\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Trans-jugular Transcutaneous Closure of Atrial Septal Defects with an
Adjustable Curved Sheath Under Echocardiography Guidance}



\author[1]{Hu xiaosong}%
\author[1]{Zhang yanwei}%
\author[1]{Yanan Li}%
\affil[1]{Central China Fuwai Hospital of Zhengzhou University}%


\vspace{-1em}



  
  \date{May 27, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
\textbf{Introduction and objectives:}Traditional transcatheter closure
of atrial septal defect (ASD) via the femoral vein carries risk of
radiation damage. Transcutaneous closure of ASD under echocardiography
guidance avoids radiation exposure and can be gradually applied. An
alternative is to transcutaneous closure of ASD trans-jugular with an
adjustable curved sheath under echocardiography guidance.
\textbf{Methods:} We retrospectively studied all cases of trans-jugular
transcutaneous closure of ASD with an adjustable curved sheath under
echocardiography guidance in the Heart Center of Henan Province People's
Hospital between 2016 and December 2022. \textbf{Results}: 156 patients
were included, 74 males and 82 females. Mean age was 6.9 \selectlanguage{ngerman}± 7.4 years and
weight 23.7 ± 14.6 kg. Mean sizes of the ASD and occluder were (9.7 ±
4.7) mm and (14.1 ± 5.7) mm. The mean operation time was (49.6 ± 29.2)
min. No complications such as atrioventricular block, reoperation, or
pericardial effusion occurred. There are 3 patients had a residual
shunt. All patients were followed-up for (38.7 ± 11.0)months. The 3
patients with residual shunt had self-closed at the 3-6-12months
follow-up. There was no complication at follow-up. \textbf{Conclusion:}
Trans-jugular transcutaneous closure of ASD with adjustable curved
sheath under echocardiography guidance is safe, effective and minimally
invasive.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{Title page}

\textbf{Title}

\textbf{Trans-jugular Transcutaneous Closure of Atrial Septal Defects
with an Adjustable Curved Sheath Under Echocardiography Guidance}

\textbf{Running title: Trans-jugular Closure Atrial Septal Defect}

\textbf{Authors:} Hu xiaosong\selectlanguage{ngerman}¹ ,MD, Zhang yanwei¹,MD,Li
yanan\textsuperscript{2},MD

\textbf{Author affiliation and address:}

1.Department of Structural Heart Disease, Fuwai Central China
Cardiovascular Hospital, Henan Provincial People´s Hospital, Central
China Fuwai Hospital of Zhengzhou University, People´s Hospital of
Zhengzhou University, Zhengzhou, Henan P.R.China

2.Department of Cardiovascular Ultrasound, Fuwai Central China
Cardiovascular Hospital, Henan Provincial People´s Hospital, Central
China Fuwai Hospital of Zhengzhou University, People´s Hospital of
Zhengzhou University, Zhengzhou, Henan P.R.China

No 1 Fuwai Road Zhengdong New District, Zhengzhou, Henan 450000, P.R.
China

\textbf{Corresponding author:}

Hu xiaosong, MD.

Email: docterhxs@163.com

Phone: +86 13838149225

Word count\selectlanguage{english}:3516

\textbf{{[}Abstract{]}}

\selectlanguage{english}\textbf{Introduction and objectives:} Traditional transcatheter closure
of atrial septal defect (ASD) via the femoral vein carries risk of
radiation damage. Transcutaneous closure of ASD under echocardiography
guidance avoids radiation exposure and can be gradually applied. An
alternative is to transcutaneous closure of ASD trans-jugular with an
adjustable curved sheath under echocardiography guidance.

\textbf{Methods:} We retrospectively studied all cases of trans-jugular
transcutaneous closure of ASD with an adjustable curved sheath under
echocardiography guidance in the Heart Center of Henan Province People's
Hospital between 2016 and December 2022.

\textbf{Results} : 156 patients were included, 74 males and 82 females.
Mean age was 6.9 +- 7.4 years and weight 23.7 +- 14.6 kg. Mean sizes of
the ASD and occluder were (9.7 +- 4.7) mm and (14.1 +- 5.7) mm. The mean
operation time was (49.6 +- 29.2) min. No complications such as
atrioventricular block, reoperation, or pericardial effusion occurred.
There are 3 patients had a residual shunt. All patients were followed-up
for (38.7 +- 11.0)months. The 3 patients with residual shunt had
self-closed at the 3-6-12months follow-up. There was no complication at
follow-up.

