Valvular heart disease
Echocardiographic Evaluation of Iatrogenic Atrial Septal Defect After Catheter-Based Mitral Valve Clip Insertion

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The geometries and sizes of persistent iatrogenic atrial septal defects (IASDs) after transseptal puncture during catheter-based mitral valve clip insertion (MVCI) have not been detailed. In this study, 11 IASDs were investigated in 10 patients who underwent MVCI using a guide catheter (24Fr proximally and 22Fr at the atrial septum). The diameters of the long and short axes and the area at maximum and minimum during a cardiac cycle were measured after MVCI using real-time 3-dimensional (RT3D) transesophageal echocardiography (TEE). A circular shape was assumed on 2-dimensional TEE, resulting in an area calculation of π × (dimension/2)2. The anatomic geometries of IASDs were visualized in a 3-dimensional en face view of the atrial septum. Furthermore, 1 month after MVCI, IASDs were evaluated using echocardiography. The IASDs had a variety of irregular geometries. The mean long-axis diameter was 1.0 ± 0.24 cm, the mean short-axis diameter was 0.51 ± 0.22 cm, and the mean area was 0.40 ± 0.24 cm2 on RT3D TEE. The diameters and area changed significantly between the maximal and minimal values during the cardiac cycle. Importantly, 2-dimensional TEE underestimated the maximal diameters of IASDs (0.54 ± 0.17 vs 1.0 ± 0.24 cm by RT3D TEE, p <0.01) and the maximal areas of IASDs (0.25 ± 0.15 vs 0.40 ± 0.23 cm2 by RT3D TEE, p <0.05). One month after MVCI, the smallest and the second smallest IASDs had closed, and the other 9 remained open. In conclusion, RT3D TEE is useful to assess the irregular geometries of IASDs created during MVCI.

Section snippets

Methods

The study included 11 IASDs in 10 patients with mitral regurgitation treated with the MitraClip device (Abbott Laboratories, Abbott Park, Illinois). All patients had moderate to severe (3+) or severe (4+) functional or degenerative mitral regurgitation with symptoms or, if asymptomatic, with compromised left ventricular function (ejection fraction <60% or end-systolic dimension >40 mm).9, 10 The MitraClip system uses a triaxial catheter system with an implantable clip in MVCI. The guide

Results

The study included 11 IASDs in 10 patients (5 [50%] men), including patients with degenerative or combined degenerative and functional disease (n = 7 [70%]) and patients with functional mitral regurgitation (n = 3 [30%]) (Table 1). The mean age was 69 ± 15 years (range 39 to 90). One patient needed 2 punctures in the atrial septum to obtain optimal positioning of the mitral valve clip. Mitral regurgitation grade decreased from 3.7 ± 0.48 to 1.3 ± 0.48, and mitral regurgitation was reduced to

Discussion

The findings of this study were as follows: (1) the shapes of IASDs were not specific, (2) the sizes of IASDs changed during the cardiac cycle, and (3) 2D TEE underestimated the longer axis dimension and the area compared to RT3D TEE.

This is the first study to investigate IASDs using RT3D TEE. We elucidated the true shapes of IASDs, which 2D echocardiography has not accurately revealed. The cross-sectional shape of the catheter is circular, but the shapes of the IASDs were different from a

Acknowledgment

We would like to thank Dr. and Mrs. Paul I. Terasaki for their kind support and encouragement.

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Drs. Siegel and Shiota are members of Philips Medical Systems Speaker Bureau, Bothell, Washington.

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