Trans-catheter closure of ASD and abnormal connection of left pulmonary vein to vertical vein: A case report.

Rationale: Partial anomalous pulmonary venous connection is a rare congenital anomaly in which one or more pulmonary veins are connected to the venous circulation leading to left to right heart shunt. Although correction of anomalous pulmonary venous connection is achieved through surgery, there are rare instances where the abnormal pulmonary vein has dual connection to both left atrium and the major systemic veins. Under these circumstances, catheter-based treatment might become a feasible option.

Patient Concerns: A 22-year-old female presented with exertional dyspnea, holo-systolic murmur in left sternal border, and fixed splitting of S2 in examination.

Diagnosis: The patient was diagnosed with secundum type atrial septal defect (ASD) and dual drainage of left upper pulmonary vein.

Interventions: The patient was candidate for device closure. Under TEE guidance, occluder devices were deployed in the upper part of vertical vein and subsequently in place of ASD.

Outcomes: Echocardiogram in the next day showed complete occlusion of flow through the vertical vein and ASD. Dual antiplatelet was prescribed on discharge. Follow-up echocardiography after 3 months showed obvious improvement in RV size. Due to suspicion for clot formation, TEE was done and thrombosis with approximate length of extension of 15 mm was detected back to the device. The patient is following for 5 years. Repeated TEE after 2 years did not show any change in the burden of clot.

Lessons: For comprehensive evaluation of patients with ASD, assessment of pulmonic veins is crucial and in the presence of a vertical vein, the dual drainage of pulmonic veins should be considered.