\textbf{Conclusion:} Trans-jugular transcutaneous closure of ASD with
adjustable curved sheath under echocardiography guidance is safe,
effective and minimally invasive.

\textbf{Key words:} Atrial Septal Defect (ASD), Adjustable Curved
Sheath, Transcutaneous, Echocardiography guidance

\textbf{Text}

\selectlanguage{english}\textbf{Abbreviation:} ASD: atrial septal defect, ICU: intensive care
unit, TEE: transesophageal echocardiography M+-SD: mean +- standard
deviation

\textbf{Introduction}

ASD is one of the most common congenital heart diseases, accounting for
about 10-20\% of all congenital heart diseases\textsuperscript{(1)}.
Traditional treatments---surgical extracorporeal circulation operation
and transcatheter intervention therapy---have advantages and
disadvantages. Transcatheter interventional therapy causes minor trauma
and provides rapid recovery, but the use of radiation can damage the
function of bone marrow, genitals, thyroid and other organs, and the use
of contrast medium has a risk of an allergic reaction or renal
insufficiency \textsuperscript{(2,3)}. The surgical extracorporeal
circulation operation method is mature and has more indications, but it
needs extracorporeal circulation, causes major trauma and unsightly
incision. In recent years, echocardiography guided transcutaneous
closure of ASD has gradually been applied. At present, the most common
approach for transcutaneous ASD occlusion under the guidance of
echocardiography is through femoral vein \textsuperscript{(4-9)}.
However, this approach requires a relatively long operation path and the
patient requires a long period of bedrest after femoral vein puncture.
The femoral vein is slender in young patients, which limits the
application of this technique. An alternative is to use the larger
dimeter jugular vein, increasing the suitability in younger
children\textsuperscript{(10-12)}. This approach also has shorter
operation path and so requires shorter delivery system
\textsuperscript{(11)}. Recent reports have highlighted the safe and
effective use of trans-jugular ultrasound-guided closure of ASD
\textsuperscript{(10-12)}. The use of an adjustable curved sheath for
transcutaneous occlusion by this approach means the head of the sheath
can be bent 0-90\textsuperscript{0} , easing entry to left atrium
through ASD under the guidance of transesophageal echocardiography
(TEE). Though trans-jugular transcutaneous closure of ASD with an
adjustable curved sheath under echocardiography guidance is few reports.
Since 2016, the Heart Center of Henan Province People's Hospital has
started to use an adjustable bent sheath to close ASD under
echocardiography guidance. The patients have been followed-up regularly,
and the procedure has achieved good results.

We report the safety and effectiveness of this method to provide more
information on this approach for clinicians interested in adopting the
method in suitable patients.

\textbf{Methods}

\textbf{Patients} : We retrospectively studied 156 cases (74 males and
82 females) who underwent trans-jugular transcutaneous closure of ASD
with an adjustable curved sheath under echocardiography guidance in the
Heart Center of Henan Province People's Hospital from January 2016 to
December 2022. All patients were diagnosed with ASD by echocardiography.
According to the guidelines for interventional treatment of congenital
heart disease\textsuperscript{(13)} . The inclusion criteria were as
follows: 1) secundum ASD; 2) increased right ventricular volume load; 3)
left-to-right shunt; 4) in addition to the absence or insufficiency of
the stump margin of atrial septum on the aortic side, the stump margin
of the superior and inferior vena cava, the stump margin opposite the
aortic root, and the stump margin of the mitral valve annulus should be
\selectlanguage{english}[?] 3 mm; 5) the maximum extension diameter of the atrial septum was
larger than the left atrial surface diameter of the selected occluder.
The exclusion criteria were as follows:1) primum ASD; 2)Severe pulmonary
hypertension; 3)age \textless{} 6 months; 4)the stump margin of the
superior and inferior vena cava, the stump margin opposite the aortic
root, and the stump margin of the mitral valve annulus should be
\textless{} 3 mm

All patient and family members were informed and agreed to performance
of this operation.

Intraoperative TEE was performed using GE Vivid EQ5 portable
ultrasonography (GE Healthcare Biosciences, Piscataway, NJ, USA). The
occluders and adjustable bent sheaths were produced by Shenzhen LifeTech
Scientific Corporation China. The conveying device included loading
sheaths and push cables (Figure 1).

