Iatrogenic Atrial Septal Defect Research Articles

Congenital and acquired Lutembacher's syndrome presenting in two adults

The coexistence of atrial septal defect (ASD) and mitral stenosis (MS) is defined as Lutembacher's syndrome (LS). LS was originally defined as the development of MS in a patient having a congenital ASD diagnosis. However, as the percutaneous interventions for MS have become widespread, the persistence of associated iatrogenic ASDs caused has given rise to a different form of the disease. LS may occur as spontaneous or iatrogenic ASD concomitant with acquired MS; this form is known as “acquired LS.” This report presents two cases illustrating congenital LS and “acquired LS.”

Initial Slovenian experience with MitraClip therapy : Careful selection of patients is crucial for optimal outcome.

MitraClip is a percutaneous mitral repair technology increasingly used for high surgical risk patients with primary or secondary mitral regurgitation. We describe initialSlovenian experiencewith MitraClip and discuss the importance of identifying the suitable candidates for this procedure. We retrospectively analyzed the first 10 patients (mean age 75.6± 6.9 years, logistic Euroscore 28.4± 10.9%) with severe and moderate to severe mitral regurgitation (8secondary, 1primary and 1mixed etiology) who underwent a MitraClip procedure between January 2015 and February 2017. Acute reduction of mitral regurgitation was achieved in all but one patient (90%). There were no periprocedural mortalities and at short to mid-term follow-up (median 12months, interquartile range3-15 months). In eight patients improvement of functional class was observed at discharge. No functional improvement was achieved in apatient with advanced ischemic cardiomyopathy, and in apatient with degenerative mitral disease in whom the MitraClip procedure had failed necessitating mitral valve surgery. One patient experienced late leaflet detachment and was effectively managed with a second MitraClip procedure. There were two vascular complications at the access site and one percutaneous closure of an iatrogenic atrial septal defect. Our initial experiences with asmall number of patients indicate that percutaneous mitral repair with MitraClip is afeasible and safe method in high-risk patients. Special attention should be paid to careful patient selection including detailed echocardiographic evaluation of mitral valve anatomy, technical performance and final result, particularly at the beginning of the learning curve in order to reduce the rate of serious complications.

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.

P479Persistent iatrogenic atrial septal defect after percutaneous mitral valve repair using the MitraClip system: one step forward or two steps back

P479Persistent iatrogenic atrial septal defect after percutaneous mitral valve repair using the MitraClip system: one step forward or two steps back

P6101Incidence and persistence rates of iatrogenic atrial septal defects following left atrial appendage closure

P6101Incidence and persistence rates of iatrogenic atrial septal defects following left atrial appendage closure

Haemodynamic and functional consequences of the iatrogenic atrial septal defect following Mitraclip therapy.

Percutaneous MitraClip placement for treatment of severe mitral regurgitation in high surgical risk patients is a commonly performed procedure and requires a transseptal puncture to reach the left atrium. The resulting iatrogenic atrial septal defect (iASD) is not routinely closed, yet the haemodynamic and functional consequences of a persisting defect are not fully understood. Despite positive effects such as acute left atrial pressure relief, persisting iASDs are associated with negative consequences, namely significant bidirectional shunting and subsequent worse clinical outcome. Percutaneous closure of the iASD may therefore be desirable in selected cases. In this review we discuss the available literature on this matter.

Persistent iatrogenic atrial septal defects after pulmonary vein isolation: long-term follow-up with contrast transesophageal echocardiography.

