Catheter-based closure of a large atrial septal defect with inferior rim deficiency using pulmonary vein slide-out assisted implantation technique: a case report

Figures

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  Figure 1. Two-dimensional transthoracic echocardiography (A) colour Doppler (B) apical four-chamber views showing a large atrial septal defect ranging from 27.1 to 28.2 mm in diameter with right heart chambers dilatation. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

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  Figure 2. (A,B) Two-dimensional transoesophageal echocardiography (TOE) colour Doppler images showing a large secundum atrial septal defect with severe left-to-right shunt, significant right atrial enlargement due to volume overload and adequate septal rims except for a deficient and very floppy postero-inferior one (yellow arrows); (C) three-dimensional (3D) transoesophageal echocardiography images demonstrating the circular index of the atrial septal defect defined as the ratio of the maximal diameter (26.1 mm) to the minimal diameter (21.7 mm) and the relationship with the surrounding structures. LA, left atrium; RA, right atrium.

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  Figure 3. Fluoro-angiographic procedural steps. (A,B): after crossing the atrial septal defect, the delivery system (DS, arrowhead) with the exchange 0.035 inch–260 cm long wire are positioned in the right upper pulmonary vein (RUPV); (C,D) deployment of the uncovered distal disc in the RUPV helding it stationary in an elongated form (red dotted lines), allowing then unsheathing of the connecting waist (white arrow) and proximal right disc (black arrow) of the device in the right atrium, engaging the right aspect of the interatrial septum.

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  Figure 4. Fluoro-angiographic procedural steps. (A) a short wiggle of the delivery system released the left atrial disc (arrowhead) from right upper pulmonary vein position allowing proper left disc deployment; white arrow is pointing at the connecting waist and black arrow at the proximal right disc of the device; (C–E) engagement of the interatrial septum from the left and right atrial aspect with a perfect configuration for atrial septal defect closure; (F) 33-mm FSO (black arrow) finally deployed in a stable and correct position.

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  Figure 5. Six-month follow-up 2D transthoracic echocardiography colour Doppler apical four-chamber views showing the 33-mm FSO in situ (yellow arrows) without residual left-to-right shunt and significant reduction in right heart chambers volume overload. LA, left atrium; LV, left ventricle; RA: right atrium; RV, right ventricle.

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