Iatrogenic atrial septal defect

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T he number of left atrial transcatheter procedures performed via a transseptal (TS) approach has grown exponentially over the last 2 decades. 1 Persistent iatrogenic atrial septal defects (iASD) after structural TS interventions are not uncommon especially when larger TS sheaths are used (25%–50% with 22 Fr sheaths). 2–5 The optimal management strategy of postpro-cedural iASD is currently unknown. In the absence of societal recommendations with regards to iASD, the decision to close iASD and the timing of the closure pose a clinical dilemma to the interventionalist caring for these patients. We present 2 cases of iASD after TS transcatheter mitral valve repair/implantation and discuss the challenges in the management of such patients. Case Presentation Two patients were seen in consultation by the Mayo Clinic structural heart service: Ms K: An 81-year-old female admitted with decompen-sated biventricular heart failure. She had hypertension, atrial fibrillation, systolic heart failure (left ventricular ejection frac-tion=42%), a permanent pacemaker, and a history of mitral valve replacement with a 33 mm St Jude EPIC prosthesis and tricuspid valve repair. On examination, she was a slender woman (5′0″, 49 kg). Heart rate was 72 bpm, blood pressure was 129/83 mm Hg, and oxygen saturation was 92% on room air. Auscultation revealed a prominent thrill at the apex radi-ating across her chest and a loud 6/6 apical holosystolic mur-mur. Jugular veins were distended, and rales were heard at both lung bases. Moderate peripheral pitting edema was also noted. Echocardiography showed a degenerative mitral prosthesis with a flail leaflet and severe mitral regurgitation (MR). It also showed severe right ventricular enlargement with moderately depressed right ventricular function. No thrombus or evidence of endocarditis was present. The heart team evaluation con-cluded that the patient was at high risk for redo mitral valve replacement (Society of Thoracic Surgeons [STS] score=10%). She then underwent a successful antegrade TS mitral valve in valve implantation with a 29-mm Sapien S3 valve. To facili-tate delivery of the S3 valve, the septum was dilated with a 15 mm Z-Med Balloon (B. Braun Inc, Melsungen, Germany; Figure 1A). After the procedure, the left atrial V wave decreased from 51 to 26 mm Hg (Figure 1D), and there was no residual MR. However, there was a residual atrial septal defect measur-ing 7×5 mm by transesophageal echocardiography (TEE) with a predominant left to right shunt (Figure 1B and 1C). Mr J: An active 89-year-old male who was evaluated in the outpatient setting for worsening dyspnea. He has history of hypertension, remote deep venous thrombosis, anemia, and chronic kidney disease stage 3 (estimated glomerular fil-tration rate=31 mL/min per 1.73 m2). On examination, the patient was obese (5′5″, 103 kg), had bradycardic (49 bpm), and had a normal blood pressure 126/78 mm Hg. There was a 4/6 holosystolic apical murmur. Echocardiography docu-mented normal left ventricular ejection fraction of 62% and a flail mitral valve posterior leaflet with severe MR. The right ventricle was mildly dilated with mildly reduced sys-tolic function. Because of his age and renal insufficiency, he was not deemed to be a candidate for mitral valve surgery. He underwent a successful transcatheter mitral valve repair (TMVR) with one MitraClip (Abbott Vascular, Santa Clara, CA). After the procedure, the MR decreased from severe to mild–moderate, and the left atrial V wave decreased from 60 to 40 mm Hg (Figure 2C). A small residual atrial septal defect measuring 3×4 mm with left to right shunt was noted (Figure 2A and 2B).




Ibarra-Pérez, C. (1973). Iatrogenic atrial septal defect. American Heart Journal. https://doi.org/10.1016/0002-8703(73)90441-9

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