Pulmonary vein isolation using cryoballoon ablation is an established approach to treating atrial fibrillation. The procedure involves insertion of a 15-Fr sheath into the left atrium across the interatrial septum. This creates an iatrogenic atrial septal defect, which may have important long-term clinical relevance, especially in younger patients. We sought to determine the long-term incidence of these defects and determine the direction of shunt using contrast transesophageal echocardiography. Individuals who had undergone a single pulmonary vein isolation procedure were invited to attend for transesophageal echocardiography (TOE). Patients who had undergone more than one procedure involving puncture of the interatrial septum were excluded. The interatrial septum was interrogated using two-dimensional imaging, color flow Doppler, and microbubble contrast study. A total of 27 patients were recruited with a median follow-up time of 553days from pulmonary vein isolation to TOE. Seven patients had persistent iatrogenic atrial septal defects with three demonstrating right to left shunt either at rest or with Valsalva. There were no reported adverse events during the study period. Persistent iatrogenic atrial septal defects are relatively common following cryoballoon ablation procedures. Right to left shunting can be observed using microbubble contrast in a subset of patients with iatrogenic atrial septal defect (iASD). Further studies that longitudinally assess shunt fraction, pulmonary artery pressure, and the incidence of paradoxical embolism are needed to better understand the clinical impacts of such defects.

176-16: Persistent iatrogenic atrial septal defect after pulmonary vein isolation for paroxysmal atrial fibrillation; a prospective single center study

176-16: Persistent iatrogenic atrial septal defect after pulmonary vein isolation for paroxysmal atrial fibrillation; a prospective single center study

Iatrogenic atrial septal defect after implantation of MitraClip device: treatment to whom and when?

AbstractSuccessful MitraClip implantation, although deteriorates mitral regurgitation, leads inevitably to the presence of an iatrogenic atrial septal defect, because of the large guiding catheter used. Half of them will close immediately after implantation of the device, in the next 6 months, but the remaining may persist. Although the primary effect of their existence, is associated with a relatively small left to right shunt, relieving left atrium from chronic elevated pressure, there is not enough data in the literature concerning progression in time, leading to the question, whether they should be closed or not. This is a case report of a patient with severe ischemic mitral regurgitation, treated by implantation of two MitraClip devices, with concomitant iatrogenic atrial septal defect and left to right shunt.

Invited Commentary

Invited Commentary

Quantitative Evaluation of Residual Atrial Septal Defect Following Transseptal Catheterization for Intracardiac Interventional Procedures

Iatrogenic residual atrial septal defect (rASD) following transseptal catheterization (TC) is a risk of many interventional procedures. In a recent issue of JACC: Cardiovascular Interventions , Schueler et al. [(1)][1] reported a 50% rASD persistence rate after transcatheter mitral valve repair

Iatrogenic atrial septal defect (iASD) after MitraClip system delivery: The key role of PaO2/FiO2 ratio in guiding post-procedural iASD closure

Iatrogenic atrial septal defect (iASD) after MitraClip system delivery: The key role of PaO2/FiO2 ratio in guiding post-procedural iASD closure

Reduction of Iatrogenic Atrial Septal Defects with an Anterior and Inferior Transseptal Puncture Site when Operating the Cryoballoon Ablation Catheter.

The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical transseptal puncture site is the fossa ovalis (FO) - the atrial septum's thinnest section. A potentially beneficial transseptal site, for the cryoballoon, is near the inferior limbus (IL). This study examines an alternative transseptal site near the IL, which may decrease the frequency of acute iatrogenic atrial septal defect (IASD). Also, the study evaluates the acute pulmonary vein isolation (PVI) success rate utilizing the IL location. 200 patients were evaluated by retrospective chart review for acute PVI success rate with an IL transseptal site. An additional 128 IL transseptal patients were compared to 45 FO transseptal patients by performing Doppler intracardiac echocardiography (ICE) post-ablation to assess transseptal flow after removal of the transseptal sheath. After sheath removal and by Doppler ICE imaging, 42 of 128 (33%) IL transseptal patients demonstrated acute transseptal flow, while 45 of 45 (100%) FO transseptal puncture patients had acute transseptal flow. The difference in acute transseptal flow detection between FO and IL sites was statistically significant (P <0.0001). Furthermore, 186 of 200 patients (with an IL transseptal puncture) did not need additional ablation(s) and had achieved an acute PVI by a "cryoballoon only" technique. An IL transseptal puncture site for cryoballoon AF ablations is an effective location to mediate PVI at all four PVs. Additionally, an IL transseptal location can lower the incidence of acute transseptal flow by Doppler ICE when compared to the FO. Potentially, the IL transseptal site may reduce later IASD complications post-cryoballoon procedures.

