Case Presentation
A 50-year-old male with no past medical history presented with shortness of breath in an outpatient clinic. He underwent transthoracic echocardiography (TTE) and was found to have left ventricle ejection fraction (LVEF) of 65%, moderate dilation of the RA, moderate to severe dilation of the RV, and possible ASD with positive bubble study. Subsequently, a month later he underwent left heart catheterization (LHC) and right heart catheterization (RHC) and was found to have nonobstructive coronary artery disease and significant left-to-right shunt at the atrial level. Immediately after the procedure, he underwent a transesophageal echocardiogram (TEE) which showed LVEF 60%, Secundum ASD measuring 36x24 millimeters in diameter with deficient retroaortic rim, and moderate enlargement of RA and RV. A month later patient was found to be an atrial flutter. A repeat TTE was performed before cardioversion and showed a large secundum ASD 35x25 millimeter with a left to right shunting.
In January 2021, the patient underwent evaluation for potential percutaneous closure with the device but the anatomy of ASD was such that there was no superior rim to land the device, and the patient was thought to be not a candidate for percutaneous closure. Afterwards, the patient was offered options for ASD closure through right thoracotomy as well as median sternotomy and he chose median sternotomy approach. In February of 2021, the patient underwent ASD repair. Intraoperatively, the interatrial septum was absent. There were no clefts in the mitral leaflet or tricuspid septal defect, but ASD extended to the aortic root. The large ASD was repaired with a CardioCel patch fixed in place with a running Prolene suture. Post repair TEE showed no residual shunt with saline contrast.
A month later in March 2021, the patient presented to the emergency department with heart palpitation. The patient was found to be in atrial flutter with a rapid ventricular response with HR of 135 and hypotension with blood pressure 70/40 mmHg. The patient was stabilized but remained in atrial flutter. TEE was done before cardioversion which showed LVEF 55%, Secundum ASD(see figure 1) measuring 12 x 14 millimeters with evidence of residual bidirectional shunting (figure 2, 3 and 4). It was thought that patient had degeneration of surgical bioprosthetic ASD repair patch. The patient was discharged with close outpatient follow-up and a plan to reevaluate in six months for a possibility of transcatheter closure of a residual ASD.