Persistent iatrogenic atrial septal defect after pulmonary vein isolation by cryoballoon: an under-recognized complication

Chan, Ngai‐Yin; Choy, Chi-Chung; Lau, Chun-Leung; Lo, Ying-Keung; Chu, Pui-Shan; Yuen, Ho-Chuen; Mok, Ngai-Shing; Tsui, Ping-Tim; Lau, Suet-Ting

doi:10.1093/europace/eur138

Cited by 33 publications

(18 citation statements)

References 20 publications

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“…2 The next-day size of the iASD correlated with its persistence at 12 months. Persistent iASD has been reported in up to 38% of patients at 6 months and in 15% to 20% of patients at 12 months among those who had a transseptal puncture performed for access to the left atrium during cryoablation 3,4 ; the clinical significance of this remains unknown. 5 The mean size of the iASD ranged from 4.6 to 5.7 mm.…”

Section: Discussionmentioning

confidence: 99%

“…Only a left-to-right shunt was seen, and no embolism was reported. 3,4 Recent reports have shown that the risk factors for extensive damage to the fossa Heart Rhythm, Vol 0, No 0, Month 2015 ovalis region, resulting in persistent iASD after cryoablation, relate to the large sheath size along with intense maneuvering of the transseptal sheath to reach and isolate the pulmonary veins successfully. 5 No functional sequelae of these iASDs have ever been reported.…”

Section: Discussionmentioning

confidence: 99%

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Hemodynamically significant atrial septal defect after atrial fibrillation ablation: A hole to remember

et al. 2015

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Hemodynamically significant atrial septal defect after atrial fibrillation ablation: A hole to remember

et al. 2015

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“…Although shunting through iASD is documented universally, follow-up or closure is not routinely performed. The shunt is predominantly left-to-right in an otherwise structurally normal heart while right-to-left shunting can be observed in patients with underlying right atrial pressure elevation [12].…”

Section: Shunting Through the Defectmentioning

confidence: 99%

“…Only a portion of patients has residual iASD, and the defect tends to close spontaneously overtime [12]. Chan et al observed the incidence of iASD after cryoballoon ablation significantly reduced from 38% at 6 months to 31% at 9 months [12].…”

Section: Dealing With the Defectmentioning

confidence: 99%

“…In patients who have undergone cryoballoon ablation delivered with 15 French sheath, the incidence of iASD is approximately 17-38% at 4-6 months [11,12] and 20-37% at 12-36 months [1,[13][14][15]. In comparison to radiofrequency ablation (RFA) technique with 8-8.5 French sheaths, 2% [11][12][13][14][15][16][17][18][19]16] are observed at 4-6 months and 12-36 months, respectively. The prevalence of persistent iASD after Watchman left atrial appendage closure delivered with 14 French from a post…”

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Iatrogenic atrial septal defect: reassurance or inquisitiveness

