Torn Atrial Septum during Transcatheter Closure

of Atrial Septal Defect Visualized by Real-Time ThreeDimensional Transesophageal Echocardiography

Yasufumi Kijima, MD, Manabu Taniguchi, MD, Teiji Akagi, MD, Koji Nakagawa, MD, Kengo Kusano, MD,
Hiroshi Ito, MD, and Shunji Sano, MD, Okayama, Japan

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 threedimensional 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. (J Am Soc Echocardiogr 2010;23:1222.e5-1222.e8.)
Keywords: Atrial septal defect, Complication, Interventional echocardiography, three-dimensional transesophageal echocardiography

In recent years, transcatheter closure of atrial septal defects (ASDs)

has become an accepted and reliable procedure.1 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.2-4
With the recent rapid developments in technology, real-time threedimensional (RT3D) transesophageal echocardiography (TEE) with
a new fully sampled matrix array transducer has become available.5
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.6,7 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

From the Department of Cardiovascular Medicine, Okayama University Graduate

School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan;
Division of Cardiac Care Unit, Okayama University Hospital, Okayama, Japan;
and Department of Cardiovascular Surgery, Okayama University Graduate
School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
Reprint requests: Manabu Taniguchi, MD, 2-5-1 Shikata-Cho, Okayama 7008558, Japan (E-mail: tmnb@md.okayama-u.ac.jp).
0894-7317/$36.00
Copyright 2010 by the American Society of Echocardiography.
doi:10.1016/j.echo.2010.04.004

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,
1222.e5

1222.e6 Kijima et al

but she refused. Three months

after discharge, 2D and RT3D
ASD = Atrial septal defects
TEE did not reveal flailed surrounding rims, and the torn rim
ASO = Amplatzer septal
seemed healed, resulting in a deoccluder
ficiency of the superoanterior
RT3D = Real-time threeand inferoposterior rims. The
dimensional
maximal diameter of the defect
was 30 mm (Figure 2).
TEE = Transesophageal
echocardiography
Therefore, transcatheter closure
of ASD was attempted again.
2D = Two-dimensional
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 patients 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).
Abbreviations

Journal of the American Society of Echocardiography

November 2010

DISCUSSION
Tearing of the rim is a rare complication in ASD closure and has been
reported in only 3 cases.2-4 In all these reports, tearing occurred
during balloon sizing. In our patient, the inferior rim was very thin,
and tearing occurred when the device and delivery sheath slipped
back into the right atrium despite gentle manipulation of the
catheter. Moreover, the rim was also torn during the second
attempt to deploy the device. Therefore, we abandoned the
procedure. In previous case reports, surgical intervention was
performed in 2 cases with this complication, and 1 was closed with
an ASO. Initially, the patient was not scheduled for defect closure
with an ASO after the first attempt for fear of device dislocation
because of the torn flailing rim. However, the torn rim appeared to
be healed 3 months after the first procedure. Therefore, we
attempted to close the defect with an ASO, and the procedure was
successful. In hindsight, because the thin rim tissue was torn, the
final ASO was deployed on the more solid rim tissue, resulting in
the stable placement of the ASO. Morphologic variations of ASDs
are common, and the surrounding rims include a thin floppy rim,

Figure 1 2D TEE (A, C) and RT3D TEE (B, D) images during transcatheter closure of ASD. A, B, The patient initially had a deficient
superoanterior rim. C, D, After the first attempt, 2D TEE showed a flailed inferoposterior rim (arrow). The rim was torn along with the
following attempt to deploy the device, and the maximal longitudinal diameter of the defect was measured at 30 mm. Ao, Aorta; LA,
left atrium; RA, right atrium; sup, superior; inf, inferior; ant, anterior; post, posterior.

Kijima et al 1222.e7

Journal of the American Society of Echocardiography

Volume 23 Number 11

Figure 2 RT3D TEE images 3 months after the first procedure.

a solid rim, an aneurismal rim, and a fenestrated rim.8 A detailed
evaluation of the surrounding rims, including these tissue morphologies, should be performed before the procedure using 2D TEE
with adequate temporal and spatial resolution.
In the present case, imaging during the procedure played a pivotal
role to evaluate the situation and determine the operative strategy. 2D
TEE and intracardiac echocardiography are mainly used for guidance
of transcatheter closure of ASDs. Although these 2D imaging modalities are sufficient to guide the procedure in cases with simple ASD
morphology, in cases with complicated ASD morphology, such as
multiple defects or our present case, it is often difficult to reconstruct
the spatial structure with the use of 2D images. In a previous case
report, the torn rim was confused with the intracardiac thrombus
by 2D TEE during the procedure.3
Previous studies have demonstrated the usefulness of 3D TEE
reconstruction in transcatheter closure of ASDs.9 Although 3D TEE
reconstruction demands a complex acquisition and lengthy data
analysis, RT3D TEE has become available in clinical practice, and it
has been used in the catheterization laboratory and intraoperative
setting.5-7 We reported previously that RT3D TEE was a feasible
and useful complementary option to 2D TEE for morphologic
evaluation of ASDs and guidance of transcatheter closure of
ASDs.7 In our case, RT3D TEE demonstrated the torn rim by easily
viewed en face images during the course of the procedure, which
allowed us to choose an appropriate therapeutic strategy. Thin
portions of the septum were visualized by 2D TEE. Areas of potential
drop-out may be related to areas of thin septum or septal fenestrations, which should be investigated carefully using 2D TEE (because
of its higher spatial resolution) and color Doppler ultrasound to determine whether true defects are present.

CONCLUSIONS
We have reported a case with a rare complication of a torn rim during
transcatheter closure of an ASD. RT3D TEE is useful for displaying the

Figure 3 2D TEE (A) and RT3D TEE (B) images after deployment
of ASO. The defect was successfully closed with a 32-mm ASO.
entire shape of the defect and its spatial relationship with its neighboring structures compared with conventional 2D echocardiography,
and 2D TEE with adequate spatial resolution shows detailed information of the rim tissue. By using both 2D and RT3D TEE, especially in
cases with complicated ASD morphology, both the echocardiologist
and interventionalist gain valuable information on the morphology of
the ASD before and after the procedure.
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