A Breath through the Window: Tailored Closure of an Atrial Septal Defect with a Fenestrated Device

Case report Managing arrhythmias, anticoagulation, and comorbidities during follow-up.Here, we report a case of ASD in an elderly male, in whom we used a fenestrated device for ASD closure, as complete closure of the defect is counterproductive, and shed light on the management of such patients who cannot undergo complete occlusion due to hemodynamic and medical reasons. Case DesCriptionA 57-year-old gentleman, hypertensive, presented to us with dyspnea, New York Heart Association (NYHA) class II for 3 months.Upon physical examination, his pulse was 85/min, regular, with introDuCtion Atrial septal defect (ASD) is one of the most common congenital heart diseases in the adult population.The estimated prevalence of ASD in adults is 0.88 per 1,000 patients. 1 In an unoperated case of ASD, by the fourth decade of life, the natural history leads to the onset of pulmonary hypertension, atrial arrhythmias, and right heart dysfunction. 2Due to its relatively less invasive approach, higher efficacy, lower rate of complications, and lower morbidity, closure by the transcatheter route has become the preferred treatment strategy for ostium secundum atrial septal defect (OS-ASD). 3 Older patients with significant comorbidities who are poor surgical candidates may benefit from this procedure.However, procedural risks are increased by long-standing atrial level shunts and agerelated cardiovascular and respiratory comorbidities.However, no age is considered a barrier for defect closure if it is hemodynamically significant because such closure is shown to enhance oxygen delivery, reduce right ventricular dimensions and pulmonary artery pressures, improve right heart function and functional status with lower morbidity and mortality.The following issues deserve special consideration during ASD closure, particularly in the elderly: 4 Changes in left ventricular (LV) compliance due to aging, agerelated risk factors, and the presence of other cardiac conditions affecting the left ventricle-diabetes mellitus, hypertension, chronic kidney disease, obesity, cardiomyopathies, and ischemic LV dysfunction. Occurrence of atrial arrhythmias, both before and following the ASD device closure. Presence of associated cardiac conditions, especially coronary artery disease (CAD). Presence of pulmonary arterial hypertension (PAH).