Author’s reply

Dear Sir, This is in response to the letter to the editor by Kardos M highlighting the significance of a dilated transverse sinus in the workup of atrial septal defect (ASD) device-related aortic wall erosion. The author has referenced an interesting case report enumerating this useful echocardiographic finding.[1] The transverse sinus is defined by the reflection of the pericardium as it folds around the great vessels and the left atrium. It is the transverse sinus area where the ASD device plays after deployment. During systole, the aorta expands, pushing against the fixed discs of the ASD device. This movement exerts a tension on the atrial free wall. This seesaw effect places repeated mechanical stress on the atrial wall, which may lead to perforation of the atrial wall and, in certain cases, may lead to perforation of the aortic wall.[2] This effect may be particularly pronounced in cases of aggressive oversizing of ASD devices. Therefore, tenting of the atrial free wall into the transverse sinus by the ASD device should prompt an evaluation for erosion and possible consideration for the surgical removal of the device. In the case we reported,[3] a careful review of the transesophageal echocardiography images and the cardiac computed tomography images were conducted. There was no evidence of a dilated transverse sinus or tenting of the atrial free wall into the transverse sinus by the ASD device. The patient continues to do well after receiving 6 months of anti-tubercular therapy. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.