\textbf{Operative Procedure}

All surgeons with more than 5 years of experience. According to the edge
length and toughness of the ASD, an occluder that was 2--6 mm larger
than the ASD diameter was selected. Heparin 1 mg/kg was routinely
administered before the operation with no postoperative protamine
neutralization. Routine postoperative with aspirin (3--5 mg/kg) for 6
months.

The ASD diameter and atrial septum length were measured in several views
(four-chamber view, parasternal short axis and double chamber section)
by TEE. The distance from the puncture point to the third intercostal on
the right side was measured, which was marked as the working distance.
The right internal jugular vein was punctured with a 16G puncture needle
using echo-guided, and the guidewire was placed through the puncture
needle into the right atrium (about working distance length), the
puncture needle was removed when the guidewire reached the superior vena
cava edge of the ASD through TEE inspection, and the guidewire was kept
in the right atrium. An adjustable bent sheath (Shenzhen LifeTech
Scientifc Corporation) was prepared, which was able to adjust the head
curvature from 0 to 90\textsuperscript{0} for ASD. (Figure 1) The
adjustable curved sheath (with inner core) entered the right atrium
through the jugular vein along the guidewire. When the length reached
the working distance, the guidewire and inner core were removed. Under
the guidance of TEE, the sheath slowly entered the middle of the ASD
parallel to the atrial septum. The manipulator was gently rotated
clockwise to gradually bend the head of the sheath make the sheath
passed through the ASD to the left atrium. The occluder with cable was
delivered into the left atrium though sheath with the help of TEE
detector.

The left side was released first, the cable was then pulled back to
release the right side. TEE was used to observe the occlude position.
This included whether it straddled the atrial septum, was parallel to
the atrial septum, encircled the aortic root, and the residual edge of
the atrial septum was located between the two plates. Also, whether
there was residual shunt, whether the occluder affected the activity of
the mitral valve, tricuspid valve, whether the occluder affected the
return of the pulmonary vein and the superior and inferior vena cava.
The occluder was released after a push-and-pull test if there was no
residual shunting, no effect on surrounding tissue, and no arrhythmia.
The manipulator was rotated to straighten the head of the adjustable
bent sheath, the sheath was pulled out, and pressure was applied to the
puncture point which was then bandaged. (Operative Procedure see Figure
2). The tracheal tube was removed in the operating room or intensive
care unit (ICU), and all patients returned to the general ward after
extubation.

\textbf{Follow up}

Follow-up was organized for all patients with clinical,
electrocardiogram (ECG), and echocardiographic assessment.
Complications, such as atrioventricular block, pericardial effusion,
thromboembolism, hematoma at puncture, before discharge, 1 month, 3
months, 6 months, and 12 months after the procedure were recorded.

\textbf{Statistical Analysis:}

SPSS21.0 software (IBM, Inc., Armonk, NY, USA) was used for statistical
analyses. The data were in normal distribution. The measurement data are
represented as means +- standard deviation and were analyzed using the
independent t-test. The enumeration data are represented as frequency
(percentage) and were analyzed using the X2 test.

\textbf{Results}

Patient characteristics

In total 156 patients were included, 74 males and 82 females. The mean
age was 6.9 +- 7.4 years and mean weight was 23.7 +- 14.6 kg. There were
114 cases with different levels of tricuspid regurgitation. The baseline
characteristics and perioperative information are shown in Table 1.

Perioperative results

The mean size of the ASD was 9.7 +- 4.7 mm, and the occluder was 14.1 +-
5.7 mm. The mean length of the superior vena cava rim, inferior vena
cava rim, aortic rim, posterior rim and atrioventricular valve rim were
8.5 +- 4.0 mm, 11.4 +- 4.3mm, 1.8 +- 2.2 mm, 9.3 +- 3.4 mm, and 9.1 +- 3.2
mm. Tricuspid regurgitation was 1.1 +- 1.0 cm\textsuperscript{2} and mean
pulmonary artery pressure was 30.9 +- 9.4 mmHg. The type of bent sheath
was 8.3 +- 1.6 F. The operation time\selectlanguage{english}(From puncture right internal
jugular vein to leaving the operating room\selectlanguage{english}) was 49.6 +- 29.2 min, the
ICU time was 6.9 +- 8.3 h, the ventilator time was 1.2 +- 1.5 h. No case
required blood transfusion. All patients were occluded successfully.
There are 3 patient had a small residual shunt of 1-2mm. The residual
shunt had disappeared at the 3-6-12month follow-up. There were no
complications such as atrioventricular block, pericardial effusion,
thromboembolism, hematoma at puncture site and arteriovenous fistula.

