Journal of JCIC

We report the case of an asymptomatic 9-year-old girl who was successfully treated with percutaneous atrial septal defect (ASD) closure for multiple secundum defects. Pre-interventional transesophageal echocardiography showed three ostium secundum defects: a 15-mm main defect, a second 5-mm accessory defect with a strand separated from the main defect, and a third posteroinferior 7-mm defect with a 5-mm inter-defect distance. The atrioventricular and aortic rims measured <5 mm. The balloon-stretched diameter of the main defect was 16.5 mm, and that of the accessory defect was 7 mm. First, we attempted to deploy one device, Figulla® Flex II (FF II) (Occlutech GmbH, Jena, Germany) 19.5 mm, to occlude all three defects because of the short inter-defect distances and successful balloon interrogation. However, the device was not released because it encroached on the mitral valve. Deploying the smaller single device, FF II 18 mm, resulted not only in mitral valve insufficiency but also posterior residual shunt. Finally, we successfully deployed double overlapped devices, AMPLATZER® Cribriform Multifenestrated Septal Occluder (Abbott, St Paul, MN, USA) 18 mm for the posterior small defect and FF II 18 mm for the main defect, with no interference with the adjacent structures and residual shunt. By deploying the posterior device first, the anterior device for the main defect was moved away from the atrioventricular valve. Using a 2-device strategy for the closure of multiple ASDs can be an option to avoid encroachment of the device on the adjacent tissue.