CASE REPORT

A case of significantly increased mitral regurgitation earlyafter atrial septal defect closure

Masataka Nishiga • Chisato Izumi • Hayato Matsutani • Sumiyo Hashiwada •

Shuichi Takahashi • Yukiko Hayama • Seiko Nakajima • Jiro Sakamoto •

Koji Hanazawa • Makoto Miyake • Toshihiro Tamura • Hirokazu Kondo •

Makoto Motooka • Kazuaki Kaitani • Yoshihisa Nakagawa

Received: 15 February 2012 / Revised: 4 April 2012 / Accepted: 5 April 2012 / Published online: 19 April 2012

� Japanese Society of Echocardiography 2012

Abstract We report a rare case in which mitral regurgi-

tation (MR) was exacerbated to a severe level early after

atrial septal defect (ASD) closure, even though the female

patient had preoperatively mild MR and mild changes in

mitral valve (MV) and sinus rhythm. The mechanism of

increased MR was considered as poor coaptation and

tethering of the MV due to the restricted motion of the

posterior leaflet in addition to geometric changes of the left

ventricle (LV) after ASD closure.

Keywords Atrial septal defect � Mitral regurgitation �ASD plaque � Tethering � Geometric change �Echocardiography

Case report

A 72-year-old woman without symptoms was referred to

our hospital because of a moderately sized atrial septal

defect (ASD). A transthoracic echocardiography (TTE)

(Fig. 1a, c) showed that she had secundum ASD with

enlarged right atrium and ventricle, which is compressing

the left ventricle (LV). The diameter of the defect was

about 20 mm. The LV ejection fraction was normal.

Moderate pulmonary hypertension was detected (tricuspid

regurgitation velocity 3.8 m/s). The leaflets of the mitral

valve (MV) were mildly thickened with mild mitral

regurgitation (MR). A transesophageal echocardiography

(TEE) (Fig. 2a, c) also showed mildly thickened mitral

leaflets without prolapse and the amount of MR was mild.

The patient underwent surgery to repair the ASD. The

defect was directly closed. Tricuspid annuloplasty was also

conducted. She underwent a concomitant Maze procedure

because she had a history of paroxysmal atrial fibrillation.

She was discharged without symptoms. However,

1 month later, she was admitted to our department because

of congestive heart failure. TTE showed normal LV

function, moderate MR, and no leak of the closed ASD.

Also, TTE (Fig. 1b, d) and TEE (Fig. 2b, d) at 2 months

after surgery showed additionally increased MR.

The size of the chambers became close to normal,

improving compression of the LV. Mitral valve leaflets

were the same as before surgery, but they were pulled to

the LV wall, associated with LV enlargement. Motion of

the posterior leaflet was slightly restricted. These resulted

in poor coaptation between the anterior and posterior

leaflets. Severe MR signal showed a wide regurgitant ori-

fice and jetted into the posterior wall of the left atrium.

There was no mitral valve prolapse, perforation, chordal

rupture, nor vegetation. She underwent mitral valve

replacement.

Discussion

There are several reports discussing preoperative and

postoperative MR in adult patients with ASD [1–3]. It is

M. Nishiga (&) � C. Izumi � Y. Hayama � S. Nakajima �J. Sakamoto � K. Hanazawa � M. Miyake � T. Tamura �H. Kondo � M. Motooka � K. Kaitani � Y. Nakagawa

Department of Cardiology, Tenri Hospital, 200 Mishima-cho,

Tenri, Nara 632-8552, Japan

e-mail: masatakanishiga@gmail.com

H. Matsutani � S. Hashiwada � S. Takahashi

Department of Clinical Pathology, Tenri Hospital, Tenri, Japan

123

J Echocardiogr (2012) 10:69–71

DOI 10.1007/s12574-012-0123-3

noted that, in some cases, MR may increase after ASD

closure. The mechanism of increased MR is commonly due

to heavily thickened anterior leaflet, called ASD plaque [4],

preoperative underestimation of MR due to decreased

trans-mitral flow, or persistent atrial fibrillation. There

seemed to be additional mechanisms in this case.

Generally, after ASD closure, geometric changes such as

improvement of the leftward deviation of the ventricular

septum are seen because of the decrease in left-to-right

shunt [1]. In this case, the mechanism of increased MR is

unclear, but it is assumed that poor coaptation may have

been masked because of the preoperatively reduced LV size

due to left-to-right shunt, though the motion of the posterior

leaflet was mildly restricted and the chordae tendineae were

slightly thickened and shortened with careful attention on

preoperative TTE. After ASD closure, because the LV size

became larger than it had been before surgery, mitral leaf-

lets were pulled to the LV wall and coaptation became

worse, which looked like ‘‘tethering’’ of ischemic MR.

From this case, we learned that it is necessary to pay

attention to the motion of the posterior mitral leaflet and

changes of the chordae tendineae, as well as thickened

anterior leaflet in patients with ASD, and to predict chan-

ges of coaptation and tethering by geometric changes of the

LV after ASD closure. In addition, it is also necessary to

follow MR closely after ASD closure.

Fig. 1 Coaptation of mitral leaflets became worse after atrial septal

defect (ASD) closure, and mitral regurgitation (MR) was increased.

a, c Parasternal view of transthoracic echocardiography (TTE) before

ASD closure (LVDd/Ds 38/27, tenting area 1.38 cm2, tenting height

7.2 mm, mitral annulus 38.4 mm). b, d Parasternal view of TTE after

ASD closure (LVDd/Ds 44/26, tenting area 1.93 cm2, tenting height

9.4 mm, mitral annulus 37.7 mm)

70 J Echocardiogr (2012) 10:69–71

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Conflict of interest There is no conflict of interest to disclose.

References

1. Park J-J, Lee SC, Kim JB, et al. Deterioration of mitral valve

competence after the repair of atrial septal defect in adults. Ann

Thorac Surg. 2011;92:1629–33.

2. Izumi C, Iga K, Kondo H, et al. Progression of mitral regurgitation

after patch closure in patients with secundum atrial septal defect.

Cardiovasc Rev Rep. 2001;22:297–301.

3. Toyono M, Pettersson GB, Matsumura Y, et al. Preoperative and

postoperative mitral valve prolapse and regurgitation in adult

patients with secundum atrial septal defects. Echocardiography.

2008;25:1086–93.

4. Nagata S, Nimura Y, Sakakibara H, et al. Mitral valve lesion

associated with secundum atrial septal defect. Analysis by real

time two dimensional echocardiography. Br Heart J. 1983;49:

51–8.

Fig. 2 Transesophageal echocardiography (TEE) showed that MR was exacerbated to a severe level after ASD closure. a, c TEE before ASD

closure. b, d TEE after ASD closure

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