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The “Peanut Sign” is a useful tool to detect spiral atrial septal defects

Published online by Cambridge University Press:  06 November 2026

Jule Marie Dittmer Hein Open the ORCID record for Jule Marie Dittmer Hein [Opens in a new window] ,
Anja Tengler  and
Nikolaus Haas Open the ORCID record for Nikolaus Haas [Opens in a new window]
Jule Marie Dittmer Hein*
Affiliation:
Department of Paediatric Cardiology and Paediatric Intensive Care, Ludwig Maximillians University of Munich, Grossharden Clinic, Germany
Anja Tengler
Affiliation:
Department of Paediatric Cardiology and Paediatric Intensive Care, Ludwig Maximillians University of Munich, Grossharden Clinic, Germany
Nikolaus Haas
Affiliation:
Department of Paediatric Cardiology and Paediatric Intensive Care, Ludwig Maximillians University of Munich, Grossharden Clinic, Germany
*
Corresponding author: Jule Marie Dittmer Hein; Email: jule.dittmerhein@med.uni-muenchen.de
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Abstract

Spiral atrial septal defects may complicate transcatheter closure and increase the risk of device embolisation. We describe a 5-year-old boy with pulmonary stenosis and a secundum atrial septal defect in whom an initially implanted 9 mm device embolised. At repeat intervention, balloon sizing revealed a bilobed, peanut-shaped configuration with a double waist, suggestive of a spiral atrial septal defect. A 15 mm device was subsequently implanted, achieving stable closure. The “Peanut Sign” may serve as a useful marker for identifying spiral atrial septal defects and guiding appropriate device selection.

Keywords

device embolisationmal-attachment of septum primumspiral atrial septal defecttranscatheter closure

Information

Type
Case Report
Information
Cardiology in the Young , First View , pp. 1 - 3
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Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2026. Published by Cambridge University Press

Introduction

Anatomical variations of secundum atrial septal defects substantially influence the success of transcatheter closure. Incomplete fusion of the atrial septum creates a spectrum of interatrial communications, ranging from patent foramen ovale to large, irregularly shaped secundum atrial septal defects. Reference Roberson, Javois, Cui, Madronero, Cuneo and Muangmingsuk1 Echocardiographic assessment of septal morphology is therefore critical to optimise device selection and prevent complications. Reference Roberson, Javois, Cui, Madronero, Cuneo and Muangmingsuk1

Vettukattil et al. described an unusual “spiral” atrial septal defect configuration in which the septum primum is widely separated from the septum secundum, resulting in a double-layered atrial septum. Reference Vettukattil, Ahmed, Salmon, Mohun and Anderson2 This morphology—also referred to as malattachment of the septum primum—is uncommon but clinically important, as it has been associated with device embolisation and technical failure of transcatheter closure. Reference Roberson, Javois, Cui, Madronero, Cuneo and Muangmingsuk1,Reference Ostermayer, Srivastava and Doucette3

Case presentation

A 5-year-old boy was referred for evaluation of a heart murmur and exertional dyspnoea. Echocardiography revealed moderate valvular pulmonary stenosis (peak gradient 43 mmHg, mean 18 mmHg) and a secundum atrial septal defect measuring 6–8 mm by transoesophageal echocardiography, with apparently adequate rims.

Cardiac catheterisation was performed under moderate sedation. Pulmonary valvuloplasty was carried out with 16 and 18 mm balloons. Subsequent balloon sizing of the atrial septal defect yielded a stretched diameter of 8 mm. A 9 mm Occlutech® Figulla Flex II occluder was implanted. Transoesophageal echocardiography confirmed correct device alignment without residual shunt, and the wiggle manoeuvre indicated stable positioning (see Figure 1) .

On the first post-procedural day, routine transthoracic echocardiography revealed embolisation of the occluder into the aortic arch. The patient remained haemodynamically stable without neurological or respiratory compromise. Urgent percutaneous retrieval and re-closure were planned.

Through an arterial sheath, a pigtail catheter was advanced into the transverse arch to stabilise the embolised device. The sheath was upsized to a 10 F long sheath, and a snare successfully captured the proximal hub of the occluder. The device was withdrawn into the sheath and removed without complication. Ascending aortography confirmed the absence of vascular injury, dissection, or stenosis, and no femoral artery complications were observed.

