Paradoxical (Right-to-Left) Shunting Across an Iatrogenic Atrial Septal Defect During Valsalva's Maneuver: A Transesophageal Doppler Echocardiographic Study

A 53-year-old female patient was referred for transesophageal echocardiography (TEE). The patient had rheumatic heart disease and had recently undergone percutaneous balloon valvuloplasty for mitral stenosis by means of a transseptal approach. This procedure involved transseptal catheterization, dilation of the atrial septal puncture with an 8 mm diameter balloon, and later dilation of the mitral valve with a 20 mm balloon. Although the patient showed hemodynamic and clinical improvement initially, she again started to complain of dyspnea on exertion and orthopnea 3 months later. She therefore was referred to Hannover University Hospital, Hannover, West Germany, for further evaluation. Because of the clinical and echocardiographic suspicion of the presence of a persistent, iatrogenic atrial septal defect (ASD), TEE was performed. TEE revealed an ASD that had resulted from the transseptal dilation. Color Doppler by means of TEE showed a high velocity turbulent left-to-right shunt across the ASD (Figure 1). The peak velocity of this shunt, as measured with pulsed Doppler, exceeded 1.5 m/sec. During Valsalva's maneuver, TEE revealed reversal of the shunt with a lower velocity color flow map showing right-to-left flow across the ASD (Figure 2). TEE with pulsed Doppler further showed that the velocity of the reversed shunt was 0.4 ml sec. During Valsalva's maneuver, there was no shunting at all from left-to-right (all flow was "paradoxical") . Cardiac catheterization then revealed a 2.3 to 1.0 left-to-right shunt at the atrial level. The mean left atrial pressure was 25 mm Hg, with a V wave of 45 mm Hg. The mean right atrial pressure was 17