Transcatheter closure of multiple atrial septal defects in an adolescent

Transcatheter closure of secundum atrial septal defect (ASD) using percutaneous approach has become accepted treatment in many cardiac centers. The majority of patients with ASD require a single device for closure, but a small proportion of ASD patients may have multiple defects and these are often considered unsuitable for device closure. Although spatial imaging to understand the relationship between the defects and adjacent structures is provided on 2-D and 3-D trans-esophageal echocardiography (TEE) 1 and cardiac magnetic resonance imaging can help determine the type, location, and size of the ASD and provide direct visualization of the atrial septum anatomy, 2 little is known about the use of devices to close multiple ASD. Here we report the case of a patient with two separate moderate-sized secundum ASD that were successfully closed using two Amplatzer septal occluders, with emphasis on angiography. Case report A 17-year-old asymptomatic boy was referred due to heart murmur. The patient’s chest X-ray showed mild cardiomegaly with increased pulmonary vascular markings and prominent pulmonary conus. The electrocardiogram showed an incomplete right bundle branch block. Transthoracic 2-D color Doppler echocardiography (TTE) showed features of mild right ventricular volume overload and two different defects in the atrial septum with left-to-right shunts. The patient then was prepared for transcatheter closure of both defects with Amplatzer septal occluders. Defect closure was performed under general anesthesia and endotracheal intubation. After hemodynamic work-up was completed the right superior pulmonary vein was entered using a 6 Fr NIH catheter and angiography was performed in the fourchamber position. TEE was performed before, during and after the procedure to provide continuous multiplane imaging of the atrial septum. The upper defect was situated in the superior– anterior part of the interatrial septum with a margin of approximately 13 mm separating it from the entrance of the superior vena cava. The defect was measured to be 14 mm on TEE. Below this, in a more inferior–posterior plane, another moderate-sized ASD was seen, approximately 13 mm, separated from the higher ASD by septal tissue measuring 16 mm in length (Fig. 1). The inferior rim was 6.3 mm. Both ASD were crossed using a 6 Fr multipurpose catheter that was exchanged for super stiff Amplatzer wires (AGA, Golden Valley, MN, USA). Balloon sizing of posterior–inferior ASD was then performed and the stretched balloon diameter was 15 mm. It was decided to close this ASD using a 16 mm device. We then proceeded to perform the same procedure for the upper ASD. On balloon sizing this defect was 14 mm in size. Under fluoroscopic and echocardiographic guidance the left disk was deployed in the left atrium, the whole assembly was pulled back gently against the septum and then the right atrial disc was deployed. The same procedure was followed as for deploying the first device. At this point the device was not released. On TEE it was seen to be properly positioned with the anterior limbs straddling the aorta. We decided to use a 15 mm device to close this defect. Before release of devices from delivery cable there was superimposition of the second device over the first one due to centering characteristics of the attached devices (Fig. 2). With both devices in place, but not released, the TEE was reviewed. It was confirmed that the devices were not interfering with the mitral and tricuspid valves. After release of both devices there was no superimposition or contact of the devices with each other (Fig. 3). Repeat TEE showed proper positioning of the devices with small residual shunt through the lower margin of the inferior device. The patient was discharged 24 h after the procedure on evaluation with chest X-ray, electrocardiography and TTE. At the time of discharge no residual shunt or rhythm disturbance were observed. Acetylsalicylic acid was prescribed 3 mg/kg daily for 6 months. At 13 month follow up, TTE showed complete device occlusion of both ASD and without obstruction of superior or inferior vena cava, coronary sinus, or right upper pulmonary vein. Although during follow up no communication was observed on TTE, possible friction between the two devices could cause a new defect. Contrast echocardiography was performed 18 months after the procedure and no shunt was observed.