Multi-hole Atrial Septal Defect: A diagnostic and therapeutic challenge

Abstract

Atrial Septal Defect (ASD) is the third most common congenital heart defect. There are three main types of ASD: ostium secundum, ostium primum and sinus venosus. There are few reports of multi-hole ostium secundum ASD, its incidence is estimated in 4-10%. A 56-year-old male attends to medical consultation due to three-month exertional dyspnea, palpitations and lower limb edema. Transthoracic echocardiogram reported dilatation of right cavities, ostium secundum ASD, severe tricuspid insufficiency, pulmonary hypertension, left ventricular ejection fraction of 60%. A cardiac examination with arrhythmic heart sounds, splitting of the second sound and systolic murmur in second right intercostal space. Electrocardiogram showed atrial fibrillation and incomplete right bundle branch block. The 2D and 3D transesophageal echocardiogram confirmed the presence of multi-hole ostium secundum ASD. Right heart catheterization showed mild pulmonary hypertension. Surgical management was suggested to correct the multi-hole ASD. The diagnosis of the ASD should always include a 3D transesophageal echocardiogram for a detailed assessment of the interatrial septum. Complex multi-hole ostium secundum ASD is a relative contraindication for closure with an Amplatzer device; therefore, a surgical treatment with opened exposure should be done.