Iatrogenic atrial septal closure for mitral stenosis after transcatheter edge-to-edge repair: A case report

Interventions for structural heart disease requiring a transvenous and transseptal approach, such as transcatheter edge-to-edge repair (TEER), cause iatrogenic atrial septal defect (IASD) after treatment. Its clinical impact remains uncertain. We present the case of an 84-year-old female patient with heart failure with preserved ejection fraction and stress-induced mitral regurgitation (MR), who was repeatedly hospitalized for acute pulmonary edema. Exercise stress echocardiography reproduced worsening MR. Intervention for MR by TEER was considered, while small mitral valve area was a concern. Mitral stenosis (MS) occurred at the time of TEER, but the clip was eventually implanted to prioritize improvement of regurgitation. IASD was subsequently a concern, as the volume of the left-to-right shunt was increasing, and cardiac output was decreasing. We decided to perform a percutaneous IASD closure, which successfully elevated her blood pressure and allowed her to be discharged home on foot. The coexistence of MS, as in the present case, may increase the negative hemodynamic impact of IASD. Percutaneous IASD closure may be a promising therapeutic strategy to stabilize hemodynamics in carefully selected cases. Learning objective: Iatrogenic atrial septal defect (IASD) closure is rarely necessary after transcatheter edge-to-edge repair (TEER). Excessively narrowing mitral valve area after TEER can increase the hemodynamic impact of left-to-right shunt flow through IASD. IASD closure may increase cardiac output, but the indication should be carefully determined after confirming the hemodynamic impact, e.g. balloon closure studies.