Absent posteroinferior and anterosuperior atrial septal defect rims: Factors affecting nonsurgical closure of large secundum defects using the Amplatzer occluder

Using transesophageal echocardiography, we sought to determine the anatomic characteristics of the secundum. atrial septal defects (ASDs) that extend into the inferior sinus venosus and have no posteroinferior (PI) rim, to determine the factors related to potential closure with an Amplatzer occluder. We also sought to understand why large secundum. ASDs with a PI but without an anterosuperior (AS) rim may require special techniques to reorient the left atrial disk before deployment of the waist and right atrial disk. We measured the lengths of 5 separate rims of the circumferences of 76 secundum ASDs, including anteroinferior, AS, superior, posterosuperior, and PI rims. We also measured anteroposterior and superoinferior defect diameters, total septal lengths, and the ratios of defect diameter to total septal length. The atrial depth was measured at the axial angle of the delivery sheath in 5 defects with no AS rim for which special techniques were required to achieve successful closure of 76 secundum ASDs, 13 (17%) had no PI rim. Each defect extended from the fossa ovalis into the inferior sinus venosus. Compared with defects with a PI rim, the factors related to potential closure included 100% larger defect diameters, shorter posterosuperior rim lengths, -larger defect to total septal length ratios, and completely flat posterior atrial walls. When the AS rim was absent the factors related to the need for special techniques included diameters greater than or equal to 22 mm, atrial depth < the calculated Amplatzer occluder left atrial disk diameter, rigid wire/disk interface, and obligatory left atrial disk orientation more or less perpendicular to the atrial septal plane.