Atrial Flow Regulator for Left Atrial Hypertension-Mediated Recurrent Heart Failure Post-Mitral Transcatheter Edge-to-Edge Repair

BACKGROUND: Impaired left atrial (LA) compliance can trigger dynamic left atrial hypertension (LAH), resulting in recurrent pulmonary edema. LAH after mitral transcatheter edge-to-edge repair (M-TEER) can cause particularly unfavorable hemodynamics. CASE SUMMARY: A 70-year-old woman developed recurrent pulmonary edema after emergent M-TEER for severe functional mitral regurgitation (MR). Echocardiography revealed only mild residual MR with severe left atrial (LA) enlargement and reduced reservoir strain. Invasive hemodynamics showed increased LA pressure with tall V-waves, suggestive of dynamic LAH because of reduced LA compliance. Balloon atrial septostomy initially improved symptoms and hemodynamics, but heart failure recurred. An atrial flow regulator (AFR) was implanted under compassionate use, producing durable left-to-right shunting with no further heart failure hospitalizations at 12 months. DISCUSSION: To our knowledge, this is the first reported use of an AFR in LAH post-M-TEER, demonstrating its potential role in these patients. TAKE-HOME MESSAGES: In patients with unexplained recurrent pulmonary edema after successful M-TEER, tall LA V-wave pressure tracings in the absence of significant residual MR can suggest reduced LA compliance and LAH. AFR implantation may offer durable LA decompression in carefully selected cases.