• Chava Chezar-Azerrad, Abid Assali, Hanna Vaknin-Assa, Yaron Shapira, Alon Eisen, and Ran Kornowski.
• Department of Cardiology, Cardiac Catheterization Laboratories, Rabin Medical Center, Petah Tikva & The "Sackler" Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address: cchezar@gmail.com.
• Cardiovasc Revasc Med. 2018 Dec 1; 19 (8S): 82-85.

AbstractA 75 year-old female with symptomatic severe mitral regurgitation of a bio-prosthetic valve secondary to valve leaflet perforation due to endocarditis underwent a mitral valve in valve replacement in an existing Hancock 27 mm valve using a trans-femoral/trans-septal approach. The procedure was complicated by an iatrogenic atrial septal defect post trans-septal puncture causing a severe right-to-left shunt due, possibly, to the combination of severe pulmonary hypertension and moderate tricuspid regurgitation the patient had suffered from at base line. Once the sheath was removed an immediate desaturation was observed which required emergent closure with an AMPLATZER ASD Occluder device (St. Jude Medical/Abbott Structural, St. Paul, Minnesota, MN). This stabilized the patient and returned her blood oxygen levels to normal. The case brings forth a rare but important complication that may occur during trans-septal procedures especially when using large sheaths. It emphasizes the importance of proper echocardiographic and hemodynamic evaluation prior to such procedures in order to be prepared for such complications.Copyright © 2018 Elsevier Inc. All rights reserved.

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