Echocardiographic approach to transcatheter closure of atrial septal defects in children with a deficient or absent aortic rim: a retrospective analysis

Introduction: Transcatheter closure of secundum atrial septal defects (ASDs) isthe standard of care. However, defects with a deficient or absent aortic rim remain technically challenging because of the risk of erosion of the aortic wall or atrial roof. Despite extensive international experience, techniques for the safe closure of such defects in children remain insufficiently studied in Russian clinical practice. Objective: To develop and evaluate the effectiveness of a differentiated occludersizing algorithm based on comprehensive echocardiographic imaging to minimize the risks of transcatheter ASD closure in children with a deficient aortic rim. Methods: A retrospective analysis was performed in 265 children with an isolated deficient or completely absent aortic rim. Transthoracic (TTE) and transesophageal echocardiography (TEE) were the principal imaging modalities used for monitoring at all stages of the procedure. A personalized approach to device sizing was applied: in patients with firm rims, device size was determined using echocardiography with color Doppler mapping; in patients with thin rims, the stop-flow technique was used. Particular attention was paid to the device-to-body-weight ratio (device diameter/ body weight). Results: The mean device-to-body-weight ratio in the study group was 0.88, which helped avoid excessive pressure on cardiac structures. Implementation of the differentiated algorithm, involving selection of an occluder 2 mm smaller to 2 mm larger than the measured size depending on the echocardiographic appearance of the rims, resulted in a high technical success rate. During the entire follow-up period (median, 38 months; interquartile range [IQR], 24–52 months; range, 6–84 months), there were no cases of aortic erosion or other life-threatening complications. Conclusion: Transcatheter ASD closure in children with a deficient aortic rim is a safe procedure provided that the imaging protocol is strictly followed and the occluder is appropriately sized. The proposed algorithm and monitoring of the device-to-bodyweight ratio minimize mechanical stress on the aortic root and provide excellent clinical outcomes. Received 17 March 2026. Revised 17 June 2026. Accepted 23 June 2026. FundingThe study did not have sponsorship. Conflict of interestThe authors declare no conflicts of interest. Contribution of the authorsConception and study design: M.M. Kurako Data collection and analysis: M.M. Kurako, M.A. Abramyan, M.G. Pursanov Statistical analysis: M.M. Kurako Drafting the article: M.M. Kurako, M.A. Abramyan Critical revision of the article: T.Yu. Kulagina, M.G. Pursanov Final approval of the version to be published: all authors