Article Text

  1. W. S. Carroll,
  2. E. S. Anderson,
  3. M. R. McMullan,
  4. M. Ebeid
  1. University of Mississippi Medical Center, Jackson, MS


Percutaneous closure of atrial septal defects (ASDs) has become commonplace for interventional cardiologists, making this procedure a viable and safe option for those with hemodynamically significant ASDs. However, closure of ASD in a patient with severe left ventricular dysfunction is currently not described in the interventional cardiology literature. We present a case where ASD closure in the setting of left ventricular dysfunction resulted in acute decompensation of heart failure. Our patient had a known EF of 15-20% and subsequently had an ASD closed percutaneously. Immediately afterward, she developed acute pulmonary edema and required mechanical intubation for hypoxic respiratory failure and dopamine for inotrophic support. After extubation, she developed acute pulmonary edema that was managed successfully with IV furosemide. She was eventually weaned off dopamine and survived to hospital discharge and was placed on an appropriate medical regimen for heart failure. She was doing well at clinic follow-up after discharge with NYHA Class II symptoms. It appears that this patient's acute heart failure decompensation was due to a relative lack of forward flow of blood from the left heart after ASD closure that resulted in acute pulmonary edema and subsequent hypoxia. The situation is akin to acute mitral regurgitation, which is sometimes seen with papillary muscle rupture after an acute coronary syndrome. This patient had a significant left to right shunt prior to ASD closure (Qp/Qs = 2.45 by catherization) and her physiological "baseline " was for a large portion of her left atrial output to flow across the ASD to her right circulation. With elimination of this pathway for blood flow and poor left ventricular ejection fraction, blood in the left atrium accumulated and backed up into the pulmonary vasculature, resulting in acute pulmonary edema. While the coexistence of an ASD and left heart failure may be rare, it is prudent to be aware of the likelihood for acute heart failure decompensation when such ASDs are closed and make plans for management of such acute decompensation.

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