Persistent iatrogenic atrial septal defects after pulmonary vein isolation: long-term follow-up with contrast transesophageal echocardiography.
OBJECTIVE
Pulmonary vein isolation using cryoballoon ablation is an established approach to treating atrial fibrillation. The procedure involves insertion of a 15-Fr sheath into the left atrium across the interatrial septum. This creates an iatrogenic atrial septal defect, which may have important long-term clinical relevance, especially in younger patients. We sought to determine the long-term incidence of these defects and determine the direction of shunt using contrast transesophageal echocardiography.


METHODS
Individuals who had undergone a single pulmonary vein isolation procedure were invited to attend for transesophageal echocardiography (TOE). Patients who had undergone more than one procedure involving puncture of the interatrial septum were excluded. The interatrial septum was interrogated using two-dimensional imaging, color flow Doppler, and microbubble contrast study.


RESULTS
A total of 27 patients were recruited with a median follow-up time of 553 days from pulmonary vein isolation to TOE. Seven patients had persistent iatrogenic atrial septal defects with three demonstrating right to left shunt either at rest or with Valsalva. There were no reported adverse events during the study period.


CONCLUSIONS
Persistent iatrogenic atrial septal defects are relatively common following cryoballoon ablation procedures. Right to left shunting can be observed using microbubble contrast in a subset of patients with iatrogenic atrial septal defect (iASD). Further studies that longitudinally assess shunt fraction, pulmonary artery pressure, and the incidence of paradoxical embolism are needed to better understand the clinical impacts of such defects.
Cardiovascular Department, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, 2305, NSW, Australia. allandavies84@gmail.com.
Allan
A
Davies
Gold Coast University Hospital, Southport, QLD, Australia.
Prasad
P
Gunaruwan
Cardiovascular Department, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, 2305, NSW, Australia.
Nicholas
N
Collins
Cardiovascular Department, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, 2305, NSW, Australia.
Malcolm
M
Barlow
Cardiovascular Department, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, 2305, NSW, Australia.
Nick
N
Jackson
Cardiovascular Department, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, 2305, NSW, Australia.
James
J
Leitch
D000328:Adult; D001281:Atrial Fibrillation / Q000000981:diagnostic imaging / Q000601:surgery*; D002908:Chronic Disease; D003287:Contrast Media; D003452:Cryosurgery / Q000009:adverse effects*; D017548:Echocardiography, Transesophageal / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006344:Heart Septal Defects, Atrial / Q000000981:diagnostic imaging* / Q000209:etiology*; D006801:Humans; D007049:Iatrogenic Disease; D008137:Longitudinal Studies; D008297:Male; D011667:Pulmonary Veins / Q000000981:diagnostic imaging / Q000601:surgery*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D016896:Treatment Outcome
D003287:Contrast Media
Atrial fibrillation; Atrial septal defect; Pulmonary vein isolation
Circ Arrhythm Electrophysiol. 2011 Apr;4(2):166-71
21248245
Europace. 2013 Aug;15(8):1143-9
23419659
J Am Soc Echocardiogr. 2003 Jan;16(1):71-6
12514638
J Am Coll Cardiol. 2013 Oct 15;62(16):1491-2
23916936
Echocardiography. 2014 Oct;31(9):1036-48
24689727
Pacing Clin Electrophysiol. 2015 Sep;38(9):1049-57
25974316
J Interv Cardiol. 2014 Dec;27(6):542-7
25418071
Heart. 2015 May;101(9):706-11
25691512
Europace. 2010 Mar;12(3):301-2
20173205
Heart Lung Circ. 2012 Aug;21(8):427-32
22554875
Europace. 2011 Oct;13(10 ):1406-10
21561902
Heart Rhythm. 2008 Jun;5(6):802-6
18534363
Am Heart J. 2006 Aug;152(2):362.e1-5
16875923
J Interv Card Electrophysiol. 2008 Sep;22(3):177-81
18461430
Am J Cardiol. 2009 Jan 1;103(1):124-9
19101242
Stroke. 2014 Nov;45(11):3352-9
25293664
Circulation. 2008 Dec 9;118(24):2498-505
19029470
Pacing Clin Electrophysiol. 2004 Oct;27(10):1411-4
15511251
J Am Coll Cardiol. 2013 Apr 23;61(16):1707-12
23199518
JACC Cardiovasc Interv. 2015 Mar;8(3):450-459
25703879
J Cardiovasc Electrophysiol. 2014 Jan;25(1):11-5
24118262