Author + information
- Jason H. Rogers, MD∗ ( and )
- Thomas Smith, MD
- ↵∗Division of Cardiovascular Medicine, 4860 Y Street, Suite 2820, Sacramento, California 95817
After reading the recent paper in JACC: Cardiovascular Interventions by Schueler et al. (1) describing the persistence of iatrogenic atrial septal defects (iASDs) after MitraClip therapy, we wish to point out an important omission. The authors stated that “persistence rates of iASDs after MitraClip procedures [are] unknown,” and “this is the first study investigating the persistence rates of iASD after interventional edge-to-edge repair.” In fact, our group published the first investigation on this topic in 2012, and we were surprised to see that our paper was not referenced in the paper or accompanying editorial (2). We reported on the incidence of iASD in 30 subjects undergoing MitraClip repair during the roll-in phase of the EVEREST II (Pivotal Study of a Percutaneous Mitral Valve Repair System) randomized trial, who had interpretable baseline, 30-day, and 6- and 12-month transthoracic echocardiograms (TTE). We found that iASDs were detectable in 27% of patients at 12 months by TTE. Although this is lower than the 50% prevalence of iASD detected at 6 months by Schueler et al. (1), their group used transesophageal echocardiography, which is more sensitive for iASD detection. Similar to Schueler et al. (1), we found that there was less regression in left ventricular size in patients with iASD. Importantly, we found that subjects with iASD at 12 months had more residual mitral regurgitation (MR), increased tricuspid regurgitation, and a trend toward larger LA volumes than non-iASD patients. Eighty-three percent of non-ASD patients were free from MR >2+ at 12 months versus 38% of those with iASD (p = 0.016). We did not note any adverse clinical events related to the presence of iASD. It is probably fair to say that the true significance of iASD remains unknown and may be related to other procedural or patient-level factors not well understood. Consideration for transcatheter closure of iASD should be evaluated on a case-by-case basis and could be considered in patients with left-to-right shunt and evidence of progressive right ventricular or atrial enlargement, right-sided chamber dysfunction, or worsening pulmonary hypertension. Closure of iASD in patients with persistent right-to-left shunt with paradoxical embolus or arterial desaturation (hypoxemia) might also be reasonable.
Please note: Dr. Rogers receives speaker honoraria from Abbott Structural Heart. Dr. Smith receives speaker honoraria from Abbott Structural Heart and receives fees as an echocardiography trainer on use of the MitraClip for Abbott Vascular.
- American College of Cardiology Foundation