Transcatheter Closure of Secundum Atrial Septal Defect with Large Multifenestrated Septum Primum Aneurysm and Double Atrial Septum: A Challenging Transesophageal Echocardiography–Guided Procedure

Figures

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  Figure 1. Transthoracic echocardiogram showing a multifenestrated (yellow arrows) ostium secundum ASD associated with a highly mobile aneurysmatic septum primum (white star) bulging toward the left atrium (A) and the right atrium (B); TTE color Doppler in subcostal view (C) confirms the presence of the two defect fenestrations (white arrows). LA, Left atrium; RA, right atrium. See also Video 1.

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  Figure 2. Three-dimensional TEE (en face view from the left atrial perspective) displays the multifenestrated interatrial septal defect. The large ASD with a slightly elliptical shape is partially covered by aneurysmatic highly mobile fibrous bands (white and yellow asterisks in two subsequent frames). Ao, Aortic root bulging on the left atrium; CS, coronary sinus. See also Video 2.

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  Figure 3. Two-dimensional TEE in the bicaval view showing the anomalous attachment of the septum primum, which fails to fuse with the septum secundum, leaving a persistent space (interatrial space) as a passage between the two atria (A, B); the total length of the aneurysmatic fossa ovalis floor at 118° and 0° TEE views is also accurately measured (C, D). LA, Left atrium; RA, right atrium; SP, septum primum; SS, septum secundum. See also Video 3.

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  Figure 4. Two-dimensional TEE in the bicaval view image (A) and the corresponding drawing (B) showing a double-membrane structure with an interatrial accessory chamber (yellow asterisk) in the inferior portion of the atrial septum. This rare cardiac anomaly is caused by malposition of the septum primum, which fails to fuse with the septum secundum, leaving a persistent space as a passage between the two atria. LA, Left atrium; RA, right atrium; S1, septum primum; S2, septum secundum.

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  Figure 5. The balloon-stretched diameter (black arrows) shown in cardiac fluoroscopy in the straight anteroposterior projection (A) and in two-dimensional TEE multiplanar views (B).

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  Figure 6. Two-dimensional TEE color Doppler (A, B) in the bicaval view showing good superior rim and unsafe inferoposterior rim anchoring of the 36 mm FSO (white arrows). Interatrial space, yellow star; LA, Left atrium; RA, right atrium; SS, septum secundum (orange arrow).

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  Figure 7. Cardiac fluoroscopy in anteroposterior projection (A) and two-dimensional TEE color Doppler images at 50° (B) and at 107° (C) showing the 39 mm FSO (white arrowhead) with better device alignment. The final result was successful superior rim anchoring without aortic impingement of the disc tips to the aortic root, and a trivial eccentric residual left-to-right shunt was located inferoposteriorly with color Doppler. LA, Left atrium; RA, right atrium.

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  Figure 8. Thirty-day follow-up TTE in the apical four-chamber view showing a well-positioned occluder device (white arrowhead) without residual shunt and significant decrease of right heart overload.