case_images: PMC11749782_01
case_images: Less than 5 microbubbles were found at the left-sided heart chambers (arrows) after effusion of the right-sided heart chambers showed by agitated saline contrast transthoracic echocardiography through the left median cubital vein.
case_images: medi-104-e41162-g001.jpg
case_images: PMC11749782_01_medi-104-e41162-g001.jpg
case_images: F1
case_images: Injection of agitated contrast agent via the left median cubital vein revealed less than 5 microbubbles in the left-sided heart chamber after more than 15 cardiac cycles (Fig. 1), which didn't indicate a significant right-to-left shunt.
case_images: Large number of microbubbles were found at the left-sided heart chambers simultaneously after the effusion of the right-sided heart chambers showed by agitated saline contrast transthoracic echocardiography through the right medial malleolus vein.
case_images: medi-104-e41162-g002.jpg
case_images: PMC11749782_01_medi-104-e41162-g002.jpg
case_images: F2
case_images: ASD, the injection site of saline microbubbles infusion was changed into the right medial malleolus vein. A large number of microbubbles were concurrently observed in the left atrium (LA) and the right atrium (Fig. 2).
case_images: Preoperative illustration demonstrates the inferior edge of the occluder leaned towards the right and straddled on the IVC orifice, drifting part of IVC blood flowing to the LA. ASD = atrial septal defect, IVC = inferior vena cava, LA = left atrium.
case_images: medi-104-e41162-g003.jpg
case_images: PMC11749782_01_medi-104-e41162-g003.jpg
case_images: F3
case_images: Furthermore, the inferior edge of the occluder leaned towards the right and straddled the IVC orifice, impeding partial IVC blood flow to the left atrium (Fig. 3).
case_images: PMC11749782_02
case_images: The apical 4-chamber view showed that <5 microbubbles were found at the left-sided heart chambers during 10 cardiac cycles after the effusion of the right-sided heart chambers by agitated saline contrast transthoracic echocardiography through left median cubital vein.
case_images: medi-104-e41162-g004.jpg
case_images: PMC11749782_02_medi-104-e41162-g004.jpg
case_images: F4
case_images: Saline contrast echocardiography conducted via the superior vena cava showed the presence of <5 microbubbles in the left-sided heart chambers during 10 cardiac cycles after the effusion of the right-sided heart chambers (Fig. 4).
case_images: The apical 4-chamber view showed that a large number of microbubbles were found at the left-sided heart chambers simultaneously after the effusion of the right-sided heart chambers by agitated saline contrast transthoracic echocardiography through right medial malleolus vein.
case_images: medi-104-e41162-g005.jpg
case_images: PMC11749782_02_medi-104-e41162-g005.jpg
case_images: F5
case_images: However, when conducted via the IVC, microbubbles were detected simultaneously in all 4 chambers (Fig. 5), confirming the flow of blood into the LA through the original ASD.
case_images: Preoperative illustration demonstrates the patch was connected with the Eustachian valve and straddled the opening of the IVC, reverting the blood flow oriented from the IVC to the LA. ASD = atrial septal defect, IVC = inferior vena cava, LA = left atrium.
case_images: medi-104-e41162-g006.jpg
case_images: PMC11749782_02_medi-104-e41162-g006.jpg
case_images: F6
case_images: During the operation, it was observed that the patch was connected to the Eustachian valve and straddled the opening of the IVC (Fig. 6).
case_images: Postoperative illustration demonstrates the closed ostium secundum ASD with the surgical patch and the modification of the iatrogenic right-to-left shunt. ASD = atrial septal defect, IVC = inferior vena cava.
case_images: medi-104-e41162-g007.jpg
case_images: PMC11749782_02_medi-104-e41162-g007.jpg
case_images: F7
case_images: The surgeon replaced the previous patch with an identical new one and reconnected the IVC to the right atrium (Fig. 7).