The Official Journal of EuroPCR and the European Association of Percutaneous Coronary Interventions (EAPCI)

Iatrogenic Interatrial Shunt Reversal with Transcatheter Tricuspid Valve Repair

DOI: 10.4244/EIJ-D-21-00243

1. University Hospital Tubingen Department of Internal Medicine: Universitatsklinikum Tubingen Medizinische Universitatsklinik, Kardiologie, Tuebingen, Germany
2. Department of Cardiology and Angiology, University Hospital of Tuebingen, Tuebingen, Germany, Germany

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An 83-year-old man presented with symptomatic primary severe mitral and secondary massive tricuspid regurgitation (MR, TR). The systolic pulmonary artery pressure was not elevated. The left and right ventricular function was moderately impaired. Due to high surgical risk a simultaneous percutaneous mitral and tricuspid valve repair (PMVR, PTVR) was performed under deep sedation with propofol without endotracheal intubation. The decision for concomitant PMVR, PTVR was made by a multidisciplinary heart team.

For PMVR a PASCAL device was placed between the anterior and posterior leaflets resulting in a reduction of severe MR to a residual moderate MR (reduction of 3D effective regurgitant orifice area (EROA) from 0.58cm2 to 0.28cm2) (Supplementary Videos 1, 2). No further device was placed because of a slightly elevated transmitral pressure gradient. A reduction of mean left atrial (LA) pressure was observed after PMVR (20 mmHg to 12 mmHg). A post-PMVR iatrogenic atrial septal defect (ASD) with a deoxygenating right-to-left interatrial shunt (IAS) was observed (Figure A, Supplementary Video 3), due to effective reduction of the MR and remaining massive TR. A decrease in peripheral oxygen saturation was observed and high-rate oxygen supply was needed to stabilize the patient (SaO2 91 % under 9-15l*min-1). Prior to PTVR the mean right atrial (RA) pressure was 20mmHg. For PTVR a PASCAL ACE device was implanted between the septal and anterior leaflets resulting in a significant TR reduction from massive to moderate (reduction of biplane vena contracta width from 15mm to 6.8mm) (Supplementary Videos 4, 5, 6, 7) and mean RA pressure reduction to 7 mmHg. Subsequently, a reversal of the IAS was observed, resulting in a left-to-right shunt (Figure B, Supplementary Video 8), proving the effectiveness of the TR reduction and leading to respiratory stabilization of the patient. Therefore, an ASD closure was not indicated. The patient reported an improvement of dyspnoea and no fluid retention at the 3-month follow-up.

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