Reduction of Iatrogenic Atrial Septal Defects with an Anterior and Inferior Transseptal Puncture Site when Operating the Cryoballoon Ablation Catheter

The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical transseptal puncture site is the fossa ovalis (FO) – the atrial septum’s thinnest section. A potentially beneficial transseptal site, for the cryoballoon, is near the inferior limbus (IL). This study examines an alternative transseptal site near the IL, which may decrease the frequency of acute iatrogenic atrial septal defect (IASD). Also, the study evaluates the acute pulmonary vein isolation (PVI) success rate utilizing the IL location. 200 patients were evaluated by retrospective chart review for acute PVI success rate with an IL transseptal site. An additional 128 IL transseptal patients were compared to 45 FO transseptal patients by performing Doppler intracardiac echocardiography (ICE) post-ablation to assess transseptal flow after removal of the transseptal sheath. After sheath removal and by Doppler ICE imaging, 42 of 128 (33%) IL transseptal patients demonstrated acute transseptal flow, while 45 of 45 (100%) FO transseptal puncture patients had acute transseptal flow. The difference in acute transseptal flow detection between FO and IL sites was statistically significant (P <0.0001). Furthermore, 186 of 200 patients (with an IL transseptal puncture) did not need additional ablation(s) and had achieved an acute PVI by a “cryoballoon only” technique. An IL transseptal puncture site for cryoballoon AF ablations is an effective location to mediate PVI at all four PVs. Additionally, an IL transseptal location can lower the incidence of acute transseptal flow by Doppler ICE when compared to the FO. Potentially, the IL transseptal site may reduce later IASD complications post-cryoballoon procedures.

Iatrogenic Atrial Septal Defect After Cryoballoon Pulmonary Vein Isolation.

Iatrogenic Atrial Septal Defect After Cryoballoon Pulmonary Vein Isolation.

Current diagnostic and treatment strategies for Lutembacher syndrome: the pivotal role of echocardiography.

Lutembacher syndrome (LS) is a rare cardiac abnormality characterized by any combination of a congenital or iatrogenic atrial septal defect (ASD) and a congenital or acquired mitral stenosis (MS). Clinical features and hemodynamic effects of LS depend on the balance of effects of the MS and the ASD. Prognosis is influenced by several factors [pulmonary vascular resistance, right ventricle (RV) compliance, size of ASD and MS severity] but the occurrence of secondary pulmonary hypertension and congestive heart failure is commonly associated with poor outcome. Echocardiography remains the gold standard for diagnosis and evaluation of LS. Timely diagnosis is critical for modifying the natural course, by allowing patients to benefit from currently available percutaneous trans-catheter therapies with favorable effects on the outcomes. This article is a review of published literature on the current diagnostic and therapeutic modalities for LS, focusing on the pivotal role of echocardiography as the key diagnostic tool. Clinical suspicion of LS should prompt extensive investigation with non-invasive and where possible, invasive technics. Multicenter registers have a potential to assist the evaluation of long term outcomes of percutaneous trans-catheter therapies in patients with LS.

Trapped cardioverter-defibrillator lead after interventional closure of an iatrogenic atrial septal defect after catheter-based mitral valve repair with the MitraClip® system

Trapped cardioverter-defibrillator lead after interventional closure of an iatrogenic atrial septal defect after catheter-based mitral valve repair with the MitraClip® system

Persistence of iatrogenic atrial septal defect after interventional mitral valve repair with the MitraClip system: a note of caution.