\textbf{Follow-up results}

The patients were followed up for 38.7+-11.0 months. No complications
(e.g., reoperation, atrioventricular block, occluder abscission,
thromboembolism) were observed.

\textbf{Discussion}

ASD is a common type of congenital heart defect in children and careful
selection of treatment is important for those who are unlikely to
self-heal. The aim of this study was to retrospectively analyze the
safety and effectiveness of trans-jugular transcutaneous closure of ASD
with an adjustable curved sheath under echocardiography guidance. We,
therefore, present the clinical data from 156 patients treated in our
department. The procedure was effective and safety.The first cases of
transcatheter closure ASD were described in1974 \textsuperscript{(14)}.
The traditional transcatheter treatment had little trauma, the patients
recovered quickly, they could get out of bed as soon as possible, return
to work, with short hospitalization time. This saved time and economic
cost; there was no surgical incision, a good cosmetic effect; no
bleeding, and complications related to blood transfusion were avoided.
Houeijeh reported their study of transcatheter closure of large ASD in
symptomatic children \textsuperscript{(15)}. This method has become
preferred for the treatment of secondary ASD \textsuperscript{(16,17)}.
However, there are some risks with the use of radiation and contrast
media may cause allergy and renal insufficiency \textsuperscript{(2,3)}.
Most of these treatments also need use expensive catheterization room or
hybrid operating room. In recent years, the use of echocardiography
instead of radiation for interventional therapy has become an important
method. Ewert showed that transcutaneous ASD occlusion guided by TEE
alone was feasible \textsuperscript{(4)}. Schubert reported 1605 cases
of transcutaneous ASD occlusion, which showed that TEE guided
transcutaneous ASD occlusion can achieve the same safety and
effectiveness as a radiation-guided method \textsuperscript{(5)}.
Seol\textsuperscript{(6)}, Sharfi\textsuperscript{(7)},
Lu\textsuperscript{(8)}, Snijder\textsuperscript{(9)}, and
Zhang\textsuperscript{(12)}, have all reported transcutaneous close ASD
under echocardiography guidance. At present, transcutaneous ASD
occlusion under echocardiography guidance is commonly through the
femoral vein \textsuperscript{(4-9)}. But this method has a long
operation path and needs long bedrest after femoral vein puncture.

We transcutaneous closure of ASD with an adjustable curved sheath under
echocardiography guidance though jugular vein which no need femoral vein
puncture or lower-limb braking. It has been suggested that this method
can reduce bedrest and significantly increase patient
comfort\textsuperscript{(10, 11)}. It may also reduce the risk of vein
thrombosis, and bleeding of puncture point may reduce because of a
relative decrease of jugular venous pressure after the operation. All
156 patients in this study had no bleeding at the point of puncture.
Especially for infants, the diameter of the jugular vein is larger than
that of the femoral vein \textsuperscript{(18)}. Transcutaneous
interventional therapy via the jugular vein can relax the restrictions
of the vascular conditions on the type of the transport sheath, which
makes it possible to treat young patients with relatively large ASD.

The operation time\selectlanguage{english}(From puncture right internal jugular vein to leaving
the operating room \selectlanguage{english})was 46.6 +-30.9 min in this study, The intracardiac
operation time is significantly less. A comparative analysis of the
duration of the procedure from when the operators started to use it
versus when they were considered experiente, could show differences. The
operation time of 56 patients in the first two years was 60.7 +-37.6 min,
and The operation time of the next 100 cases was significantly reduced
43.6 +-21.3 min\selectlanguage{english}(P\textless{}0.01\selectlanguage{english})

, and a range of 25 to 30 minutes\textsuperscript{(10.11)} in other
studies that used a similar approach. So, this method has a relatively
short operation time when compared to transcutaneous ASD occlusion under
the guidance of echocardiography through the femoral vein which Shubert
showed had a median procedure time of 50 min with a range of 20-170
min\textsuperscript{(5)}. The safety of the method was shown by no
complications occurring during the procedure of during follow-up. This
was also similar to previous studies with similar
methods\textsuperscript{(10, 11)}.

