Iatrogenic atrial septal defect caused by repeated catheter ablation.

Iatrogenic atrial septal defect is an issue after percutaneous interventions for structural heart disease. A 63-year-old man, who had previously received 5 catheter ablations for paroxysmal atrial fibrillation, was found to have an iatrogenic atrial septal defect that persisted after the fourth intervention. Approximately 4 years later, he suffered exertional dyspnea. Pulmonary hypertension was caused by a left-to-right shunt via a large iatrogenic atrial septal defect. We performed surgical closure and the symptom improved. The timing of treatment for persistent iatrogenic atrial septal defect is difficult to determine, but preferable before the appearance of right ventricular dysfunction or embolism.

The influence of iatrogenic atrial septal defect on the prognosis of patients with atrial fibrillation between cryoablation and radiofrequency ablation.

OBJECTIVE: The present study was to compare the incidence of septal defect (SD) in patients with atrial fibrillation (AF) who received radiofrequency ablation or cryoablation. METHODS: A total of 293 AF patients were performed with radiofrequency ablation and cryoablation. Cardiac ultrasonography was performed to calculate left atrial diameter (LAD), left atrial ejection fraction (LAEF%), strain rate (SR), left ventricular systolic (SRs), left ventricular diastolic (SRe), and left atrial systole (SRa) before surgery, 3 months and 1 year after surgery. The patients were followed up to observe statin and angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) medication, AF recurrence, 6-min walk test, stroke, any symptoms caused by arrhythmia, and re-hospitalization. RESULTS: The levels of LAD and SD were higher, while SRe and SRa were lower in the cryoablation group in the comparison with the radiofrequency ablation group after surgery (P<0.05). LAEF was lower in the cryoablation group than the radiofrequency ablation group after 3 months (P<0.05). After 1-year follow-up, no right-to-left shunt occurred in all patients with SD. The AF recurrence rate in SD group was higher than that in the normal group (P<0.05). The use of statin and the application of ACEI/ARB were protective factors, whereas hypertension, LAD, left atrial operation time, and surgical plan were risk factors. CONCLUSION: SD affects left atrial function and increases the risk of AF recurrence. Hypertension, LAD, and left atrial operation time are risk factors for SD, whereas statin and ACEI/ARB drugs can reduce SD.

Provisional Closure of an Iatrogenic Atrial Septal Defect for Shunt Reversal After Transcatheter Treatment of Tricuspid Regurgitation.

We present a patient with severe TR who underwent transcatheter tricuspid valve repair (TTVR) using the MitraClip system, with the development of LR shunt through an iatrogenic ASD. Provisional occlusion of ASD after TTVR should be considered in patients with residual LR shunt and iatrogenic ASD.

Iatrogenic atrial septal defect closure after transseptal mitral valve interventions: Indications and outcomes.

OBJECTIVES: Review indications and outcomes for transcatheter iatrogenic atrial septal defect (iASD) closure in patients undergoing MitraClip or transseptal (TS) mitral valve-in-valve/ring (ViV/ViR) procedures. BACKGROUND: Mitral valve transcatheter interventions require large-diameter TS sheaths that can result in iASDs that necessitate post-procedure transcatheter closure. Although the presence of iASD has been well-described, indications for closure and outcomes after TS mitral valve interventions have not been reported. METHODS: Patients undergoing MitraClip repair and ViV or ViR transcatheter mitral valve replacement (TMVR) from February 14, 2014, to January 16, 2018, were studied retrospectively in this single center study. RESULTS: Seventeen patients had iASD closure: 11 MitraClip and 6 TMVR (5 ViV, 1 ViR). Indications for iASD closure included large iASD (n = 7), large left-to-right shunt (n = 9), pulmonary hypertension (n = 8), large right-to-left shunt (n = 1), severe RV dysfunction (n = 2), thin/aneurysmal septum (n = 2), and mobile material on pacemaker leads (n = 2). Closures were performed without complications using Amplatzer septal occluders. At 30 days, 94% of subjects (n = 16) were alive with one patient deceased from unknown causes. There were no myocardial infarctions or strokes. At 12 months, follow-up was available for 14 of 17 patients, and 71% of patients (10/14) were alive. One patient died due to cardiac causes, two from noncardiac causes and one for unknown reasons. There was one myocardial infarction, one intraparenchymal hemorrhage, and no ischemic strokes. CONCLUSIONS: The most common reasons for iASD closure after TS MV procedures are: large ASD unlikely to spontaneously close, large left-to-right shunt, and pulmonary hypertension. Patients who required iASD closure had low 30-day mortality but higher one-year mortality potentially reflecting a population with substantial comorbidities.

