Balloon dilation atrial septostomy for advanced pulmonary hypertension in patients on prostanoid therapy

Transcatheter interventions in refractory pulmonary artery hypertension and pulmonary embolism

Pulmonary artery hypertension causes remodeling of distal pulmonary arterial vasculature leading to increased resistance of the pulmonary arterial system, right ventricular dysfunction, and sudden cardiac death. The diagnosis of pulmonary arterial hypertension (PAH) diagnosis is made when mean pulmonary artery pressure during catheterization is ≥25 mmHg at rest, pulmonary vascular resistance (PVR) more than 3 wood units, a pulmonary capillary wedge pressure of <15 mmHg. One year survival rate is 86.3% and 5 year survival rate in PAH is 61.2%, and only 7 years of median survival. Although several breakthrough advances are made in the medical management for PAH, there are some patients who do not respond to medications and continue to detoriate despite optimal medical therapy. The non-responders to medical management are those patients whose right atrial pressure is >20 mmHg or cardiac index is <2.0 L/min/m2, which are pointers of poor prognosis. For medical refractory patients invasive procedures such as atrial septostomy, Potts shunt, and pulmonary artery denervation are a therapeutic or palliative strategy in the treatment of pulmonary artery hypertension and serve as a bridge before surgery and heart lung transplantation.

Outcomes of atrial septostomy and effect on long-term survival in patients with idiopathic pulmonary arterial hypertension: A single-center cohort

OBJECTIVE

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.

METHODS

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.

RESULTS

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%.

CONCLUSIONS

In selected IPAH patients with refractory RHF, BAS is an additional therapeutic strategy, especially when PAH-specific drugs could not achieve the treatment target. BAS can improve hemodynamic variables, bring clinical and cardiac functional benefits and increase the 3-year survival.

Is combined use of radiofrequency ablation and balloon dilation the future of interatrial communications?

INTRODUCTION

Personalized and stable interatrial communication is an important palliative therapy for patients with heart failure. However, this remains a technically challenging task.

AREAS COVERED

In the past decades, substantial advancements in atrial septostomy for the creation of controllable and durable interatrial communication have been made, and numerous novel devices and techniques are in various stages of development. In this review, we discuss the evolving indications for atrial septostomy, current approaches with or without device implantation, and indicators for optimal interatrial communication. The combined use of radiofrequency ablation and balloon dilation (CURB) is an individualized management approach based on underlying hemodynamics, which demonstrates unique advantages in creating a sufficient interatrial communication with satisfactory stability. The advantages and disadvantages of this implant-free procedure are analyzed and its clinical prospects are assessed.

EXPERT OPINION

With ready availability, high safety, and efficacy, CURB is a promising procedure for creating personalized and stable interatrial communication without device implantation. Further research is required to simplify the procedure, screen optimal reference parameters for personalized therapy, and evaluate the long-term outcome in a large population of patients.

Intracardiac echocardiography Chinese expert consensus

In recent years, percutaneous catheter interventions have continuously evolved, becoming an essential strategy for interventional diagnosis and treatment of many structural heart diseases and arrhythmias. Along with the increasing complexity of cardiac interventions comes ever more complex demands for intraoperative imaging. Intracardiac echocardiography (ICE) is well-suited for these requirements with real-time imaging, real-time monitoring for intraoperative complications, and a well-tolerated procedure. As a result, ICE is increasingly used many types of cardiac interventions. Given the lack of relevant guidelines at home and abroad and to promote and standardize the clinical applications of ICE, the members of this panel extensively evaluated relevant research findings, and they developed this consensus document after discussions and correlation with front-line clinical work experience, aiming to provide guidance for clinicians and to further improve interventional cardiovascular diagnosis and treatment procedures.

Study of the effect of Occlutech Atrial Flow Regulator on symptoms, hemodynamics, and echocardiographic parameters in advanced pulmonary arterial hypertension

Optimal sized balloon atrial septostomy improves hemodynamics in advanced pulmonary arterial hypertension. Occlutech Atrial Flow Regulator is designed to provide an atrial septal fenestration diameter titrated according to the age and right atrial pressures. This observational study analyzed symptoms, exercise distance, oxygen saturations, hemodynamics and echocardiographic parameters after Atrial Flow Regulator implantation in patients with syncope or right-heart failure. Patients with high-risk predictors of mortality during septostomy were scrutinized. Thirty-nine patients (9 children) with syncope (34/39) or right-heart failure (27/39) underwent Atrial Flow Regulator implantation without procedural complications. Six-minute walk distance increased from 310 ± 158.2 to 376.4 ± 182.6 m, none developed syncope. Oxygen saturations reduced from 96.4 ± 6.4% to 92 ± 4.9% at rest and further to 80.3 ± 5.9% on exercise. Right atrial pressures reduced from 9.4 ± 5 (2-27) mmHg to 6.9 ± 2.6 (1-12) mmHg, while cardiac index increased from 2.4 ± 0.8 (0.98-4.3) to 3 ± 1 (1.1-5.3) L/min/m² and systemic oxygen transport increased from 546.1 ± 157.9 (256.2-910.5) to 637.2 ± 191.1 (301.3-1020.2) ml/min. Echocardiographic improvement included significant reduction of pericardial effusion and inferior caval congestion at a median follow-up of 37 months. Overall survival improved except two early and one late deaths in high-risk patients. Five of seven patients with advanced disease and key hemodynamic predictors of mortality survived. Acute hemodynamic benefits in pulmonary arterial hypertension after Atrial Flow Regulator were improved cardiac output, systemic oxygen transport, and reduced right atrial pressures. Improvement of symptoms especially syncope, exercise duration, and right ventricular systolic function as well as device patency were sustained on mid-term follow-up. Implantation was safe in all including young children without procedural complications. Mortality was noted only in patients who had high-risk predictors and patients at advanced stage of the disease.

