Successful percutaneous closure of an extremely large secundum atrial septal defect during pregnancy

Abstract

A 27-year-old Caucasian female at 20 weeks gestation presented with NYHA class II-III dyspnoea and lethargy. Prior to pregnancy, she reported progressive exercise intolerance over the previous year. During adolescence, she often struggled with exercise and physical activities. Her past medical history was only significant for infrequent episodic asthma.Since the onset of pregnancy, the patient experienced worsening dyspnoea on exertion. Screening blood tests including full blood examination and iron studies were unremarkable. Ultrasound of her foetus demonstrated normal foetal development at 20 weeks gestation. A transthoracic echocardiogram (TTE) was requested following the detection of a systolic murmur. This demonstrated a large atrial septal defect (ASD) associated with haemodynamically significant, continuous left-to-right inter-atrial shunting (Qp:Qs shunt ratio: 2.2) and significant right ventricular dilatation. Estimated pulmonary artery systolic pressure was normal.Transoesophageal echocardiogram (TOE) demonstrated an extremely large secundum type ASD (measuring 31, 38 and 30 mm at 0, 50 and 110 degrees respectively). Her right ventricle was moderate-to-severely dilated with low normal right ventricular ejection fraction (Figure 1).The ladies exercise tolerance further worsened at 25 weeks gestation with her walking distance limited to 20 meters walking on flat ground. Her severe symptomatic limitation precluded attempting an exercise test and a cardiac magnetic resonance imaging study was not performed as the ASD and right ventricular size and function were felt to be adequately assessed on TTE and TOE. The patient's case was then extensively discussed at a multi-disciplinary team meeting, involving obstetricians, cardiologists and cardiac surgeons. Conservative management of the ASD was strongly considered as the vast majority of ASDs are well tolerated during pregnancy. However, the decision was made to perform percutaneous closure in this case, given the size of the defect along with her progressive symptoms to NYHA class III. Open surgical management was also considered, however, the need for cardiopulmonary bypass, a sternotomy with the greater associated maternal and foetal risks mandated attempted closure using a percutaneous approach. The patient was also counselled regarding the risks of the procedure, including the requirement of Abstract: Atrial septal defects (ASDs) are one of the most of the most common acyanotic congenital heart lesions. Awareness of potential clinical presentations and complications during pregnancy is essential for those managing these patients. We report successful percutaneous closure of an extremely large secundum ASD, using the largest available percutaneous ASD closure device in a 27-year-old pregnant female. Large ASDs may have their initial clinical presentation and diagnosis during pregnancy. If indicated, percutaneous closure can be performed safely. Only a very small number of cases have previously reported this being performed safely during pregnancy.

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

“… 4 Nevertheless, serious safety concerns are raised by percutaneous device closure during pregnancy regarding radiation dose exposure to the mother and fetus. 1 , 5 , 6 In this case report, we demonstrate the viability of percutaneous balloon-assisted ASD closure without fluoroscopy in a pregnant woman.…”

“…Percutaneous device closure during pregnancy raises serious safety concerns regarding radiation dose exposure to the mother and the fetus. 1 , 5 The potential of percutaneous ASD closure without fluoroscopy was initially performed by Ewert et al . 7 Recently, many hospitals, including ours, have treated both newborns and adults using non-fluoroscopy–guided closure.…”

“…When severe pulmonary hypertension is present, there is a very significant risk of maternal (up to 50%) and fetal (up to 60%) mortality. 1 , 5 , 10 Invasive RHC is advised in accordance with the ESC 2018 guidelines if there is diagnostic uncertainty and to support significant therapeutic decisions. 4 However, no RHC procedure was performed prior to ASD closure in our patient.…”

“…Surgery can be performed to fix large ASD defects, but there is a substantial risk of maternal and fetal morbidity and mortality. 5 , 11 We, therefore, made the decision to carry out the closure percutaneously.…”

Management of Pregnant Women with Atrial Septal Defect and Pulmonary Hypertension: A Case Report

“…Progressive dyspnea and arrhythmias during pregnancy are possible in those with significant hemodynamic abnormalities. 3 Arrhythmias (2%), as well as thromboembolic consequences, can affect pregnant women with ASD. There is a very high maternal mortality rate (up to 50%) and a very high fetal mortality rate (up to 60%) when severe pulmonary hypertension is present alongside an ASD.…”