title: Persistence of iatrogenic atrial septal defect after pulmonary vein isolation--an underestimated risk?
abstract: BACKGROUND
  According to present knowledge, pulmonary vein isolation (PVI) bears a low interventional risk and has a high feasibility. For completion of PVI, left atrial access is achieved via single or double transseptal puncture. We sought to determine the incidence and echocardiographic characteristics of persistent iatrogenic atrial septal defect (iASD) after PVI. Further objectives were to define clinical and periprocedural risk factors for the development of iASD.
  
  
  METHODS
  Every patient admitted for PVI at our hospital was screened for eligibility for study participation. Exclusion criteria were inability for undergoing transesophageal echocardiography, preexisting atrial septal defect, open-heart surgery or another transseptal procedure during the follow-up period. Transesophageal echocardiography was performed before PVI and after 9 months. Interatrial shunt was characterized by echocardiographic parameters; right-to-left-shunting (RLS) was quantified by contrast echocardiography.
  
  
  RESULTS
  Forty-two patients were included, 27 patients underwent PVI with single transseptal puncture and additional advancement of a second electrophysiologic catheter (group A) 15 patients underwent PVI with double transseptal puncture (group B). In 8 patients of group A, iASD persisted after the follow-up period, including 6 patients with distinct RLS. We saw no iASD in group B (P = .011, CI -0.79 to -0.11). Preprocedural pulmonary artery pressure was significantly higher in patients with iASD and accompanying RLS, compared with patients with iASD and no evidence of RLS (23.75 +/- 0.50 vs 17.59 +/- 5.82, P = .048, CI 0.048-12.27).
  
  
  CONCLUSIONS
  This is the first study that demonstrates a high incidence of long-term persistent iatrogenic atrial septal defect with RLS after PVI. All interatrial shunts occurred after single transseptal puncture with passage of 2 electrophysiologic catheters into the left atrium. Increased preprocedural pulmonary artery pressure seems to promote the occurrence of RLS across iASD.
authors.affiliation: Department of Medicine-Cardiology, University of Bonn, Bonn, Germany. christoph.hammerstringl@marien-hospital-bonn.de
authors.forename: Christoph
authors.initials: C
authors.lastname: Hammerstingl
authors.forename: Lars
authors.initials: L
authors.lastname: Lickfett
authors.forename: Kyung-Mi
authors.initials: KM
authors.lastname: Jeong
authors.forename: Clemens
authors.initials: C
authors.lastname: Troatz
authors.forename: Jan-Arne
authors.initials: JA
authors.lastname: Wedekind
authors.forename: Klaus
authors.initials: K
authors.lastname: Tiemann
authors.forename: Berndt
authors.initials: B
authors.lastname: Lüderitz
authors.forename: Thorsten
authors.initials: T
authors.lastname: Lewalter
mesh_terms: D000328:Adult; D006328:Cardiac Catheterization / Q000009:adverse effects*; D006348:Cardiac Surgical Procedures / Q000379:methods; D018618:Echocardiography, Doppler, Color; D017548:Echocardiography, Transesophageal; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D006344:Heart Septal Defects, Atrial / Q000000981:diagnostic imaging / Q000209:etiology*; D006346:Heart Septum / Q000000981:diagnostic imaging; D006801:Humans; D007049:Iatrogenic Disease; D008297:Male; D008875:Middle Aged; D011667:Pulmonary Veins / Q000601:surgery*; D011677:Punctures / Q000009:adverse effects* / Q000379:methods; D013318:Stroke Volume