An 18-year-old girl was referred for an atrial septal defect (ASD) closure. Transthoracic echocardiography (TTE) revealed a small secundum ASD near the aortic root and another large posteroinferior-lying ASD (Figure 1). The measured Qp:Qs was 2.5:1. Intraoperative transesophageal echocardiography (TEE) also demonstrated findings similar to TTE (Figure 2A-C). Under standard cardiopulmonary bypass (CPB), the surgeon closed 2 defects using pericardial patches. After weaning from the first CPB, the systemic oxygen saturation suddenly decreased to 82%. Emergently performed intraoperative TEE revealed that the lower margin of patch closure was incorporated into the Eustachian valve, and the blood flow was diverted from the inferior vena cava (IVC) into the left atrium (LA) (Figure 2D, Movie 1). On the second CPB, the surgeon repositioned the patch and reconnected the IVC to the right atrium (Figure 2E and F, Movies 2 and 3). The second CPB was weaned, and the systemic oxygen saturation was 100%.
Figure 1. Transthoracic echocardiography. (A) The right ventricle is enlarged. (B) Two defects are noted. The smaller ASD (white asterisk) is near the aortic root, and the larger ASD (yellow asterisk) is located posteriorly with a deficient posterior rim of the interatrial septum. Color Doppler shows the left-to-right shunt. (C, D) The large ASD (yellow asterisk) shows a deficient rim near the opening of the RLPV. Color Doppler shows the blood flow from the RLPV to the RA.
Ao: aortic root, LA: left atrium, ASD: atrial septal defect, left atrium, LV: left ventricle, RA: right atrium, RLPV: right lower pulmonary vein, RV: right ventricle.
Figure 2. Intraoperative TEE. (A) Before CPB, a small ASD (white asterisk) is noted near the aortic root. (B) A large IVC type of sinus venosus ASD (yellow asterisk) with a deficient inferior rim is noted. The straddling of IVC is noted. The Eustachian valve is not prominent. (C) The straddling of IVC is confirmed by color Doppler. The flow returning from the IVC splits into 2 components, one entering the left atrium (orange arrow) and the other entering the right atrium (white arrow). (D) After the first CPB, the lower margin of the patch closure (yellow arrow) is incorporated into the Eustachian valve, and the IVC is diverted into the LA. (E, F) After the second CPB, the lower margin of the patch closure (blue arrow) is incorporated into the correct position, and the blood from the IVC is flowing into the RA (Movie 3).
Ao: aortic root, ASD: atrial septal defect, CPB: cardiopulmonary bypass, EV: Eustachian valve, IAS: interatrial septum, IVC: inferior vena cava, LA: left atrium, LV: left ventricle, RA: right atrium, RV: right ventricle, TEE: transesophageal echocardiography.
Iatrogenic diversion of the IVC is a rare complication after surgically closing a large posteroinferior-lying ASD.1) When an Eustachian valve is present, its rim may be mistaken for the ASD margin, and the IVC would be connected to the LA. Early recognition of iatrogenic diversion is important because it may cause fatal complications.2) Unfortunately, diagnoses of some cases are delayed until after the development of cyanosis or the features of Eisenmenger’s syndrome.3),4) Our case demonstrated the importance of intraoperative TEE for monitoring and guiding the surgical management of ASD, especially the IVC type of ASD with deficient rim near the IVC.5) The IVC type of ASD includes both IVC type of sinus venosus ASD and inferior extension of a secundum ASD. Both situations have the same risk of advertent diversion of the IVC into the LA because of the deficiency of the rim near the IVC.
The Institutional Review Board (IRB) of Ulsan University Hospital approved this study and the patient’s informed consent was waived (IRB number: UUH202201009-HE003).
Footnotes
Conflict of Interest: The authors have no financial conflicts of interest.
- Conceptualization: Kim SJ.
- Writing - original draft: Kim SJ.
- Writing - review & editing: Kim SJ, Ann SH, Park S.
SUPPLEMENTARY MATERIALS
Lower esophageal transesophageal echocardiography at 26° demonstrated that the lower margin of patch closure was incorporated into the Eustachian ridge, and the inferior vena cava was diverted into the left atrium. As a result, the right atrium collapsed.
Lower esophageal transesophageal echocardiography at 64° demonstrated that the lower margin of patch closure was incorporated into the correct position, and the inferior vena cava drained into the right atrium.
Lower esophageal transesophageal echocardiography with color Doppler at 64° demonstrated that blood from the inferior vena cava flowed into the right atrium.
References
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Associated Data
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Supplementary Materials
Lower esophageal transesophageal echocardiography at 26° demonstrated that the lower margin of patch closure was incorporated into the Eustachian ridge, and the inferior vena cava was diverted into the left atrium. As a result, the right atrium collapsed.
Lower esophageal transesophageal echocardiography at 64° demonstrated that the lower margin of patch closure was incorporated into the correct position, and the inferior vena cava drained into the right atrium.
Lower esophageal transesophageal echocardiography with color Doppler at 64° demonstrated that blood from the inferior vena cava flowed into the right atrium.