Device closure of complex ASD – safe and feasible

Device closure of complex ASD e safe and feasible I read with interest the article "Techniques and outcomes of transcatheter closure of complex atrial septal defects e single center experience" by Ajith Ananthakrishna Pillai et al. 1 The authors should be appreciated for the high technical success (92%) achieved with transcatheter closure of complex atrial septal defect (ASD).This can be attributed to careful case selection and utilization of modified techniques of device deployment.The authors had used conventional device deployment in only 8.4% of patients.So familiarity with modified techniques is mandatory before attempting complex device closures.One of the crucial steps in ASD closure is device sizing.The manufacturers recommend not exceeding 20e30% of defect size measured by balloon sizing or by echocardiographic assessment.The authors had used sizes ranging 2.4e4.9 mm more than the measured defect size.It will be useful if authors can clarify when to use a device much larger than the recommended diameter and whether it can contribute to device embolization.The incidence of air embolism in the study is 5%.This increased incidence of air embolism is probably due to the prolonged procedure.Adequately hydrating the patient before and during the procedure, removing the dilator in the inferior vena cava and back bleeding with de-airing of delivery sheath periodically can prevent this complication.As the authors had pointed, 3-D echocardiography is likely to give better perception and orientation to close complex ASDs.Also, it will be interesting to know the long term outcome in patients with device >35 mm especially with reference to erosion of left atrial wall and perforations.