Atrial Septostomy in Treatment of End-Stage Right Heart Failure in Patients With Pulmonary Hypertension

doi:10.1378/chest.06-1227

Chest

Volume 131, Issue 4, April 2007, Pages 977-983

https://doi.org/10.1378/chest.06-1227 Get rights and content

Background

Right ventricular (RV) failure is the main cause of death in patients with pulmonary hypertension (PH). Balloon atrial septostomy (BAS) is believed to relieve symptoms of PH by increasing systemic flow and reducing RV preload.

Methods

Fourteen BAS procedures were performed in 11 patients (5 men and 6 women; mean [± SD] age, 33 ± 12 years) with RV failure in the course of PH that was refractory to conventional treatment. BAS consisted of a puncture of the interatrial septum and subsequent dilatations with balloons of increasing diameter in a step-by-step manner.

Results

After BAS, the mean oxygen saturation of aortic blood decreased (before, 93 ± 4%; after, 84 ± 4%; p = 0.001), while mean cardiac index increased (before, 1.54 ± 0.34 L/min/m²; after, 1.78 ± 0.35 L/min/m²; p = 0.001), resulting in a positive trend for mean systemic oxygen transport (before, 270 ± 64 mL/min; after, 286 ± 81 mL/min; p = 0.08). Pulmonary vascular resistance (PVR) slightly increased immediately after the procedure, and this rise inversely correlated with mixed venous blood partial oxygen pressure both before BAS (r = −0.69; p = 0.009) and after BAS (r = −0.64; p = 0.018). Mean functional class improved from 3.2 ± 0.4 to 2.6 ± 0.7 (p = 0.03) after 1 month. At follow-up (mean time to follow-up, 8.1 ± 6.2 months; range, 0.8 to 20.2 months), seven patients died and two underwent lung transplantation. There was no difference in the survival rate compared to that obtained from National Institutes of Health equation. A significant size reduction in the created defect was observed in six patients, requiring repeat BAS procedures in three cases.

Conclusions

The current BAS technique improves cardiac index and functional class without significant periprocedural complications, except for a transient increase in PVR related to acute desaturation of mixed venous blood. At long-term follow-up, a high incidence of spontaneous decrease in orifice size has been observed.

Section snippets

Study Population

We performed 14 BAS procedures in 11 patients (5 men and 6 women; mean [± SD] age, 33 ± 12 years) with refractory right heart failure in the course of idiopathic PAH (9 patients). One patient had PAH associated with corrected aortopulmonary window, and another patient had chronic distal thromboembolic PH that was unsuitable for surgical treatment because of the distal location of the thrombi. A differential diagnosis of PH subclasses was established according to European Society of Cardiology

Procedure and Periprocedural Period

No serious complications were observed during the BAS, and all patients survived the procedure. The most common problem was transient ventricular or supraventricular tachyarrhythmia, which was related to mechanical irritation by catheters. In one case, atrial fibrillation occurred, which was successfully treated.

At catheterization, the mean right atrial pressure (RAP) for the whole group was significantly elevated and contrasted with the low mean left atrial pressure (LAP), which could be

Discussion

Despite similar levels of PAP, patients with Eisenmenger syndrome survive much longer than patients with primary PH.⁷ Interestingly, right-to-left shunt through a patent foramen ovale was reported to indicate better prognosis in patients with primary PH.⁸ Atrial septostomy was first performed in 1983 in the hope of providing similar benefits to remaining patients with primary PH.⁹ An artificially created right-to-left shunt across the interatrial septum improves left ventricular filling and

