Discussion

Compared to surgical closure, transcatheter ASD closure is associated with fewer complications and faster hemodynamic improvement.^{Reference Eerola, Pihkala, Boldt, Mattila, Poutanen and Jokinen2} In the presence of an obstruction or interruption of the IVC, alternate vascular access is needed for the intervention. Transhepatic access has been used as an alternative venous access for the percutaneous ASD closure, but an increased risk of complications is possible.^{Reference Hussain, Strumpf, Ghandforoush, Jamal and Diethrich3} We chose the jugular vein on the left side as the patient had left superior vena cava. From this approach, we could not achieve stable wire and sheath position from the pulmonary veins because of the anatomy and stiffness of the wire, and the procedure became challenging due to dextrocardia. A single case has been reported so far in which device closure of the ASD was done in the presence of interrupted IVC and dextrocardia.^{Reference Oliveira, Moura, Almeida, Ribeiro and Nascimento4}

Multiple challenges were observed in this procedure. First, crossing the ASD due to abnormal orientation of the atrial septum, which needed an Amplatz curve catheter. Second, the extra stiff wire could not be placed in the pulmonary vein due to the tortuosity resulting in the inability to utilise pulmonary vein device deployment. Third, the device could not be aligned to the septum from the left atrium. The upper side of the left atrial disc would prolapse into the right atrium immediately after deployment leading to malalignment. The device could only be aligned and deployed after releasing the left atrial disc in the left ventricle inflow across the mitral valve leaflets. A similar approach has been taken before, but the device was opened only after pulling it back into the left atrium by Ozdemir E et al.^{Reference Ozdemir, Emren, Eren, Nazli and Tokac5}; but in our patient, we had to do it in the left ventricle inflow across the mitral valve to align it to the septum. Caution was taken to open it just across the leaflets and not entangle in the chordae. Other methods that could have been tried are the balloon-assisted technique and modification of the tip of the delivery sheath. A balloon positioned in the upper part of the defect may prevent the device from prolapsing, but it needs another jugular vein puncture in our patient. If the tip of the sheath is bevelled, it can retain the device in the left atrium, but it needs modification by the physician. Due to the lack of a proper transesophageal echo window, the procedure was done under transthoracic echo guidance. Lastly, the co-existing pulmonary stenosis needed the passage of a wire/balloon-tip catheter across the right ventricular outflow tract, which was difficult due to the extremely tortuous course. The pulmonary valve was doming with favourable anatomy, which had a high chance of success. ASD was a complex lesion, so device closure was attempted before the valvuloplasty.