The atrial septal defect was re-crossed, and balloon sizing was repeated using a 20 mm balloon. The balloon assumed a characteristic bilobed contour with two distinct waists measuring 14 and 15 mm, producing a “Peanut Sign” appearance (see Figure 2). This was interpreted as diagnostic of a spiral atrial septal defect. In retrospect, the same configuration had been visible, though overlooked, during the initial sizing. TEE corroborated the presence of overlapping septal structures. Guided by this finding, a 15 mm Occlutech® Figulla Flex II occluder was deployed under TEE guidance. Both septum primum and septum secundum were securely captured between the device discs, with no residual shunt (see Figure 2). The patient’s subsequent course was uneventful. He was discharged the following day, and follow-up at 6 months confirmed a stable device position without erosion, residual shunt, or embolisation.

Discussion

This case highlights the importance of recognising complex septal anatomy during transcatheter atrial septal defect closure. The key finding was the deformation of the sizing balloon into a bilobed configuration with two consecutive waists, consistent with compression between two distinct septal planes. We propose that this angiographic morphology—the “Peanut Sign”—is pathognomonic of a spiral atrial septal defect.

The spiral atrial septal defect, first described in detail by Roberson et al., Reference Roberson, Javois, Cui, Madronero, Cuneo and Muangmingsuk1 results from a wide separation of the septum primum and septum secundum.

These defects are prone to device embolisation if the occluder does not encompass both septal layers. Reference Ostermayer, Srivastava and Doucette3,Reference Alobaidan, Saleem, Abdo and Simpson4 In our patient, undersizing with a 9 mm device failed to trap the mal-attached septum primum, resulting in embolisation. Subsequent recognition of the “Peanut Sign” during balloon sizing prompted appropriate upsizing, leading to durable closure.

Previous reports support this strategy. Alobaidan et al. described a similar case in which an initially unstable device required replacement with a larger occluder to achieve secure anchoring of both septal components. Reference Alobaidan, Saleem, Abdo and Simpson4 Ostermayer et al. demonstrated that deficient rims in spiral atrial septal defects independently predict closure failure. Reference Ostermayer, Srivastava and Doucette3 Our experience is consistent with these observations and suggests that careful attention to balloon morphology may improve pre-implantation recognition of spiral atrial septal defects.

Although balloon sizing is primarily used to determine stretched defect diameter, our findings suggest it may also reveal valuable anatomical information. A bilobed balloon with a pair of adjacent waists should alert the operator to the possibility of a spiral atrial septal defect, prompting confirmation with echocardiography and consideration of an oversized occluder. This approach aligns with the principle that both septal components must be securely captured to avoid embolisation. Reference Alobaidan, Saleem, Abdo and Simpson4

Finally, this case also illustrates the safe management of device embolisation. Percutaneous retrieval with a large sheath and snare was effective and uncomplicated, allowing re-closure in the same session. The safety and efficacy of transcatheter atrial septal defect closure with occluder devices have been confirmed in large cohorts. In the IRFACODE registry, Occlutech® occluders achieved successful closure in more than 1,300 patients with excellent outcomes and low complication rates, and balloon sizing was shown to significantly reduce the risk of embolisation. Reference Haas, Soetemann and Ates5 Our case further demonstrates that even in complex anatomy such as a spiral atrial septal defect, reliable closure can be achieved when careful sizing guides device selection.

Conclusion

We report a paediatric case of spiral atrial septal defect in which the characteristic bilobed deformation of the sizing balloon with two consecutive waists—the “Peanut Sign”—proved to be a key diagnostic indicator. Recognition of this sign enabled correct anatomical interpretation, leading to the choice of a larger occluder, and facilitated successful percutaneous closure after an initial complication.

Clinicians performing atrial septal defect interventions should be aware that unusual balloon morphologies may signal complex septal anatomy such as spiral atrial septal defect. Recognition of the “Peanut Sign,” combined with thorough echocardiographic assessment, can guide appropriate device selection, prevent embolisation, and ensure durable closure.

Figure 1.

First attempt of transcatheter occluder implantation in a spiral atrial septal defect (ASD) with consecutive device embolisation. ( a ) Mid-oesophageal transesophageal echocardiography (TEE) view demonstrating a secundum ASD measuring approximately 8 mm. The anteroinferior septum primum (SP) is displaced posteriorly and leftward relative to the septum secundum (SS), creating a characteristic spiral ASDmorphology with an interatrial space (*). ( b ) Mid-oesophageal TEE view after initial device deployment. A 9 mm Figulla Flex II ASD occluder is well seated across the defect without residual shunt; both discs are firmly opposed to the septal rims, confirming satisfactory placement. ( c ) Fluoroscopic frame from the first balloon sizing attempt. In retrospect, the sizing balloon (stretched diameter ∼8–10 mm) shows a subtle bilobed contour, suggesting compression by two septal structures, consistent with a spiral ASD.