The purpose of this study was to investigate the persistence rates of iatrogenic atrial septal defect (iASD) after interventional edge-to-edge repair with serial transesophageal echocardiography examinations and close clinical follow-up (FU). Transcatheter mitral valve repair (TMVR) with the MitraClip system (Abbott Vascular, Abbott Park, Illinois) is a therapeutic alternative to surgery in selected high-risk patients. Clip placement requires interatrial transseptal puncture and meticulous manipulation of the steerable sheath. The persistence of iASD after MitraClip procedures and its clinical relevance is unknown. A total of 66 patients (76.7% male, mean age 77.1 ± 7.9 years) with symptomatic mitral regurgitation (MR) at prohibitive surgical risk (EuroSCORE II 10.1 ± 6.1%) underwent MitraClip procedures and completed 6 months of FU. Transesophageal echocardiography after FU showed persistent iASD in 50% of cases. Patients with iASD did not significantly differ from patients without ASD concerning baseline characteristics, New York Heart Association functional class, severity of MR, and acute procedural success rates (p > 0.05). When comparing procedural details and hemodynamic measures between groups, MitraClip procedures took longer in patients without iASD (82.4 ± 39.7 min vs. 68.9 ± 45.5 min; p = 0.05), and echocardiography after FU showed less decrease of systolic pulmonary artery pressures in the iASD group (-1.6 ± 14.1 mm Hg vs. 9.3 ± 17.4 mm Hg; p = 0.02). Clinically, patients with iASD presented more often with New York Heart Association functional classes >II after FU (57% vs. 30%; p = 0.04), showed higher levels of N-terminal pro-brain natriuretic peptide (6,667.3 ± 7,363.9 ng/dl vs. 4,835.9 ± 6,681.7 ng/dl; p = 0.05), and had less improvement in 6-min walking distances (20.8 ± 107.4 m vs. 114.6 ± 116.4 m; p = 0.001). Patients with iASD showed higher death rates during 6 months (16.6% vs. 3.3%; p = 0.05). Cox regression analysis found that only persistence of iASD (p = 0.04) was associated with 6-month survival. The persistence rate of 50% iASD after MitraClip procedures is considerably high. Persistent interatrial shunting was associated with worse clinical outcomes and increased mortality. Further studies are warranted to investigate if persistent interatrial shunting is the mediator or marker of advanced disease in these patients.

Tissue Properties of the Fossa Ovalis as They Relate to Transseptal Punctures: A Translational Approach

This study focused on how catheter size affects transseptal puncture, what transseptal indication means, and whether the swine model is predictive for humans. Transseptal puncture is a common procedure that gains access to the left atrium, allowing percutaneous mitral valve repair, left atrial appendage closure, and left-sided ablations. The basic approach has not changed in many years; however, the frequency of transseptal punctures and the size of devices are increasing with emerging treatments. A broad range of devices (4 F to 18 F) were advanced through atrial septa of swine hearts; some devices were inserted in both swine and human hearts using 10 F catheters. Greater forces were required to puncture through the septa of human hearts compared to those of swine. Larger catheters used in swine hearts required greater force to advance them through the septa, causing greater dilation of tissue and sometimes tearing the floor of the fossa ovalis; analyses indicated an exponential increase in the size of the iatrogenic atrial septal defect. Specific tissue property testing of the septum primum showed that this tissue sheared at a lower exerted force in a superior to inferior direction. Results may provide physicians with important knowledge about what to expect when treating a possible iatrogenic atrial septal defect or help them understand the consequences of transseptal punctures. Comparative data between swine and human atrial septal tissue properties provide critical insights between the species and offer clinicians and device designers important information relative to differences in tissue behaviors.

Closure of Iatrogenic Atrial Septal Defect with Percutaneous Closure Device or Surgery: Which Technique is Safe?

An iatrogenic atrial septal defect (iASD) is a rare complication in cardiac surgery. A postoperative iASD was closed with a percutaneous closure device in a 37-year-old patient who had undergone mitral valve replacement via transseptal incision. Hemodynamic instability occurred in the 6th hour of the post-procedural period, and echocardiography imaging showed the closure device free in the left atrium. An emergent operation was performed on the patient, the device was retrieved, and the iASD was closed with a pericardial patch. In this study we evaluated the efficiency and safety of percutaneous closure devices, which have been used for iASDs.