Transcatheter closure of atrial septal defects (ASDs) has become an accepted and reliable procedure. Although various complications have been recognized, tear of the atrial septal rim is a rare complication. We report a case of atrial septal rim tear that was diagnosed during the procedure by real-time three-dimensional transesophageal echocardiography (TEE). The device was successfully implanted 3 months after the initial intervention. RT3D TEE is more useful for displaying the entire shape of the defect and its spatial relationship (RT3D) with its neighboring structures compared with conventional two-dimensional echocardiography. By using both two-dimensional and RT3D TEE images, especially in cases with complicated ASD morphology, both the echocardiologist and interventionalist gain valuable information on the morphology of the ASD before and during the procedure.
In recent years, transcatheter closure of atrial septal defects (ASDs) has become an accepted and reliable procedure. Tearing of the atrial septum during the procedure is a rare complication, and it is sometimes difficult to make a rapid and accurate diagnosis during the procedure.
With the recent rapid developments in technology, real-time three-dimensional (RT3D) transesophageal echocardiography (TEE) with a new fully sampled matrix array transducer has become available. RT3D TEE provides clear and easily understandable en face images. Therefore, this modality has been applied to select patients for transcatheter closure of ASDs and to guide the procedure. We report a case of an atrial septum tear during transcatheter closure of an ASD that was visualized by RT3D TEE, allowing us to make an accurate diagnosis during the procedure and to choose an appropriate therapeutic strategy.
Clinical Summary
A 40-year-old woman with exertional dyspnea was referred to the Okayama University Graduate School of Medicine for transcatheter device closure of a secundum ASD. Transthoracic echocardiography showed a left-to-right shunt across the ASD and enlargement in the right atrium and ventricle with no additional associated cardiovascular abnormality.
Transcatheter ASD closure was performed under general anesthesia with the assistance of two-dimensional (2D) TEE, RT3D TEE (Philips IE 33, Philips Medical Systems, Andover, MA), and fluoroscopy. The maximum diameter of the ASD was measured at 18 mm, and an adequate rim around the defect, with the exception of a deficient superoanterior rim, was observed on preprocedural 2D and RT3D TEE. 2D TEE also revealed a thin inferoposterior rim. Pulmonary to systemic flow ratio (Qp/Qs) revealed a significant left-to-right shunt (Qp/Qs ratio 1.93). Balloon sizing with a 34-mm AGA balloon (AGA Medical, Plymouth, MN) resulted in a stretched defect diameter of 20 mm using the stop-flow technique. A 10F AGA sheath was used to deliver the device. A 20-mm Amplatzer septal occluder (ASO) (AGA Medical Corp, Plymouth, MN) was selected on the first attempt. However, the device and delivery sheath easily slipped back into the right atrium, and the device could not be deployed in the proper position. After the first attempt, 2D TEE showed a flailed inferoposterior rim. On the second attempt, a 24-mm ASO was selected, but the device could not be deployed in the proper position. Finally, the maximal longitudinal diameter of the defect was measured at 30 mm. The procedure was terminated, and the ASD could not be closed. Although it was difficult to view the defect in detail using only 2D TEE images, RT3D TEE clearly demonstrated that the borders of the inferior rim were torn and that the defect had increased in size during the procedure ( Figure 1 ). The en face image seen on RT3D TEE made it easier for the operator to evaluate the problem. The inferior rim had been torn when the ASO and delivery sheath slipped back into the atrium, and the defect had become larger during the procedure. The patient was hemodynamically stable during the intervention even after the rim was torn.
After the patient was discharged, no clinical deterioration was observed. The patient was scheduled for surgical closure of the defect, but she refused. Three months after discharge, 2D and RT3D TEE did not reveal flailed surrounding rims, and the torn rim seemed healed, resulting in a deficiency of the superoanterior and inferoposterior rims. The maximal diameter of the defect was 30 mm ( Figure 2 ). Therefore, transcatheter closure of ASD was attempted again.
Right-sided catheterization was performed before the procedure, showing a normal pulmonary artery systolic pressure of 15 mm Hg. The Qp/Qs ratio had increased to 2.88. A 32-mm ASO was selected. The device was successfully implanted, and the ASD was occluded ( Figure 3 ). The patient’s exertional dyspnea was improved 1 month after device closure of the ASD. At 1-year follow-up, the patient was still asymptomatic and had no complications (eg, device dislocation).
