• Hanwen Zhang, Qianqian Liu, Hong Meng, and Changming Xiong.
• Department of Center for Pulmonary Vascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
• Medicine (Baltimore). 2025 Jan 17; 104 (3): e41162e41162.

RationaleThe transcatheter closure and atrioseptopexy are the main treatment methods for atrial septal defect (ASD). However, persistent hypoxemia due to iatrogenic diversion of inferior vena cava (IVC) to the left atrium (LA) is reported as a rare complication after ASD closure. Contrast echocardiology is a reliable and powerful tool to detect iatrogenic diversion and identify the etiology accurately.Patient ConcernsWe reported 2 patients (a 11-year-old boy [Patient 1] and a 39-year-old female [Patient 2]) with persistent hypoxemia and exertional dyspnea after ASD transcatheter closure and robotic atrioseptopexy, respectively.DiagnosesContrast echocardiography confirmed the presence of a right-to-left shunt at the atrial level which was presented only in femoral venous contrast injection instead of upper extremity venous contrast injection.Interventions And OutcomesSubsequent surgical exploration found that the occluder straddling the entry of IVC and the fibrous membrane proliferating along the lower edge of the occlude in the first patient, and the patch improperly linked to the Eustachian valve in the second patient. The misoperation led to IVC partially draining into LA. After the surgeries, both of them had their hypoxic symptoms relieved.LessonsPersistent unexplained hypoxemia after ASD closure might be considered to result from a right-to-left shunt. An iatrogenic right-to-left shunt flow from the IVC to the LA was usually caused by the misplaced interatrial occluder or patch. Transthoracic agitated saline contrast echocardiography via combined peripheral venous access has the well-performed capability to hint some insidious right-to-left shunts and guides clinical therapy as soon as possible.Copyright © 2025 the Author(s). Published by Wolters Kluwer Health, Inc.

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