Medical images showing atrial septal defect and device deployment.

Figure 2.

Final transcatheter occluder implantation in a spiral atrial septal defect (ASD) with stable device positioning. ( a – b ) Fluoroscopic frame from the second balloon sizing. The 20 mm balloon is clearly pinched into two distinct waists (14 and 15 mm), confirming compression by separate septal structures. Recognition of this characteristic bilobed balloon contour or “Peanut Sign” should prompt suspicion of a spiral ASD and consideration of a larger occluder to capture both septal components. ( c ) Mid-oesophageal two-dimensional transesophageal echocardiography (TEE) after deployment of the 15 mm occluder. The device fully encompasses both septum primum and septum secundum, with no residual shunt on colour Doppler and no interference with adjacent structures.

Medical imaging of a heart procedure with fluoroscopic and echocardiographic views.

Acknowledgements

None.

Financial support

This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.

Competing interests

Nikolaus Haas is working as a scientific consultant for Occlutech®. The other authors have no conflict of interest relevant to this article to declare.

Ethical standard

The patient’s guardians provided informed consent for the publication of this case report.

References

Roberson, DA, Javois, AJ, Cui, W, Madronero, LF, Cuneo, BF, Muangmingsuk, S. Double atrial septum with persistent interatrial space: echocardiographic features of a rare atrial septal malformation. J Am Soc Echocardiog 2006; 19(9): 1175–1181.10.1016/j.echo.2006.04.001CrossRefGoogle ScholarPubMed
Vettukattil, JJ, Ahmed, Z, Salmon, AP, Mohun, T, Anderson, RH. Defects in the oval fossa: morphologic variations and impact on transcatheter closure. J Am Soc Echocardiog 2013; 26(2): 192–199.10.1016/j.echo.2012.10.019CrossRefGoogle ScholarPubMed
Ostermayer, SH, Srivastava, S, Doucette, JT et al. Malattached septum primum and deficient septal rim predict unsuccessful transcatheter closure of atrial communications. Catheter Cardiovasc Interv 2015; 86(7): 1195–1203.Google ScholarPubMed
Alobaidan, M, Saleem, A, Abdo, H, Simpson, J. Successful percutaneous closure of spiral atrial septal defect. Echo Res Pract 2015; 2(1): K7.10.1530/ERP-14-0101CrossRefGoogle ScholarPubMed
Haas, NA, Soetemann, DB, Ates, I et al. Closure of secundum atrial septal defects by using the occlutech occluder devices in more than 1300 patients: the IRFACODE project: a retrospective case series. Catheter Cardiovasc Interv 2016; 88(4): 571–581.Google Scholar
Figure 0

Figure 1. First attempt of transcatheter occluder implantation in a spiral atrial septal defect (ASD) with consecutive device embolisation. (a) Mid-oesophageal transesophageal echocardiography (TEE) view demonstrating a secundum ASD measuring approximately 8 mm. The anteroinferior septum primum (SP) is displaced posteriorly and leftward relative to the septum secundum (SS), creating a characteristic spiral ASDmorphology with an interatrial space (*). (b) Mid-oesophageal TEE view after initial device deployment. A 9 mm Figulla Flex II ASD occluder is well seated across the defect without residual shunt; both discs are firmly opposed to the septal rims, confirming satisfactory placement. (c) Fluoroscopic frame from the first balloon sizing attempt. In retrospect, the sizing balloon (stretched diameter ∼8–10 mm) shows a subtle bilobed contour, suggesting compression by two septal structures, consistent with a spiral ASD.

Figure 1

Figure 2. Final transcatheter occluder implantation in a spiral atrial septal defect (ASD) with stable device positioning. (a–b) Fluoroscopic frame from the second balloon sizing. The 20 mm balloon is clearly pinched into two distinct waists (14 and 15 mm), confirming compression by separate septal structures. Recognition of this characteristic bilobed balloon contour or “Peanut Sign” should prompt suspicion of a spiral ASD and consideration of a larger occluder to capture both septal components. (c) Mid-oesophageal two-dimensional transesophageal echocardiography (TEE) after deployment of the 15 mm occluder. The device fully encompasses both septum primum and septum secundum, with no residual shunt on colour Doppler and no interference with adjacent structures.