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

J INVASIVE CARDIOL 2019;31(10):E298-299.

Key words: color Doppler TEE, iatrogenic ASD, shunt reversal

A 73-year-old woman who had undergone transcatheter mitral valve repair (TMVR) and surgical valve replacement for mitral regurgitation due to short-term failure of the MitraClip presented with dyspnea (New York Heart Association class III). Transesophageal echocardiography (TEE) revealed severe tricuspid regurgitation (TR) (Figure 1A) and bidirectional shunt flow through a residual iatrogenic atrial septal defect (ASD) (Figures 1B-1D; Video 1), which was not evident at the surgery. Estimated systolic pulmonary arterial pressure (SPAP) was 48 mm Hg. The heart team planned a transcatheter tricuspid valve repair (TTVR) using the MitraClip XTR system (Abbott Vascular).

Guided by TEE, two clips were placed between the anterior and septal leaflet of the tricuspid valve, resulting in residual mild TR (Figure 1E). After clipping, TEE revealed complete decline of right-to-left shunt flow through the iatrogenic ASD, suggesting decrease of right atrial pressure due to correction of TR. A continuous left-to-right shunt flow was also observed (Figures 1F and 1G; Video 2), with an estimated volume of 34.8 mL and Qp/Qs of 1.6. Therefore, a 14 mm Amplatzer septal occluder (St. Jude Medical) was subsequently implanted (Figure 1H), resulting in a decrease of the estimated SPAP by 33 mm Hg. 

Significant TR is associated with poor prognosis in patients undergoing TMVR. In addition, iatrogenic ASD with a left-to-right shunt has been shown to be associated with increased risk of adverse events. This case demonstrates that provisional occlusion of ASD after TTVR should be considered in patients with residual left-to-right shunt and iatrogenic ASD.

View the Supplemental Video here.

From the Herzzentrum Bonn, Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Drs Sinning, Nickenig, and Werner report speaker honoraria and research grants from Medtronic, Edwards Lifesciences, Abbott Vascular, and Boston Scientific. The remaining authors report no conflicts of interest regarding the content herein. 

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted April 24, 2019.

Address for correspondence: Atsushi Sugiura, MD, Herzzentrum Bonn, Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Sigmund-Freud-Straße 25, 53127 Bonn, Germany. Email: sssugi@me.com