Secondary right heart failure due to haemodynamically relevant iatrogenic atrial septal defect: does the sequence of structural interventions sometimes matter? A case report

BACKGROUND: Edge-to-edge mitral valve repair is a common procedure for treating severe symptomatic mitral valve regurgitation in patients not eligible for surgery. CASE SUMMARY: After necessary transseptal puncture during the MitraClip procedure, an iatrogenic atrial septal defect (iASD) routinely remains and closes spontaneously in most cases. We present a case in which this shunt persisted due to increased left heart pressure, causing repeated rehospitalization, and ultimately requiring interventional closure: after successful transcatheter edge-to-edge repair of severe, symptomatic mitral regurgitation, the iASD persisted presumably due to underestimated paradoxical low-flow, low-gradient aortic valve stenosis. Despite transcatheter aortic valve implantation, the iASD became haemodynamically relevant requiring successful interventional iASD closure in the end after a long period of rehospitalizations. We evaluated the symptoms, haemodynamic, and functional characteristics of the patient using several diagnostic tools, as well as the comorbidities of the patient, in terms of their potential to favour the persistence and haemodynamic relevance of iASDs. DISCUSSION: The combination of sophisticated diagnostic tools, such as cardiac magnetic resonance imaging and transoesophageal echocardiography (TOE), physical examination, and symptoms can be used to identify patients vulnerable to the development of a haemodynamic-relevant iASD that will need early interventional treatment.