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The potential clinical and physiological consequences of iatrogenic atrial septal defect (iASD) following MitraClip™-implantation are currently subject to controversial debates. In this setting, the presence of an iASD has been linked to worse clinical outcome and even increased mortality. In contrast, others have demonstrated that an iASD can lower left atrial pressures and the risk for pulmonary oedema.

Here we report the case of an 80-year-old patient presented with right ventricular (RV) heart failure, poor functional state (NYHA classes III–IV), weight gain, and ascites 3 months following MitraClip™-implantation. Echocardiography (TEE) showed preserved left ventricular (LV) function with mild mitral regurgitation following implantation of two Mitraclips™ with a transmitral gradient of 5 mmHg and an iASD with a broad left-to-right shunt.

Balancing the benefit of iASD closure for reduction in RV volume overload and the potential risk of increased left atrial and LV filling pressures, we performed balloon test occlusion with recording of pressure–volume–loops (PVL) using a conductance-catheter. Pressure–volume–loop analysis demonstrated shift of volume work away from the RV to the LV, with improved systemic cardiac output and no increase in LV filling pressures or RV systolic pressures. Subsequently, the iASD was closed percutaneously. Iatrogenic atrial septal defect closure was associated with dramatic clinical improvement within days (NYHA classes I–II).

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Cardiovascular Flashlights
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