Physiology-Guided Closure of Iatrogenic Atrial Septal Defect After Paravalvular Leak Repair.

OBJECTIVE

To describe a physiology-guided approach to evaluating and closing a clinically significant iatrogenic atrial septal defect after transseptal structural heart intervention.

KEY STEPS: The approach included echocardiographic identification of right-to-left shunting, invasive assessment of interatrial pressure gradients and pulmonary vascular load, inhaled nitric oxide as rescue therapy and an adjunctive physiologic maneuver, 3-dimensional assessment of defect morphology, and urgent transcatheter closure.

POTENTIAL PITFALLS: Inhaled nitric oxide should not be used as a stand-alone determinant of closure. Closure decisions should integrate shunt direction, interatrial pressure gradient, oxygenation, right-sided loading conditions, and whether the defect may serve as left atrial decompression.

TAKE-HOME MESSAGE: Postprocedural iatrogenic atrial septal defect closure should be individualized according to physiology rather than anatomy alone.