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Right ventricular (RV) function and eventually failure determine outcome in patients with pulmonary arterial hypertension (PAH). Initially, RV responds to an increased load caused by PAH with adaptive hypertrophy; however, eventually RV failure ensues. Unfortunately, it is unclear what causes the transition from compensated RV hypertrophy to decompensated RV failure. Moreover, at present, there are no therapies for RV failure; those for left ventricular (LV) failure are ineffective, and no therapies specifically targeting RV are available. Thus there is a clear need for understanding the biology of RV failure and differences in physiology and pathophysiology between RV and LV that can ultimately lead to development of such therapies. In this paper, we discuss RV adaptation and maladaptation in PAH, with a particular focus of oxygen delivery and hypoxia as the principal drivers of RV hypertrophy and failure, and attempt to pinpoint potential sites for therapy.
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Pulmonary hypertension (PH) is a haemodynamic manifestation of cardiorespiratory and non-cardiorespiratory pathologies. Cardiorespiratory pathologies account for nearly three-fourths of patients with PH. It is now increasingly being recognised due to routine requests for transthoracic echocardiographic examination in the perioperative setting in patients undergoing intermediate- to high-risk non-cardiac surgery. The increased risks of perioperative morbidity and mortality attributed to PH have been widely acknowledged in the literature. The importance of PH in perioperative decision-making and postoperative outcomes has had little mention in all the guidelines. Understanding the complexity of the pathophysiology of PH may help in anaesthetic and surgical decision-making. Preoperative evaluation and risk assessment are guided by the nature, extent, invasiveness, and duration of surgery. Surgical decision-making and anaesthetic management involve preoperative risk stratification, understanding the interactions between surgical procedures and PH, and understanding the interactions between anaesthetic procedures, PH, and cardiopulmonary interactions. Intraoperative and postoperative monitoring is crucial for maintaining the haemodynamic parameters and helps titrate anaesthetic agents and medication. This narrative review focusses on all issues related to anaesthetic and surgical challenges in patients with PH. This review aimed to suggest a preoperative evaluation plan, surgical decision-making, anaesthetic plan, and anaesthetic management based on the evidence available in the literature.
Outcomes of atrial septostomy and effect on long-term survival in patients with idiopathic pulmonary arterial hypertension: A single-center cohort
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Pulmonary arterial hypertension (PAH) is a chronic progressive disease that may lead to right heart failure (RHF) and early death. Balloon atrial septostomy (BAS) may be used for the palliative treatment of RHF from PAH. We present our contemporary institutional experience of utilizing BAS in idiopathic PAH (IPAH) patients with refractory RHF to investigate the effect on the safety, efficacy and long-term survival.
This retrospective analysis included 12 IPAH patients with severe RHF from March 2017 to May 2019 who were assessed as high risk. All patients received standard treatment including combination of PAH-specific drugs. Graded BAS was performed on these patients due to unsatisfactory clinical response. Clinical, functional and hemodynamic variables before and immediately after the procedure were collected. 1-year follow-up outcomes and 3-year survival rate were further analyzed.
Successful septostomy was achieved in cases with no procedure-related complications. All patients obtained hemodynamic improvement immediately after the procedure. The WHO functional class and exercise endurance improved at 1-year follow-up, 7 of 12 patients achieved intermediate-low risk status, while the rest remained at intermediate-high risk. 2 patients died at 18 and 20 months due to malignant arrhythmia and advanced heart failure, respectively. Survival at 1 year and 3 years was 100% and 83.3%.
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Pulmonary hypertension (PHT) is a arterial vascular disease that leads to severe cardiac and pulmonary deterioration. It is a complex disease the requires monitoring and treatment in multidisciplinary units. It is classified into five groups, encompassing pathologies with different etiologies, but a similar pathophysiology. Patients classified as PHT group 1 are characterized by the involvement of vasodilatory capacity and remodeling of blood vessels, those in group 2 by left heart involvement, those in group 3 by involvement secondary to a pulmonary disease or hypoxia, those in group 4 by arterial obstruction, and those in group 5 by unknown or multifactorial causes. The clinical manifestations can overlap with other cardiopulmonary diseases. Therefore, it is important to define the criteria of suspicion in at-risk patients, follow the diagnostic algorithm, and start treatment early. The treatment is different in the three groups, but its purpose is mainly to decrease pulmonary artery pressure or treat the causes that trigger it.
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: The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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Chest

Original ResearchPulmonary HypertensionAtrial Septostomy in Treatment of End-Stage Right Heart Failure in Patients With Pulmonary Hypertension

Background

Methods

Results

Conclusions

Section snippets

Study Population

Procedure and Periprocedural Period

Discussion

Chest

J Am Coll Cardiol

Am J Cardiol

J Thorac Cardiovasc Surg

Clin Chest Med

Interventional and surgical modalities of treatment for pulmonary arterial hypertension

J Am Coll Cardiol

Guidelines on diagnosis and treatment of pulmonary arterial hypertension: the Task Force on Diagnosis and Treatment of Pulmonary Arterial Hypertension of the European Society of Cardiology

Eur Heart J

Atrial septostomy for severe primary pulmonary hypertension: report on two cases

Kardiol Pol

Original Research
Pulmonary Hypertension
Atrial Septostomy in Treatment of End-Stage Right Heart Failure in Patients With Pulmonary Hypertension