Comparison of Sizing Methods to Optimize Device Selection for Percutaneous Closure of Atrial Septal Defects.

Background and Aims: Accurate sizing of atrial septal defects (ASDs) is crucial for appropriate device selection during percutaneous transcatheter closure. Despite the availability of multiple imaging and sizing techniques, no consensus exists on the optimal method for determining device size. This study aimed to compare preprocedural ASD measurements obtained using different techniques with the final device waist diameter and to identify the measurement method demonstrating the most favorable agreement and reproducibility. Methods: This retrospective study included 149 pediatric patients (64 males, 85 females) who underwent percutaneous transcatheter ASD closure. Preprocedural defect sizing was performed using transthoracic echocardiography (TTE), balloon sizing, and transesophageal echocardiography (TEE). TEE measurements were obtained in the four-chamber, aortic, and bicaval views. In addition to individual diameters, the arithmetic mean, cube root-derived diameter, and maximal TEE-measured diameter were calculated and compared with the final device waist diameter. The final device waist diameter, measured fluoroscopically after deployment, was used as the reference comparator, reflecting operator-selected device sizing rather than true anatomical defect dimensions. Results: Among TEE-based measurements, both the cube root-derived diameter and the arithmetic mean of TEE measurements demonstrated high reproducibility and favorable agreement with the final device waist diameter, with only marginal numerical differences between the two methods. Bland-Altman analysis supported these findings by showing minimal bias and narrow limits of agreement, whereas TTE and balloon sizing demonstrated lower, though statistically significant, concordance with the final device waist diameter. Conclusion: Combining multiple measurement techniques improves agreement with the operator-selected device size during percutaneous ASD closure. While TTE alone may be sufficient in patients with simple defects and adequate acoustic windows, integrated approaches incorporating TEE and multiaxis measurements showed favorable agreement characteristics, particularly in anatomically heterogeneous defects or resource-limited settings. These findings should be interpreted as reflecting agreement with operator-selected device sizing rather than anatomical sizing accuracy, given the inherent circularity of using implanted device size as a reference standard.