Novel shunt modification with an adjustable stent-embedded "fenestrated" septal occluder in a patient with pulmonary hypertension.

A 60-year-old woman with progressive dyspnea and cyanosis, O2-dependent pulmonary hypertension despite optimal medical therapy and remote atrial septostomy presented with worsening cyanosis and right-to-left shunting. The creation of a "fenestrated" ASD closure device with the insertion of a peripheral stent through an AMPLATZER™ ASD closure device was deployed to minimize right to left shunting and allow for enlargement of the shunt if needed. This case demonstrates the benefit of diminishing a right to left shunt with a self-fabricated fenestrated AMPLATZER device to improve symptoms in pulmonary hypertension patients with a pre-existing ASD.

Closure of foramen ovale triggered by injury to tunnel surfaces of septum primum and secundum.

INTRODUCTION: We investigated the feasibility to proactively stimulate subsequent closure of a patent foramen ovale (PFO) by injuring (mechanical trauma or radiofrequency [RF] energy) the opposing surfaces of the septum primum (SP) and septum secundum (SS). METHODS: 1. Mechanical Injury: The interatrial septum of patients who underwent multiple left atrial (LA) ablations over 6 years, where a PFO was used for LA access, were examined. Patients whose PFO was absent during a later procedure were identified. Eleven patients with LA accessed via a PFO also underwent subsequent LA procedures. 2. Ablation: Ten patients undergoing ablation for drug-resistant atrial fibrillation (AF), who also had a PFO, were studied. RF delivery was extended along the upper SP. Transthoracic echocardiogram (TTE) bubble study was repeated after 3 months. RESULTS: 1. Mechanical Injury: Seven were male with a mean age of 58.3 ± 9.99. LA size was 42.73 ± 3.52 mm. The mean left ventricular ejection fraction (EF) was 62 ± 7.4%. During the repeat procedure, in 4 patients, the PFO could not be visualized and the fossa ovalis (FO) was punctured. The fourth patient had three procedures. During the second procedure the PFO was accessed, but with difficulty. During the third procedure, it was no longer present. All four patients had subsequent TTE showing no PFO. 2. Ablation: Seven were male with a mean age of 61.1 ± 9.8 years. The mean EF and LA diameters were 55 ± 5% and 4.4 ± 0.8 cm respectively. The mean RF time was 5.4 ± 2.2 min. At 3 months, 9 patients out of 10 showed no interatrial communication. CONCLUSION: Injury of tunnel surfaces of the SP and SS by mechanical trauma or ablation can fuse the foramen ovale.

Left atrial pressure is associated with iatrogenic atrial septal defect after mitral valve clip.

