Secundum Atrial Septal Defect Closure via the Transhepatic Approach in a Patient With Situs Ambiguus and a Left-Sided Inferior Vena Cava.

Secundum atrial septal defect (ASD) is the most common type of ASD. Symptoms including dyspnea on exertion usually manifest in the third and fourth decade of life. The transcatheter closure is the treatment of choice for secundum ASD. The transfemoral venous approach has been the mainstay. However, this approach can be challenging or impossible in patients with congenital absence or interruption of the inferior vena cava (IVC). The latter has been reported in patients with situs ambiguus and inversus. In this patient population, other forms of venous access such as the transjugular or transhepatic approach are used. We present a unique case of symptomatic secundum ASD in a patient who was incidentally found to have situs ambiguus with a left-sided intact IVC. An initial attempt at the ASD closure via the transfemoral approach was unsuccessful due to acute angulation. A repeat attempt was successful via the transhepatic approach with the guidance of real-time ultrasound, transesophageal echocardiogram, and the involvement of an interventional radiologist. The procedure was well tolerated without any complications. Repeat transthoracic echocardiogram with agitated saline the day after the procedure was negative for interatrial shunting.

Two cases of apical ballooning syndrome masking apical hypertrophic cardiomyopathy.

Apical akinesis and dilation in the absence of obstructive coronary artery disease is a typical feature of stress-induced (takotsubo) cardiomyopathy, whereas apical hypertrophy is seen in apical-variant hypertrophic cardiomyopathy. We report the cases of 2 patients who presented with takotsubo cardiomyopathy and were subsequently found to have apical-variant hypertrophic cardiomyopathy, after the apical ballooning from the takotsubo cardiomyopathy had resolved. The first patient, a 43-year-old woman with a history of alcohol abuse, presented with shortness of breath, electrocardiographic and echocardiographic features consistent with takotsubo cardiomyopathy, and no significant coronary artery disease. An echocardiogram 2 weeks later revealed a normal left ventricular ejection fraction and newly apparent apical hypertrophy. The 2nd patient, a 70-year-old woman with pancreatitis, presented with chest pain, apical akinesis, and a left ventricular ejection fraction of 0.39, consistent with takotsubo cardiomyopathy. One month later, her left ventricular ejection fraction was normal; however, hypertrophy of the left ventricular apex was newly noted. To our knowledge, these are the first reported cases in which apical-variant hypertrophic cardiomyopathy was masked by apical ballooning from stress-induced cardiomyopathy.