Concomitant Percutaneous Atrial Septal Defect Closure With an Amplatzer Septal Occluder and HeartMate 3 Implantation for High-Risk Heart Failure Patients: A Novel Hybrid Strategy

THE MITRACLIP (Abbott Vascular, Santa Clara, CA) is approved by the United States Food and Drug Administration to treat functional mitral regurgitation in patients with end-stage heart failure and has been shown to improve patient symptoms and survival. 1 Stone GW Lindenfeld J Abraham WT et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med. 2018; 379: 2307-2318 Crossref PubMed Scopus (1735) Google Scholar , 2 Giustino G Lindenfeld J Abraham WT et al. NYHA functional classification and outcomes after transcatheter mitral valve repair in heart failure: The COAPT trial. JACC Cardiovasc Interv. 2020; 13: 2317-2328 Crossref PubMed Scopus (27) Google Scholar , 3 Arnold SV Chinnakondepalli KM Spertus JA et al. Health status after transcatheter mitral-valve repair in heart failure and secondary mitral regurgitation: COAPT trial. J Am Coll Cardiol. 2019; 73: 2123-2132 Crossref PubMed Scopus (73) Google Scholar To implant the MitraClip, a catheter is guided into the right atrium via femoral venous access, and then a transeptal puncture is created to access the left atrium and anterior and posterior mitral valve leaflets. The resulting iatrogenic atrial septal defect (ASD) made from the transseptal puncture routinely remains patent after completing MitraClip implantation, and a residual left-to-right shunt flows across the ASD because of intrinsic higher left atrial pressures. However, if worsening left ventricular (LV) failure later necessitates escalation to durable continuous-flow LV assist device (LVAD) therapy, a patent ASD becomes problematic. Activation of the LVAD causes a reversal of the shunt direction—to a right-to-left shunt, which causes recirculation of deoxygenated blood and profound hypoxemia. Thus, it is mandatory to repair an ASD or patent foramen ovale during LVAD insertion to avoid right-to-left shunting of blood after left heart decompression with the LVAD. 4 Essandoh M Whitson B Dong L et al. Atrial septal defect in a patient with a mechanical mitral valve prosthesis undergoing implantation of a left ventricular assist device: To repair or not to repair. J Cardiothorac Vasc Anesth. 2017; 31: 1370-1373 Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar