Skip to main content
Log in

Persistent iatrogenic atrial septal defects after pulmonary vein isolation: long-term follow-up with contrast transesophageal echocardiography

  • Published:
Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Purpose

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Jackson N, Barlow M, Leitch J, Attia J. Treating atrial fibrillation: pulmonary vein isolation with the cryoballoon technique. Heart Lung Circ. 2012;21(8):427–32.

    Article  PubMed  Google Scholar 

  2. Klein G, Oswald H, Gardiwal A, Lusebrink U, Lissel C, Yu H, et al. Efficacy of pulmonary vein isolation by cryoballoon ablation in patients with paroxysmal atrial fibrillation. Heart Rhythm. 2008;5(6):802–6.

    Article  PubMed  Google Scholar 

  3. Jais P, Cauchemez B, Macle L, Daoud E, Khairy P, Subbiah R, et al. Catheter ablation versus antiarrhythmic drugs for atrial fibrillation: the A4 study. Circulation. 2008;118(24):2498–505.

    Article  PubMed  Google Scholar 

  4. Neumann T, Wojcik M, Berkowitsch A, Erkapic D, Zaltsberg S, Greiss H, et al. Cryoballoon ablation of paroxysmal atrial fibrillation: 5-year outcome after single procedure and predictors of success. Europace. 2013;15(8):1143–9.

    Article  PubMed  Google Scholar 

  5. Vogt J, Heintze J, Gutleben KJ, Muntean B, Horstkotte D, Nolker G. Long-term outcomes after cryoballoon pulmonary vein isolation: results from a prospective study in 605 patients. J Am Coll Cardiol. 2013;61(16):1707–12.

    Article  PubMed  Google Scholar 

  6. Rillig A, Meyerfeldt U, Birkemeyer R, Treusch F, Kunze M, Jung W. Persistent iatrogenic atrial septal defect after pulmonary vein isolation: incidence and clinical implications. J Interv Card Electrophysiol. 2008;22(3):177–81.

    Article  PubMed  Google Scholar 

  7. Hammerstingl C, Lickfett L, Jeong KM, Troatz C, Wedekind JA, Tiemann K, et al. Persistence of iatrogenic atrial septal defect after pulmonary vein isolation—an underestimated risk? Am Heart J. 2006;152(2):362 e1–5.

    Article  Google Scholar 

  8. Sommer P, Hindricks G. Iatrogenic atrial septal defect after catheter ablation of atrial fibrillation: do we have to worry? Europace. 2010;12(3):301–2.

    Article  PubMed  Google Scholar 

  9. Sieira J, Chierchia GB, Di Giovanni G, Conte G, De Asmundis C, Sarkozy A, et al. One year incidence of iatrogenic atrial septal defect after cryoballoon ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2014;25(1):11–5.

    Article  PubMed  Google Scholar 

  10. Mugnai G, Sieira J, Ciconte G, Hervas MS, Irfan G, Saitoh Y, et al. One year incidence of atrial septal defect after PV isolation: a comparison between conventional radiofrequency and cryoballoon ablation. Pacing Clin Electrophysiol. 2015;38(9):1049–57.

    Article  PubMed  Google Scholar 

  11. Mojadidi MK, Winoker JS, Roberts SC, Msaouel P, Zaman MO, Gevorgyan R, et al. Accuracy of conventional transthoracic echocardiography for the diagnosis of intracardiac right-to-left shunt: a meta-analysis of prospective studies. Echocardiography. 2014;31(9):1036–48.

    Article  PubMed  Google Scholar 

  12. Cronin EM, Collier P, Wazni OM, Griffin BP, Jaber WA, Saliba WI. Persistence of atrial septal defect after cryoballoon ablation of atrial fibrillation. J Am Coll Cardiol. 2013;62(16):1491–2.

    Article  PubMed  Google Scholar 

  13. Chan NY, Choy CC, Lau CL, Lo YK, Chu PS, Yuen HC, et al. Persistent iatrogenic atrial septal defect after pulmonary vein isolation by cryoballoon: an under-recognized complication. Europace. 2011;13(10):1406–10.

    Article  PubMed  Google Scholar 

  14. Goel SS, Tuzcu EM, Shishehbor MH, de Oliveira EI, Borek PP, Krasuski RA, et al. Morphology of the patent foramen ovale in asymptomatic versus symptomatic (stroke or transient ischemic attack) patients. Am J Cardiol. 2009;103(1):124–9.

    Article  PubMed  Google Scholar 

  15. Natanzon A, Goldman ME. Patent foramen ovale: anatomy versus pathophysiology—which determines stroke risk? J Am Soc Echocardiogr. 2003;16(1):71–6.

    Article  PubMed  Google Scholar 

  16. Katsanos AH, Spence JD, Bogiatzi C, Parissis J, Giannopoulos S, Frogoudaki A, et al. Recurrent stroke and patent foramen ovale: a systematic review and meta-analysis. Stroke. 2014;45(11):3352–9.

    Article  CAS  PubMed  Google Scholar 

  17. Nyboe C, Olsen MS, Nielsen-Kudsk JE, Hjortdal VE. Atrial fibrillation and stroke in adult patients with atrial septal defect and the long-term effect of closure. Heart. 2015;101(9):706–11.

    Article  CAS  PubMed  Google Scholar 

  18. Rigatelli G, Dell’avvocata F, Tarantini G, Giordan M, Cardaioli P, Nguyen T. Clinical, hemodynamic, and intracardiac echocardiographic characteristics of secundum atrial septal defects-related paradoxical embolism in adulthood. J Interv Cardiol. 2014;27(6):542–7.

    Article  PubMed  Google Scholar 

  19. Obel O, Mansour M, Picard M, Ruskin J, Keane D. Persistence of septal defects after transeptal puncture for pulmonary vein isolation procedures. Pacing Clin Electrophysiol. 2004;27(10):1411–4.

    Article  PubMed  Google Scholar 

  20. Schueler R, Ozturk C, Wedekind JA, Werner N, Stockigt F, Mellert F, et al. Persistence of iatrogenic atrial septal defect after interventional mitral valve repair with the MitraClip system: a note of caution. JACC Cardiovasc Interv. 2015;8(3):450–9.

    Article  PubMed  Google Scholar 

  21. Singh SM, Douglas PS, Reddy VY. The incidence and long-term clinical outcome of iatrogenic atrial septal defects secondary to transseptal catheterization with a 12F transseptal sheath. Circ Arrhythm Electrophysiol. 2011;4(2):166–71.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

This study was funded by the Cardiovascular Department at the John Hunter Hospital, Newcastle, Australia.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Allan Davies.

Ethics declarations

All patients gave informed consent to participate in the study.

Conflict of interest

The authors declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Davies, A., Gunaruwan, P., Collins, N. et al. Persistent iatrogenic atrial septal defects after pulmonary vein isolation: long-term follow-up with contrast transesophageal echocardiography. J Interv Card Electrophysiol 48, 99–103 (2017). https://doi.org/10.1007/s10840-016-0193-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10840-016-0193-7

Keywords

Navigation