Objective Assessment of the effectiveness and stability of atrial septal defect closure using a mini thoracotomy and transvenous occlusion via the internal jugular vein guided by transesophageal echocardiography. Methods A total of 72 cases of ostium secundum ASD patients with deficient rim

who underwent mini-invasive closure under the guidance of TEE at the Department of Cardiac Surgery in Sichuan Provincial People's Hospital were enrolled. The subjects were classified into two groups by the different surgical closure paths: 26 cases in the mini-incision transthoracic device closure （transthoracic group） and 46 cases in the trans-jugular vein device closure （trans-jugular vein group）. TEE was used to screen suitable cases before operation. Under anesthesia

TEE re-evaluated the ASD defect status

including the maximum diameter and defect edge of ASD

selected the appropriate type of occluder and guided the monitoring placement. Immediately after occlusion

the blood flow status （i.e. residual shunt） of atrial septum and the status index of occluder （i.e. occluder diameter

occluder angles of the aortic edge and the SVC edge angle） were recorded. ECG and TTE were followed up 3 days

2 weeks

6 months and 12 months after operation to record related cardiac complications（i.e. occluder dislocation，valve injury）. Results ①Among 72 ASD patients with insufficient rim

69 cases were successfully closed

and 3 cases underwent second minimally invasive closure operation because of occluder dislocation.Small residual shunts were found in 2 cases after operation

1 case disappeared by TEE observation 3 days after the procedure

and 1 case disappeared after re-occlusion due to the dislocation of occluder. No cardiovascular complication occurred during the later follow-up. ②The occluder angles of the aortic edge and the superior vena cava （SVC） edge in the trans-jugular vein group were positively correlated with the maximal defect diameter. The occluder angles of the aortic edge were negatively correlated with the posterior rim

and the occluder angles of the SVC edge were negatively correlated with the atrioventricular valve rim in the trans-jugular vein group（P < 0.05）.The occluder angles of the aortic edge and the SVC edge were not correlated with the maximal defect diameter and each rim length in the transthoracic group （P > 0.05）. Conclusions TEE-guided minimally invasive surgical closure of ASD with insufficient edge is a feasible and effective procedure for ASD patients with deficient rims. TEE can accurately assess the defect state of ASD before operation and the state of occluder immediately after surgery. The occluder angles of the aortic edge can quantify the extent of the occluder riding across the aortic end

and the occluder angle of the SVC edge can reflect the changes of the anatomical position between the umbrella surface of the occluder and the superior vena cava after suture fixation. The above two ultrasonic indexes can be applied to the quantitative evaluation of the stability of the occluder after minimally invasive closure of ASD.