case_images: PMC10243662_01
case_images: The large atrial septal defect measured 43 mm using the stop-flow technique on a sizing balloon interrogation even though no waist was noted. Creation of waist between LA and RA was avoided to prevent a tear of the small posteroinferior margin. A parallel catheter placed in the LUPV showed elevation of LA pressure from 7 mmHg to 30 mmHg. LA: Left atrium, RA: Right atrium, LUPV: Left upper pulmonary vein
case_images: APC-16-52-g001.jpg
case_images: PMC10243662_01_APC-16-52-g001.jpg
case_images: apc_126_22-f001
case_images: When the stop-flow size of ASD measured 43 mm on balloon interrogation, the left atrial pressure measured with a catheter across the defect into the left upper pulmonary vein increased to 30 mmHg with "v" waves of 55 mmHg indicating a restrictive LV physiology [Figure 1].
case_images: The large 16F delivery sheath entangled with the RV lead (a). Its anterior relation was recognized on a lateral view (b) and the sheath was repositioned posteriorly (c). This maneuver prevented an interaction between the sheath and the lead (d). The more superiorly located RA lead did not cause any interference. RV: Right ventricular, RA: Right atrial
case_images: APC-16-52-g002.jpg
case_images: PMC10243662_01_APC-16-52-g002.jpg
case_images: apc_126_22-f002
case_images: ASD entangled the leads. After identifying the sheath to be anterior to the leads on a lateral view, the sheath was withdrawn and positioned posterior to the leads, preventing an interaction between the sheath and the lead [Figure 2].
case_images: Balloon-assisted technique (a) was utilized for deploying the LA disc followed by the RA disc (b). Final position of the device after withdrawal of the balloon was shown in (c). LA: Left atrium, RA: Right atrium
case_images: APC-16-52-g003.jpg
case_images: PMC10243662_01_APC-16-52-g003.jpg
case_images: apc_126_22-f003
case_images: The LV end-diastolic pressures increased to 12 mmHg after the fenestrated device release, deployed using balloon-assisted technique [Figure 3].
case_images: Transesophageal echocardiogram after 4 years (a) showed the fenestration (arrow), with color flows (b) from the LA to the RA. Three-dimensional echocardiogram (c) showed the fenestration in the left atrial enface view. LA: Left atrium, RA: Right atrium
case_images: APC-16-52-g004.jpg
case_images: PMC10243662_01_APC-16-52-g004.jpg
case_images: apc_126_22-f004
case_images: A recent echocardiogram showed stable device position, normal pulmonary artery pressures, and a patent fenestration with left-to-right flows [Figure 4].
case_images: Multiplanar reformatted computed tomographic images in modified sagittal (a), axial (b), and coronal (c) views demonstrated good remodeling of the RA. The device waist measured 46 mm in the coronal plane and fenestration measured 7 mm. RA: Right atrium
case_images: APC-16-52-g005.jpg
case_images: PMC10243662_01_APC-16-52-g005.jpg
case_images: apc_126_22-f005
case_images: The device waist measured 46 mm and the left atrial disc measured 62 mm [Figure 5].