Transjugular closure of a two-hole atrial septal defect in a child with iliac vein thrombosis
A 4-year-old girl, who weighted 13 kg, presented to our department for a scheduled follow-up for the transcatheter closure of a multiple secundum ASD. She also had a history of a transcatheter closure of a large patent ductus arteriosus at the age of 10 months, because of congestive heart failure. A transthoracic echocardiographic examination revealed two atrial septal defects measuring 12 and 4 mm, respectively, thatwere 5 mm apart. The total septum was 32 mm in length and had adequate surrounding rims []. In addition, a dilated right ventricle and tricuspid valve regurgitation were present, and no remarkable findings were observed in the other investigations.\nCardiac catheterization was performed under general anesthesia using transesophageal echocardiography control. We originally intended to place a 5-French (Fr) sheath in the right femoral vein and the right femoral artery for hemodynamic measurements and monitoring. However, we could not pass the guidewire into the inferior vena cava. Manual contrast injection was performed in the femoral vein, and an obstruction in the inferior vena cava was observed and identified as a thrombus. Catheterization was continued by using the right internal jugular venous access with a 5 Fr sheath. Heparin 100 units per kilogram of body weight was administered, and a 5 Fr Judkins right catheter with a hydrophilic guidewire was introduced, under transesophageal echocardiographic control through the larger defect into the left atrium and the left lower pulmonary vein instead of the left upper pulmonary vein. A manually curved, stiff exchange guidewire then replaced the catheter in that position, over which a 7F long sheath and a 16 mm Amplatzer septal occluder (St. Jude Medical, Inc.; Plymouth, MN, USA) device were glided into the left atrium. The left and right device discs were opened sequentially under fluoroscopic and transesophageal echocardiographic guidance, and a successful deployment of the device was accomplished after several and repeated trials, aiming for an ideal device orientation []. Transesophageal echocardiography revealed no residual shunts, normal atrioventricular valve function, and normal superior and inferior vena cava blood flow. The next day, a transthoracic echocardiographic examination was normal. Aspirin therapy was started with a six-month course, and a follow-up was planned for the patient. The coagulation profile tests were normal, and the patient was discharged the next day.