Interventionelle Behandlungsverfahren der pulmonalen Hypertension im Kindesalter

Die pulmonale Hypertension (PH) ist eine progressive Gefäßerkrankung und führt über eine Widerstands- und/oder Druckerhöhung im kleinen Kreislauf zu einem fortschreitenden Rechtsherzversagen. Auch wenn mithilfe aktueller medikamentöser Therapien eine deutliche Verbesserung der Lebensqualität und des Überlebens der Betroffenen erreicht werden konnte, bleibt die PH eine zumeist nichtheilbare Erkrankung, die im fortgeschrittenen Stadium eine Lungentransplantation notwendig macht. Interventionelle Verfahren, wie die Anlage eines interatrialen Shunts (z. B. durch atriale Septostomie oder den Atrial Flow Regulator) oder eines Reversed Potts Shunt, verbessern die RV-Funktion und die ventrikuläre Interaktion durch Schaffung einer prä- oder posttrikuspidalen „Eisenmenger-Physiologie“ und stellen eine Überbrückung oder sogar Alternative zur Lungentransplantation dar. Bei Patienten mit segmentaler PH oder chronisch thrombembolischer pulmonaler Hypertension (CTEPH) stellt die Ballonangioplastie eine bereits etablierte Intervention zur Verbesserung der pulmonalen Perfusion und damit rechtsventrikulären (RV-)Funktion dar. Dagegen ist die pulmonalarterielle Denervation ein neuartiges Verfahren, mit dem Ziel, die neurohumorale Dysregulation bei PH positiv zu beeinflussen. Der individuelle Einsatz solcher Interventionen, additiv zu den bereits etablierten medikamentösen Therapien, erweitert die Behandlungsmöglichkeiten und kann die Prognose betroffener Patienten noch weiter verbessern.

Reversed Potts Shunt Outcome in Suprasystemic Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis

BACKGROUND

Reversed Potts shunt has been a prospective approach to treat suprasystemic pulmonary hypertension, particularly when medication treatment fails to reduce right ventricular afterload.

OBJECTIVE

This meta-analysis aims to review the clinical, laboratory, and hemodynamic parameters after a reversed Potts shunt in suprasystemic pulmonary hypertension patients.

METHODS

Six electronic databases were searched from the date of inception to August 2021, where the obtained studies were evaluated according to the PRISMA statement. The effects of shunt creation were evaluated by comparing preprocedural to postprocedural or follow-up parameters, expressed as a mean difference of 99% confidence interval. Quality assessment was conducted using the STROBE statement.

RESULTS

Seven studies suited the inclusion criteria which were included in this article. A reduction in upper and lower limb oxygen saturation [Upper limb: St. Mean difference -0.55, 99% CI -1.25 to 0.15; P=0.04; I2=6%. Lower limb: St. Mean difference -4.45, 99% CI -7.37 to -1.52; P<0.00001; I2=65%]. Reversed Potts shunt was shown to improve WHO functional class, 6-minute walk distance, NTpro-BNP level, and hemodynamic parameters including tricuspid annular plane systolic excursion, interventricular septal curvature, and end-diastolic right ventricle/left ventricle ratio.

CONCLUSION

Reversed Potts shunt cannot be said to be relatively safe, although it allows improvement in the clinical and functional status in patients with suprasystemic PAH. Reversed Potts shunt procedure may be the last resort for drug-resistant pulmonary hypertension as it is considered a high-risk procedure performed on patients with extremely poor conditions.

Pulmonary-to-Systemic Arterial Shunt to Treat Children With Severe Pulmonary Hypertension

BACKGROUND

The placement of a pulmonary-to-systemic arterial shunt in children with severe pulmonary hypertension (PH) has been demonstrated, in relatively small studies, to be an effective palliation for their disease.

OBJECTIVES

The aim of this study was to expand upon these earlier findings using an international registry for children with PH who have undergone a shunt procedure.

METHODS

Retrospective data were obtained from 110 children with PH who underwent a shunt procedure collected from 13 institutions in Europe and the United States.

RESULTS

Seventeen children died in-hospital postprocedure (15%). Of the 93 children successfully discharged home, 18 subsequently died or underwent lung transplantation (20%); the mean follow-up was 3.1 years (range: 25 days to 17 years). The overall 1- and 5-year freedom from death or transplant rates were 77% and 58%, respectively, and 92% and 68% for those discharged home, respectively. Children discharged home had significantly improved World Health Organization functional class (P < 0.001), 6-minute walk distances (P = 0.047) and lower brain natriuretic peptide levels (P < 0.001). Postprocedure, 59% of children were weaned completely from their prostacyclin infusion (P < 0.001). Preprocedural risk factors for dying in-hospital postprocedure included intensive care unit admission (hazard ratio [HR]: 3.2; P = 0.02), mechanical ventilation (HR: 8.3; P < 0.001) and extracorporeal membrane oxygenation (HR: 10.7; P < 0.001).

