case_images: PMC10482038_01
case_images: 2D-TEE and 4D-TEE images revealed lipomatous hypertrophy of the atrial septum with atrial septal defect. (A) On 2D-TEE imaging, a single secundum ASD (arrow) and interatrial septum thickened to 20.7 mm in diameter were observed from 0  view. The septum with brightness features is characterized by the deposition of unencapsulated fat cells in the atrial septum. (B) 2D-TEE further documented a "dumbbell"-shaped involvement of the cephalad and caudal regions with sparing of the fossa ovalis (arrow) from 119  view. The interatrial septal fatty infiltration was demonstrated (*). (C) Color Doppler ultrasound of 2D-TEE showing a blood shunt from the left atrium to the right atrium (arrow) from 0  view. (D) Color Doppler ultrasound of 2D-TEE showing left-to-right shunt through ASD (arrow) from 119  view. (E) RT4D-TEE imaging reflected the whole ASD was surrounded by lipomatous hypertrophy of atrial septum (arrow) from 86  view. (F) Color Doppler ultrasound of RT4D-TEE showing blood flow of the ASD from the left to the right atrium (arrow). LA, left atrium; RA, right atrium.
case_images: fcvm-10-1245213-g001.jpg
case_images: PMC10482038_01_fcvm-10-1245213-g001.jpg
case_images: F1
case_images: The atrial septum presented with a brightness feature, a rare condition characterized by the deposition of unencapsulated fat cells in this area (Figures 1A,B). A two-dimensional color Doppler ultrasound evidenced a left-to-right shunt through ASD (Figures 1C,D). I). In addition, a color Doppler ultrasound of RT4D-TEE demonstrated the defect appeared foraminal in a location with a significant left-to-right shunt, suggesting a "foraminal" or "fossa" ASD (Figure 1F and Supplementary Movie II). The patient was asymptomatic postoperation and followed up in an outpatient clinic (Supplementary Figures 1A-C).
case_images: CCTA evaluating the LASH with ASD from different perspectives. (A) MPR image of CCTA found the loss of echogenicity between the left atrium and the right atrium (*). (B) MPR showed significant hypertrophy of the atrial septum (arrow), producing a dumbbell shape. (C) VR image indicated the thickened interatrial septum (arrow). (D) VR image of CCTA demonstrating the ASD and significant hypertrophy of atrial septum (arrow and *). MPR, multiplanar reconstruction; VR, volume rendering; LV, left ventricle; RV, right ventricle; RPA, right pulmonary artery; AAO, ascending aorta; DAO, descending aorta.
case_images: fcvm-10-1245213-g002.jpg
case_images: PMC10482038_01_fcvm-10-1245213-g002.jpg
case_images: F2
case_images: The CCTA images demonstrated a 9 mm x 13 mm defect on the atrial septum (Figures 2A,B). The volume rendering image of the CCTA scan showed a non-enhancing, smooth, well-marginated mass with an appearance similar to subcutaneous fat (Figures 2C,D).
case_images: Cardioangiography (CAG) images demonstrating the closure with a Pushi septal occluder device. (A) CAG image visualized the position of a Pushi septal occluder device during the operation (arrow). (B) CAG image revealed the position of the septal occluder device was good, and there was no shunt between the left atrium and the right atrium after occlusion (arrow).
case_images: fcvm-10-1245213-g003.jpg
case_images: PMC10482038_01_fcvm-10-1245213-g003.jpg
case_images: F3
case_images: ASD could be visualized by ICE from different angles. After balloon sizing, an 18 mm septal occluder device (Pushi, Shanghai) was successfully deployed (Figures 3A,B and Supplementary Movie IV).