Outcomes of Atrioseptostomy with Stenting in Patients with Pulmonary Arterial Hypertension from a Large Single-Institution Cohort

The aim of this study was to analyze results of stenting atrioseptostomy in patients with pulmonary arterial hypertension and a different level of risk for one-year mortality that is not well described. Patients that underwent atrioseptostomy with stenting were retrospectively divided in two groups: "intermediate" (n = 55) or "high" risk (n = 13), according to the 2015 ESC/ESR guideline. Results of atrioseptostomy were assessed during hospital period and at follow-up. Patients from "intermediate" risk group demonstrated lower mortality rate (10/55, vs. 6/13) during the course of the study period, as well as higher freedom from lung transplantation or Potts shunt. At discharge, patients of both groups presented improvement in functional class and mobility. Patients from "intermediate" risk group showed longer 6-min walking distance, and lower levels of brain natriuretic peptide. At the latest follow-up, stable position and full patency of stents with right-to-left or bidirectional shunt at atrial level and absence of syncope was confirmed in patients of both groups. Patients from the "intermediate" risk group demonstrated higher functional class, better performance of walking test, and lower levels of brain natriuretic peptide. Stenting atrioseptostomy reliably secured interatrial communication and improved clinical condition in patients with idiopathic pulmonary arterial hypertension. Mid-term results were better in "intermediate" risk group.

Use of Balloon Atrial Septostomy in Patients With Advanced Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis

BACKGROUND

Despite the use and purported benefits of balloon atrial septostomy (BAS), its safety, efficacy, and therapeutic role in the setting of advanced pulmonary arterial hypertension (PAH) are not well defined.

OBJECTIVE

The goal of this study was to conduct a systematic review and meta-analysis to better determine the evidence supporting the use of BAS in PAH.

METHODS

MEDLINE, Scopus, Cochrane Library, and Clinicaltrials.gov were searched from inception through May 2018 for original studies reporting outcomes with PAH prior to and following BAS. Studies comparing BAS vs other septostomy procedures were excluded. Weighted mean differences and 95% CIs were pooled by using a random effects model.

RESULTS

Sixteen studies comprising 204 patients (mean age, 35.8 years; 73.1% women) were included. Meta-analysis revealed significant reductions in right atrial pressure (-2.77 mm Hg [95% CI, -3.50, -2.04]; P < .001) and increases in cardiac index (0.62 L/min/m² [95% CI, 0.48, 0.75]; P < .001) and left atrial pressure (1.86 mm Hg [95% CI, 1.24, 2.49]; P < .001) following BAS, along with a significant reduction in arterial oxygen saturation (-8.45% [95% CI, -9.93, -6.97]; P < .001). The pooled incidence of procedure-related (48 h), short-term (≤ 30 day), and long-term (> 30 days up to a mean follow-up of 46.5 months) mortality was 4.8% (95% CI, 1.7%, 9.0%), 14.6% (95% CI, 8.6%, 21.5%), and 37.7% (95% CI, 27.9%, 47.9%), respectively.

CONCLUSIONS

The present analysis suggests that BAS is relatively safe in advanced PAH, with beneficial hemodynamic effects. The relatively high postprocedural and short-term survival with less impressive long-term survival suggest a bridging role for BAS; its contribution to this change needs to be verified by using a comparator group.

Interventional Therapies in Pulmonary Hypertension

Despite advances in drug therapy, pulmonary hypertension-particularly arterial hypertension (PAH)-remains a fatal disease. Untreatable right heart failure (RHF) from PAH eventually ensues and remains a significant cause of death in these patients. Lowering pulmonary input impedance with different PAH-specific drugs is the obvious therapeutic target in RHF due to chronically increased afterload. However, potential clinical gain can also be expected from attempts to unload the right heart and increase systemic output. Atrial septostomy, Potts anastomosis, and pulmonary artery denervation are interventional procedures serving this purpose. Percutaneous balloon pulmonary angioplasty, another interventional therapy, has re-emerged in the last few years as a clear alternative for the management of patients with distal, inoperable, chronic thromboembolic pulmonary hypertension. The current review discusses the physiological background, experimental evidence, and potential clinical and hemodynamic benefits of all these interventional therapies regarding their use in the setting of RHF due to severe pulmonary hypertension.