OBJECTIVES: Mitral valve (MV) clip procedure requires interatrial trans-septal puncture to access the left atrium (LA). Iatrogenic atrial septal defect (iASD) is not uncommon and may remain for a while. However, haemodynamic and echocardiographic determinants of persistent iASD are not well investigated. We sought to find haemodynamic and echocardiographic determinants of iASD after MV clip. METHODS: A total of 131 patients with grades 3 to 4+ mitral regurgitation who underwent MitraClip and completed invasive haemodynamic measurement, baseline, 1 month and approximately 12 months of transthoracic echocardiography (TTE) follow-up were retrospectively reviewed. RESULTS: TTE at 1 month showed persistent iASD in 57% (1M-iASD). Mean LA pressure after clip was significantly higher in patients with 1M-iASD than patients without 1M-iASD (17±6 mm Hg vs 15±5 mm Hg, p=0.01). Among patients with 1M-iASD, 24 patients (35%) had persistent iASD at 12 months (12M-iASD). Mean LA pressure after clip was significantly higher in patients with 12M-iASD than patients without 12M-iASD (19±6 mm Hg vs 16±6 mm Hg, p=0.04). Patients with 12M-iASD did not significantly differ from patients without 12M-iASD in terms of right heart enlargement, estimated systolic pulmonary artery pressure, New York Heart Association functional class and brain natriuretic peptide at 12 months. Logistic regression analysis, however, showed that mean LA pressure after clip was significantly associated with persistent iASD at 12 months in patients with 1M-iASD even after adjustment for cardiac index after clip and the prevalence of mitral regurgitation ≥3+ at 12 months (OR 1.10 per 1 mm Hg, 95% CI 1.01 to 1.21, p=0.04). CONCLUSIONS: Elevated LA pressure after MV clip was associated with persistent iASD.

Interatrial Septal Dissection Complicating a MitraClip Procedure.

Left atrial dissection is an exceedingly rare complication of cardiac surgery, with an incidence of 0.16%-0.84%. We report the first case of interatrial dissection and hematoma in association with the MitraClip procedure. Hemodynamically stable patients can be managed conservatively, with echocardiographic imaging, often with resolution of the dissection over the course of weeks. Our patient remained hemodynamically stable and asymptomatic post operation; at 1-month follow-up, echocardiogram showed resolution of the interatrial septal dissection.

The influence of iatrogenic interatrial septum leaks after left atrial appendage closure on cardiac function test results.

AIM: Left atrial appendage occlusion (LAAO) is a technique for preventing thromboembolism in patients with atrial fibrillation and a high risk of irreversible bleeding. In some patients, a spontaneous iatrogenic transseptal leak (ITL) remains after LAAO. The aim of this study was to assess the correlation between ITL incidence and the results of cardiac function tests in patients who underwent LAAO. METHODS AND RESULTS: LAOO was performed in 62 consecutive patients using the Amplatzer Amulet. Before and 3 months after LAA occlusion, the 6-min walking distance (6MWD) test was performed in all patients and oxygen consumption assessment (VO2max ) was performed in 32. All patients had transesophageal echocardiography before and 3 months after LAAO to assess ITL incidence. The patients were divided according to the presence and absence of ITL and the subgroup of patients with heart failure (HF) were further analyzed. In patients with HF and ITL, an increased VO2max (12.8 ± 5.2 vs 15.3 ± 4.7; P < 0.05) and 6MWD (350.1 ± 77.4 vs 414.3 ± 70.6; P < 0.05) was observed after the procedure comparing to the results before the procedure. The 6MWD was also significantly higher in the patients with transseptal leaks in comparison to those without (P < 0.0001). CONCLUSION: The presence of transseptal leaks after LAAO does not influence overall cardiac function test results. However, in patients with HF, there is an increase in oxygen consumption and 6MWD. These results indicate that ITLs in patients with HF decrease left atrial pressure, which is the key contributor to the symptoms of heart failure during physical activity.

Persistence of an iatrogenic atrial septal defect after a second-generation cryoballoon ablation of atrial fibrillation.

