Difficulties in percutaneous closure of atrial septal defect associated with situs solitus and dextrocardia

Background Percutaneous closure of secondum atrial septal defect (ASD II) in cases of dextrocardia and situs inversus has been reported in only very few cases in the literature. ASD II device closure in case of isolated dextrocardia with situs solitus, according to our knowledge, was never reported before. Objective To describe the unexpected problems encountered in decision making during the deployment of the device in a case of ASD-II with dextrocardia and situs solitus. Methods and results 19 months old girl, a case of situs solitus, dextrocardia, fenestrated ASD-II, moderate pulmonary hypertension since 4 months of age. Echocardiography showed situs solitus, dextrocardia, persistent left superior vena cava draining to coronary sinus and normal pulmonary veins. Fenestrated ASD-II (12 mm size in total) with left to right shunt. The total septal length was 28 mm. Volume loaded right atrium and right ventricle. The procedure During cardiac catheterization we found that in situs solitus with dextrocardia, the left atrium is more superior in relation to the right atrium and the septum seems to be more horizontally oriented. Therefore, when probing the left pulmonary veins, in the lateral view, it appeared much more anteriorly, than anticipated. Despite these difficulties we could deploy and release the device in stable and safe position. Post catheterization, X-Ray of the chest, showed device in good position. The post cath ECG was unchanged. Echocardiography 24 h after the procedure showed device in good position and sandwiching the rims well with no residual shunt. Conclusion Our case highlights the technical difficulties encountered during device closure of ASD II in a case with situs solitus associated with dextrocardia. It further shows that though it is doable, but attention should be paid to the abnormal orientation of the interatrial septum and guidance by hand injections as well as the pressure tracing are occasionally more important than TEE. To the best of our knowledge, this is the first report of a case of successful ASD device closure in a patient with situs solitus and dextrocardia.