device within the defective device was discussed, but surgery repair was preferred because of the unclear mechanism of the malfunction. Two similar cases were previously reported 1 with the ASD Atriasept II (Cardia Inc, Eagan, MN) closure device, a previous generation of the device used in the current cases, which also uses a PVA-based material. The mechanism of PVA membrane disappearance was not reported. PVA is a water-soluble polymer, which becomes insoluble for medical purposes with formaldehyde or glutaraldehyde cross links. The biocompatibility of PVA is recognized as good.2 Intolerance reactions to PVA are not known. A recent literature review did not indicate unexpected biodegradability of PVA membranes in ASD closure devices.3 An usual procedure followed for our 2 cases included soaking of the device in sterile saline before loading in the delivery sheath. A severe adverse event notification form was sent to the manufacturer. The 2 devices were not from the same manufacturing lot. The explanted devices were macroscopically and microscopically examined. The metallic frame and all sutures used to attach the PVA membrane to the frame were intact. Examination of the residual PVA membrane was unremarkable. All processes used to create the PVA membranes were reviewed. Several chemic...

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