Our experience of trans-jugular transcutaneous closure of ASD with
adjustable curved sheath under echocardiography yielded the following
conclusions

1. The preoperative ultrasound diagnosis is clear, and the cooperation
of experienced ultrasound doctors is important. During the operation,
multiple sections of TEE are needed to evaluate the ASD size and each
edge situation. The operator needs to have certain ultrasound knowledge,
if the defect edge is tough, even if only 3mm closure can be tried; the
operation is easier under the guidance of a double chamber view. The
movement of the adjustable sheath into the left atrium should be gentle
to avoid damaging left atrium.

2. Select the appropriate occlude. We choose to use a double chamber
view, four chamber view and aortic short axis view to measure the
maximum diameter of the ASD, and take the average value as the ASD size.
We then added 2-6mm to the find the correct occluder size, if the edge
was tough, we chose a relatively small occluder, if the quality was
soft, we chose a relatively large occluder.

3. After the right disk of the occluder is released, due to a certain
angle traction at the head of the transport sheath, TEE shows the
occluder may be unnatural in shape; at this time, multiple views are
needed to check if the atrioventricular valve rim, inferior vena cava
rim, superior vena cava rim, posterior rim and aortic rim are ''stuck''
between the left and right disk of the occluder, the occluder can be
released. In general, the shape will become very natural after the
occluder is released.

4. The operation needs a team of doctors with experience in minimally
invasive procedures. If transcutaneous closure is unsuccessful, it can
then be directly changed to transthoracic minimally invasive closure or
cardiopulmonary bypass close ASD.

Our study has some limitations. The retrospective analysis method is
likely to have patient selection bias. More studies that directly
compare this method with other methods are needed to confirm that this
method can be recommended.

\textbf{Conclusion}

Trans-jugular transcutaneous closure of ASD with an adjustable curved
sheath under echocardiography guidance is safely, effective and
minimally invasive. With the development of science and technology and
research into the application of a degradable
occluder\textsuperscript{(19)}, its application will be more extensive.

\textbf{References}

1. Ding W, Su Z. Modern pediatric cardiac surgery. Shandong science \&
technology press, 2013\selectlanguage{english}:470---476\selectlanguage{english}.

2. Roguin A, Goldstein J, Bar O, et al. Brain and neck tumors among
physicians performing interventional procedures. Am. J. Cardiol., 2013,
111: 1368-72.

3. Tanaka A, Suzuki Y, Suzuki N, et al. Does N-acetylcysteine reduce the
incidence of contrast-induced nephropathy and clinical events in
patients undergoing primary angioplasty for acute myocardial infarction?
Intern. Med., 2011, 50: 673-7.

Zhu, Peng et al. ``Clinical evaluation of percutaneous and
intra-operative device closure of atrial septal defects under
transesophageal echocardiographic guidance: one center experience and
mid-term follow-up.''~\emph{Journal of cardiothoracic surgery} ~vol.
15,1 20. 14 Jan. 2020

Ewert P, Berger F, Daehnert I, et al. Transcatheter Closure of Atrial
Septal Defects Without Fluoroscopy: Feasibility of a New Method.
Circulation, 2000, 101(8):847-849.

6. Seol Jae-Hee,Kim Ah-Young,Jung Se-Yong et al. Intracardiac
Echocardiogram: Feasibility, Efficacy, and Safety for Guidance of
Transcatheter Multiple Atrial Septal Defects Closure.{[}J{]} .J Clin
Med, 2022, 11.

7. Sharfi MH, Al-Ata J, Al-Kouatli A, et al. Safety and efficacy of
transcatheter closure of atrial septal defect type II under
transthoracic echocardiographic guidance: A case control study. J Saudi
Heart Assoc, 2019, 31: 2-8.

8. Lu H, Chen L, Zhang G, et al. Clinical evaluation of percutaneous
atrial septal defect closer guided by transthoracic echocardiography
and/ or transesophageal echocardiography. Journal of Central South
University: Medical Sciences\selectlanguage{english},2015\selectlanguage{english},40(6):646-650. (in Chinese)

9. Snijder Roel J R,Renes Laura E,Swaans Martin J et al.
Microtransesophageal Echocardiographic Guidance during Percutaneous
Interatrial Septal Closure without General Anaesthesia.{[}J{]} .J Interv
Cardiol, 2020, 2020: 1462140.