Naksuk

Asirvatham

2018

J Interv Card Electrophysiol

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Editorial commentsSince pulmonary vein isolation for treatment of atrial fibrillation (AF) was introduced in 1990s, several unexpected complications, including atrioesophageal fistula, pulmonary vein stenosis, and stiff left atrial syndrome, have been discovered in those who apparently tolerated the procedure well. Iatrogenic atrial septal defect (iASD) following transseptal puncture is increasingly recognized and may be another nuance surrounding AF ablation unknown. In this issue of the Journal of Interventional Cardiovascular Electrophysiology, Linhart et al. [1] confirmed that iASD is more frequent than our previous estimates. In 102 patients who had undergone cryoballoon ablation with single transseptal puncture, transesophageal echocardiography performed at approximately 3-year post-procedure revealed 37% persistent iASD. However, the authors highlighted that an absence of clinical complications or deterioration of echocardiographic parameters was an optimistic message to our community. Is this enough to reassure electrophysiologists and patients that persistent iASD, an unavoidable consequence after transseptal puncture, is a benign defect? Congenital defectCongenital atrial septal defect (ASD) and patent foramen ovale (PFO) are related to hemodynamic consequence, atrial arrhythmias, and systemic emboli in late adulthood. Guidelines recommend clinical and echo surveillance in patients with ASD, and closure is indicated for right atrial and right ventricular enlargement [2].A search for PFO is crucial in patients with cryptogenic stroke because closure of the PFO effectively reduces recurrent paradoxical emboli [3][4][5]. While PFO is so common in general population with a prevalence around 20-25%, not all PFOs are associated with stroke. High-risk characteristics of PFO include moderate-to-large right-to-left shunt, large PFO size (more than 8.0 × 8.0 mm) and concomitant atrial septal aneurysm [3][4][5]. Observational studies also found an association between PFO and paradoxical emboli in the setting of pre-existing cardiac implantable electronic devices (CIEDs) [6]. During transvenous lead extraction, debris surrounding the extracted leads can be dislodged through the preexisting PFO. The risk is likely augmented by general anesthesia or during the perioperative period which predisposes to right atrial pressure elevation [7].Other clinical manifestations, including decompression sickness, may be related to PFO [8]. Expert consensus advises against continued diving in individuals with an intracardiac right-to-left shunt [9]. The association between migraine with aura and right-to-left shunt is controversial. Results from the only randomized controlled trial available did not support the benefit of PFO closure [10]. Iatrogenic defectTransseptal puncture is widely performed during a percutaneous intervention to gain access to the left atrium and the left ventricle. Many studies confirmed that transseptal puncture leaves an unavoidable defect on the fossa ovalis. However, the reported incidence of iASD varie...

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Persistence of an iatrogenic atrial septal defect after a second-generation cryoballoon ablation of atrial fibrillation

et al. 2018

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Persistent iatrogenic atrial septal defects (iASDs) can be observed after intervention requiring a left atria (LA) access, including pulmonary vein isolation (PVI) of atrial fibrillation (AF). We investigated the incidence of iASDs post-second-generation cryoballoon ablation and the pre-procedural predictors. Eighty-three paroxysmal AF patients underwent PVI using second-generation cryoballoons. The LA was accessed with single 15-Fr steerable sheaths following a radiofrequency transseptal puncture, and the iASD was evaluated with transthoracic echocardiography (TTE), a median of 9.3 (7.1-13.3) months post-procedure. All patients underwent pre-procedural contrast-enhanced multi-detector computed tomography (CT) to evaluate the LA and PV anatomy. iASDs were detected by TTE in 7 (8.4%) patients, a median of 15.5 (6.8-17.3) months post-procedure. Patients with iASDs had significantly larger LA volumes and smaller atrial septal angles, defined as the angle between the atrial septum and sagittal line on the horizontal section at the height of the fossa ovalis, which could be the transseptal puncture site measured on CT, and more likely hypertension than those without. Multivariate analyses revealed that the atrial septal angle was the sole predictor of iASDs [odds ratio 0.764, 95% confidence interval (CI) 0.624-0.935, p = 0.009], and the optimal cut-off value was 57.5° (sensitivity 85.7%, specificity 88.2%, 95% CI 0.873-0.995, p < 0.0001). Patients with iASDs were asymptomatic and had no adverse clinical events during a 17.7 (14.4-25.8) month median follow-up. iASDs were still detectable in 8.4% of patients a median of 15.5 months after the second-generation CB ablation, and the atrial septal angle might aid in predicting persistent iASDs.

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Persistent iatrogenic atrial septal defect after pulmonary vein isolation by cryoballoon: an under-recognized complication

Cited by 33 publications

References 20 publications

Hemodynamically significant atrial septal defect after atrial fibrillation ablation: A hole to remember

Hemodynamically significant atrial septal defect after atrial fibrillation ablation: A hole to remember

Iatrogenic atrial septal defect: reassurance or inquisitiveness

Persistence of an iatrogenic atrial septal defect after a second-generation cryoballoon ablation of atrial fibrillation

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