Persistent iatrogenic atrial septal defects (iASDs) can be observed after intervention requiring a left atria (LA) access, including pulmonary vein isolation (PVI) of atrial fibrillation (AF). We investigated the incidence of iASDs post-second-generation cryoballoon ablation and the pre-procedural predictors. Eighty-three paroxysmal AF patients underwent PVI using second-generation cryoballoons. The LA was accessed with single 15-Fr steerable sheaths following a radiofrequency transseptal puncture, and the iASD was evaluated with transthoracic echocardiography (TTE), a median of 9.3 (7.1-13.3) months post-procedure. All patients underwent pre-procedural contrast-enhanced multi-detector computed tomography (CT) to evaluate the LA and PV anatomy. iASDs were detected by TTE in 7 (8.4%) patients, a median of 15.5 (6.8-17.3) months post-procedure. Patients with iASDs had significantly larger LA volumes and smaller atrial septal angles, defined as the angle between the atrial septum and sagittal line on the horizontal section at the height of the fossa ovalis, which could be the transseptal puncture site measured on CT, and more likely hypertension than those without. Multivariate analyses revealed that the atrial septal angle was the sole predictor of iASDs [odds ratio 0.764, 95% confidence interval (CI) 0.624-0.935, p = 0.009], and the optimal cut-off value was 57.5° (sensitivity 85.7%, specificity 88.2%, 95% CI 0.873-0.995, p < 0.0001). Patients with iASDs were asymptomatic and had no adverse clinical events during a 17.7 (14.4-25.8) month median follow-up. iASDs were still detectable in 8.4% of patients a median of 15.5 months after the second-generation CB ablation, and the atrial septal angle might aid in predicting persistent iASDs.

Iatrogenic Atrial Septal Defect After Percutaneous Mitral Valve Repair With the MitraClip System.

This study examines the incidence of iatrogenic atrial septal defect (iASD) after the MitraClip procedure and its influence on echocardiographic and clinical outcomes. We examined 96 patients who underwent a successful MitraClip procedure and who also had baseline and 1-year postprocedure transthoracic echocardiograms. At 1-year follow-up, iASD were observed in 24% of cases. Compared with the patients without iASD, the patients with iASD had a larger right atrium and greater severity of tricuspid regurgitation (TR) at baseline. After the MitraClip procedure, mitral regurgitation lessened significantly in both groups. Although right atrial area and right ventricular diameters increased significantly in patients with iASD (25.3 ± 8.0 to 28.3 ± 9.5 cm2, 39.7 ± 7.1 to 42.2 ± 8.1 mm, p <0.05 for both comparisons), these variables did not change in patients without iASD. In addition, patients with iASD had worse TR at follow-up. The incidence of stroke was comparable between the 2 groups during 1-year follow-up (4.3% vs 4.1%). However, patients with iASD had a markedly higher re-hospitalization rate for heart failure (26% vs 2.7%, p <0.05). In conclusion, iASD occurred in 24% of patients who underwent the MitraClip therapy and the presence of iASD was associated with right-sided heart enlargement, worse TR, and a higher re-hospitalization rate for heart failure.

When to close iatrogenic atrial septal defect after percutaneous edge to edge repair of mitral valve regurgitation.

Transseptal puncture is increasingly utilized in electrophysiology and interventional cardiology. With a wide range of therapeutic indications, incidence of iatrogenic atrial septal defect (iASD) is likely to increase. However, the clinical and hemodynamic significance of iatrogenic atrial septal defect is not clear. We report a case of an 88year old woman with prior transcatheter aortic valve implantation and symptomatic severe degenerative mitral regurgitation. She developed persistent hypoxemia following MitraClip(®) procedure, requiring closure of iASD resulting in immediate recovery of hemodynamics. In here, we discuss the hemodynamic changes following percutaneous mitral valve repair and review the evidence supporting the closure of iatrogenic atrial septal defects.

Acute Traumatic Right to Left Cardiac Shunt.

Cardiac injuries after penetrating chest trauma are uncommon but potentially life threatening; these injuries can remain occult during the early stage because of the cardiac reserve of youthful physiology and may present at a later stage as the initial damage progresses or compensatory mechanisms fail. We report a case of unusual penetrating cardiac trauma from a posterior intercostal stab wound that affected both the interatrial septum and the tricuspid valve, leading to a stormy presentation as a result of the development of an acute right-to-left shunt followed by a successful surgical repair.