Physiology-Guided Closure of Iatrogenic Atrial Septal Defect After Paravalvular Leak Repair

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  Visual Summary. Physiology-Guided Closure of Iatrogenic Atrial Septal Defect After Paravalvular Leak Repair Schematic summary of the clinical course, imaging findings, invasive hemodynamics, and physiologic decision-making process in a patient who developed refractory hypoxemia after transcatheter paravalvular leak closure. (Left) Clinical course demonstrating development of refractory hypoxemia after paravalvular leak closure, inhaled nitric oxide challenge, subsequent transcatheter iatrogenic atrial septal defect (iASD) closure, and clinical recovery. (Upper Right) Imaging and hemodynamic findings demonstrating predominant right-to-left interatrial shunting with right atrial pressure exceeding left atrial pressure at baseline, followed by improvement in oxygenation and reversal toward predominant left-to-right shunting after inhaled nitric oxide administration. (Lower Right) Proposed physiologic mechanism and clinical interpretation. Elevated right-sided loading conditions promoted pathologic right-to-left shunting through the iASD. Reduction in right-sided loading conditions after inhaled nitric oxide helped characterize dynamic shunt physiology before transcatheter iASD closure. LA = left…

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  Figure 1. Hemodynamically Significant Iatrogenic Atrial Septal Defect With Sustained Right-to-Left Shunting (A) Transesophageal echocardiography (midesophageal bicaval view, color Doppler imaging) demonstrating predominant right-to-left shunting across the iatrogenic atrial septal defect. (B) Continuous-wave Doppler recording across the interatrial septum demonstrating sustained right-to-left flow throughout nearly the entire cardiac cycle, suggesting hemodynamically significant shunting.

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  Figure 2. Morphologic Assessment of the Iatrogenic Atrial Septal Defect for Transcatheter Closure Planning (A) Three-dimensional transesophageal echocardiography viewed from the right atrial perspective demonstrating a tear-type or slit-like morphology of the iatrogenic atrial septal defect. (B) Multiplanar reconstruction imaging used to assess defect geometry and procedural feasibility for transcatheter closure.

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  Figure 3. Dynamic Reversal of Interatrial Shunting After Inhaled Nitric Oxide Administration (A) Transesophageal echocardiography obtained 2 minutes after initiation of inhaled nitric oxide demonstrating reduction of right-to-left shunting with emergence of left-to-right flow across the iatrogenic atrial septal defect. (B) At 6 minutes after nitric oxide initiation, color Doppler and continuous-wave Doppler imaging demonstrated predominant left-to-right shunting. These findings suggest that reversible right-sided loading conditions contributed to the abnormal shunting physiology.