10. Xie S, Fang J, Yang C, et al. Percutaneous trans-jugular vein
closure of atrial septal defect with steerable introducer under
echocardiographic guidance. J Thorac Dis. 2015,7(10):1850--1853.

11. Gao M, Li Z, Zhao Y, Wen P. Analysis of the therapeutic effect of
transesophageal echocardiography-guided percutaneous device closure of
atrial septal defects via the right internal jugular vein in children.
Echocardiography. 2019,36(7):1357--1363.

12. Zhang D, Pan X, Li P, et al. Tram-jugular transcatheter closure of
atrial septal defect solely under echocardiography guidance in infants.
Natl Med J China, 2019,99(6):458-461.

13. Interventional treatment of common congenital heart diseases: the
common view of Chinese medical experts. Part one: Interventional
treatment of atrial septal defect Journal of Interventional Radiology
2011,20(1):3-9\selectlanguage{english}.

14. King TD, Thompson SL, Steiner C, Mills NL. Secundum atrial septal
defect. Nonoperative closure during cardiac catheterization. JAMA
1976;235 (23):2506--9

15. Houeijeh A, Hascoet S, Bouvaist H, et al. Transcatheter closure of
large atrial septal defects (ASDs) in symptomatic children with
device/weight ratio\selectlanguage{english}[?]1.5. Int. J. Cardiol., 2018, 267: 84-87.

16. Rao PS. Role of Echocardiography in the Diagnosis and Interventional
Management of Atrial Septal Defects. Diagnostics (Basel). 2022 Jun
18;12(6):1494.

17. Villablanca PA, Briston DA, Rodes-Cabau J, et al. Treatment options
for the closure of secundum atrial septal defects: A systematic review
and meta-analysis. Int. J. Cardiol., 2017, 241: 149-155.

18. Butera G, Lovin N, Basile DP. How to deal with atrial septal defect
closure from right internal jugular vein: Role of venous-arterial
circuit for sizing and over-the-wire device implantation{[}J{]}.
Catheter Cardiovasc Interv\selectlanguage{english},2016,89(1):120-123\selectlanguage{english}.

19. Xing QS, Wu Q. Development of biodegradable occluders in device
closure treatment for congenital heart defects Chin J Thorac Cardiovase
Surg 2017, 33(6):380-384

\textbf{Figure legend}

Figure 1. Images of the device used to perform atrial septal defect
closure.

A:The conveying device includes loading sheaths, push cables, adjustable
bent sheath and inner core.

B:The adjustable bent sheath can adjust the head curvature from 0 to
90\textsuperscript{0}

Figure 2.Operative procedure images.

A: The central ASD.

B: The guidewire is placed through the superior venacava into the right
atrium.

C and D:The adjustable curved sheath enters the right atrium through the
guidewire, the manipulator is rotated and gently rotates the sheath. The
sheath passes through the ASD to the left atrium.

E and F:A steel cable is used to feed the occluder along the sheath,and
the occluder is delivered into the left atrium and the left side is
released.

G: push-and-pull test.

H: The occluder is released.

ASD: atrial septal defect.

\textbf{IRB information:} The study was approved by the Medical Ethics
Committee of the Henan Provinces of People's Hospital.

\textbf{Consent for publication:} The patient's next to kin has given
their consent for publication of this case report and any accompanying
images. Written informed consent for publication was obtained from the
patient's next to kin.

\textbf{Funding:} There was no funding supporting this study

\textbf{Competing interests:} The authors declare that they have no
competing interests.

\textbf{Authors' contributions:} Hu Xiaonsong conceived the idea for the
manuscript,revised the manuscript and acted as guarantors of the
manuscript. Ai feng,Zhang yanwei,Zheng jiayong drafted the manuscript
and operation. Li yanandrafted the manuscript and Echocardiography
Guidance. All authors read and approved the final manuscript.

\textbf{Hosted file}

\verb`figure.docx`  available at \url{https://authorea.com/users/618708/articles/643673-trans-jugular-transcutaneous-closure-of-atrial-septal-defects-with-an-adjustable-curved-sheath-under-echocardiography-guidance}

\textbf{Hosted file}

\verb`table.docx`  available at \url{https://authorea.com/users/618708/articles/643673-trans-jugular-transcutaneous-closure-of-atrial-septal-defects-with-an-adjustable-curved-sheath-under-echocardiography-guidance}

\selectlanguage{english}
\FloatBarrier
\end{document}

