The “Peanut Sign” is a useful tool to detect spiral atrial septal defects

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Spiral atrial septal defect and moderate valvular pulmonary stenosis (n=1). Intervention: Transcatheter atrial septal defect closure guided by balloon sizing ('Peanut Sign') using a 15 mm Occlutech Figulla Flex II occluder. Primary outcome: Stable transcatheter closure of spiral atrial septal defect without residual shunt or embolisation.

Q: What does this research mean for the field?

A bilobed balloon morphology with a double waist, termed the 'Peanut Sign', during balloon sizing identifies spiral atrial septal defects and guides appropriate device selection to prevent embolisation. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Jule Marie Dittmer Hein; Anja Tengler; Nikolaus A. Haas

doi:10.1017/s1047951126124603

November 6, 2026Cardiology in the YoungOpen Access

The “Peanut Sign” is a useful tool to detect spiral atrial septal defects

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Key result

Balloon-sizing Peanut Sign identifies spiral ASDs to guide successful closure after device embolization.

n=1

Why the study?

Spiral atrial septal defects may complicate transcatheter closure and increase the risk of device embolisation.

Does recognition of the bilobed 'Peanut Sign' during balloon sizing facilitate appropriate device selection and stable transcatheter closure in a pediatric patient with a spiral atrial septal defect?

Key Points

To describe the utility of the balloon sizing "Peanut Sign" in diagnosing spiral atrial septal defects and guiding appropriate transcatheter occluder sizing to prevent device embolisation.
Evaluated a 5-year-old boy presenting with valvular pulmonary stenosis and a secundum atrial septal defect who experienced device embolisation following transcatheter closure.
Conducted percutaneous retrieval of an embolised 9 mm occluder from the aortic arch using a 10 F sheath and snare, followed by repeat defect evaluation using a 20 mm sizing balloon and transoesophageal echocardiography.
The initial 9 mm occluder embolised into the aortic arch on the first post-procedural day and was retrieved percutaneously without vascular complication.
Repeat balloon sizing with a 20 mm balloon revealed a bilobed "Peanut Sign" contour with two waists measuring 14 mm and 15 mm, leading to stable closure using a 15 mm occluder that encompassed both the septum primum and septum secundum.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

Does recognition of the bilobed 'Peanut Sign' during balloon sizing facilitate appropriate device selection and stable transcatheter closure in a pediatric patient with a spiral atrial septal defect?

P

Population

1 five-year-old boy with moderate valvular pulmonary stenosis and a spiral secundum atrial septal defect complicated by initial device embolisation, followed for 6 months.

I

Intervention

Pulmonary valvuloplasty (16 and 18 mm balloons) and transcatheter atrial septal defect closure; initial implantation of a 9 mm Figulla Flex II occluder (which embolised to the aortic arch), followed by percutaneous snare retrieval, repeat balloon sizing with a 20 mm balloon revealing a bilobed 'Peanut Sign' (waists of 14 and 15 mm), and subsequent implantation of a 15 mm Figulla Flex II occluder under transoesophageal echocardiography guidance.

O

Outcome

Stable device position without erosion, residual shunt, or embolisation at 6 months follow-up.hard clinical

A bilobed, double-waisted balloon deformation ('Peanut Sign') during balloon sizing can identify spiral atrial septal defects and guide device upsizing to prevent occluder embolisation.

Limitations

Single-patient case report

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Implication

Peanut sign on balloon sizing may guide device selection after embolization in spiral ASD; leaves open prospective validation before routine use.

Abstract

Spiral atrial septal defects may complicate transcatheter closure and increase the risk of device embolisation. We describe a 5-year-old boy with pulmonary stenosis and a secundum atrial septal defect in whom an initially implanted 9 mm device embolised. At repeat intervention, balloon sizing revealed a bilobed, peanut-shaped configuration with a double waist, suggestive of a spiral atrial septal defect. A 15 mm device was subsequently implanted, achieving stable closure. The "Peanut Sign" may serve as a useful marker for identifying spiral atrial septal defects and guiding appropriate device selection.

Discussion

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Cite This Study

Hein et al. (2026) conducted a case report in Spiral atrial septal defect and moderate valvular pulmonary stenosis (n=1). Transcatheter atrial septal defect closure guided by balloon sizing ('Peanut Sign') using a 15 mm Occlutech Figulla Flex II occluder was evaluated on Stable transcatheter closure of spiral atrial septal defect without residual shunt or embolisation. Recognition of a bilobed 'Peanut Sign' with 14 and 15 mm waists during balloon sizing identified a spiral atrial septal defect and guided stable closure with a 15 mm occluder after a 9 mm device embolised.

synapsesocial.com/papers/6aefbd4950d2071ffda4bc42 https://doi.org/10.1017/s1047951126124603

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The “Peanut Sign” is a useful tool to detect spiral atrial septal defects

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

The “Peanut Sign” is a useful tool to detect spiral atrial septal defects

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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