Transoesophageal echocardiography-guided balloon-assisted percutaneous closure of a large secundum atrial septal defect in a pregnant woman: a case report

Abstract

Background: According to the 2018 European Society of Cardiology guidelines, atrial septal defect (ASD) closure can be performed during pregnancy but is rarely indicated. In this case, we demonstrate the viability of percutaneous balloon-assisted ASD closure without fluoroscopy in a pregnant woman.

Case summary: A 23-year-old G₃P₂A₀ woman who was 20 weeks pregnant had primary complaints of breathlessness [New York Heart Association functional class (NYHA fc) III and IV] for 1 week prior to admission. A transthoracic echocardiography showed a dilatation of the right atrium (RA), a dilated right ventricle, a dilated main pulmonary artery (28.1 mm), and an oval-shaped 22 × 33 mm-sized secundum ASD with a left-to-right shunt. Despite optimal pharmacological treatment, the NYHA fc persisted. Under transoesophageal echocardiography monitoring, we introduced a 40 mm Cera™ ASD Occluder (Lifetech, China) via the delivery sheath. The device was deployed in the usual position; however, despite numerous placement adjustments, the left atrium disc kept getting dislodged to the RA and could not engage correctly. Therefore, we decided to use a balloon-assisted approach using a sizing balloon of No. 34 mm. The device was successfully positioned, and a wiggle test was conducted to make sure that the device remained stable. The patient was able to give birth to the child normally several months later.

Discussion: Despite the fact that pregnant women with ASD receive a very low dose of radiation, it is nevertheless recommended to avoid radiation because this demographic is particularly vulnerable to it. It is possible to treat a large ASD in pregnant women with a successful balloon-assisted approach.

Keywords: Atrial septal defect; Balloon-assisted; Case report; Non-fluoroscopy; Occluder; Pregnant.

Figure 1

Echocardiography features in pregnant atrial septal defect patients. A transthoracic echocardiography showed a dilatation of the right atrium, right ventricle, main pulmonary artery (28.1 mm), and an oval-shaped 22 × 33 mm-sized secundum atrial septal defect, with an L-to-R shunt. (A) A four-chamber view. (B) A parasternal short-axis view. Ao, aorta; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

Figure 2

Balloon-assisted non-fluoroscopy secundum atrial septal defect closure in pregnant women. (A) An oval-shaped 22 × 33 mm-sized secundum atrial septal defect with a left-to-right (L-to-R) shunt and transvalvular gradient of the tricuspid valve of 55 mmHg. (B) A transoesophageal echocardiography short-axis image indicates that the left atrial disc dislodged from the right atrium and could not engage correctly (green arrowhead). (C–E) A balloon-assisted approach using a sizing balloon of No. 34 mm (red arrowhead). After the device was finally stowed, a wiggle test was conducted to make sure that it remained stable (orange arrowhead), which was confirmed in a transoesophageal echocardiography bicaval view, (F) transthoracic echocardiography parasternal long-axis view (G), and apical four-chambered view (H).