CONCLUSIONS

A pulmonary-to-systemic arterial shunt can provide a child with severe PH significant clinical improvement that is both durable and potentially free from continuous prostacyclin infusion. Five-year survival is comparable to children undergoing lung transplantation for PH. Children with severely decompensated disease requiring aggressive intensive care are not good candidates for the shunt procedure.

Pediatric Pulmonary Hypertension: Definitions, Mechanisms, Diagnosis, and Treatment

Pediatric pulmonary hypertension (PPH) is a multifactorial disease with diverse etiologies and presenting features. Pulmonary hypertension (PH), defined as elevated pulmonary artery pressure, is the presenting feature for several pulmonary vascular diseases. It is often a hidden component of other lung diseases, such as cystic fibrosis and bronchopulmonary dysplasia. Alterations in lung development and genetic conditions are an important contributor to pediatric pulmonary hypertensive disease, which is a distinct entity from adult PH. Many of the causes of pediatric PH have prenatal onset with altered lung development due to maternal and fetal conditions. Since lung growth is altered in several conditions that lead to PPH, therapy for PPH includes both pulmonary vasodilators and strategies to restore lung growth. These strategies include optimal alveolar recruitment, maintaining physiologic blood gas tension, nutritional support, and addressing contributing factors, such as airway disease and gastroesophageal reflux. The outcome for infants and children with PH is highly variable and largely dependent on the underlying cause. The best outcomes are for neonates with persistent pulmonary hypertension (PPHN) and reversible lung diseases, while some genetic conditions such as alveolar capillary dysplasia are lethal. © 2021 American Physiological Society. Compr Physiol 11:2135-2190, 2021.

Potts shunt as an effective palliation for patients with end stage pulmonary arterial hypertension

BACKGROUND

Potts shunt has been suggested as an effective palliative therapy for patients with pulmonary artery hypertension (PAH) not associated with congenital heart disease.

MATERIALS AND METHODS

This is a prospective single-center study performed to assess outcomes of Potts shunt in patients with PAH who are in functional class III or IV.

RESULTS

52 patients in functional class III/IV with pulmonary arterial hypertension without significant intra or extracardiac shunt on maximal medical therapy were evaluated and counseled for undergoing Potts shunt/patent ductus arteriosus (PDA) stenting. 16/52 patients (13 females) consented for the procedure; 14 patients underwent surgical creation of Potts, and 2 underwent transcatheter stenting of PDA, which physiologically acted like a Potts shunt. Standard medical therapy was continued in patients who did not consent for the procedure. 12/16 patients survived the procedure. Patients who did not survive the procedure were older, with severe right ventricular systolic dysfunction, and functional class IV. Patients who survived the procedure were followed up in the pulmonary hypertension clinic. The Median follow-up was 17 months (1-40 months). 11/13 patients discharged after the operation showed sustained clinical, echocardiographic, and biochemical improvement, which reduced need for pulmonary vasodilator therapy in 10/13 patients. There was one death in the follow-up period 16 months post-surgery due to lower respiratory tract infection.

CONCLUSION

Potts shunt is feasible in patients with PAH without significant intra or extracardiac shunts. It can be done safely with an acceptable success rate. Patient selection, preoperative stabilization, and meticulous postoperative management are essential. It should be performed at the earliest sign of clinical, echocardiographic, or laboratory deterioation for optimal outcomes. Long-term follow-up is required to see a sustained improvement in functional class and the need for a lung transplant in the future.

Potts anastomosis in children with severe pulmonary arterial hypertension and atrial septal defect

Aims

Potts shunt has been proposed as a bridge or alternative to lung transplantation for children with severe and drug‐refractory suprasystemic pulmonary arterial hypertension (PAH). We describe the management of the atrial shunt when a Potts shunt is planned in refractory PAH.

Methods and results

We report a case series of children in whom a Potts shunt was done for severe PAH associated with an atrial septal defect to illustrate the different clinical and haemodynamic scenarios. Five children (2 to 13 years) underwent a Potts shunt: three surgical, one percutaneous Potts shunt, and one percutaneous stenting of a restrictive arterial duct. All had associated atrial septal defect. Those who had generalized cyanosis before the procedure had a complicated postoperative course and required longer ventilatory and inotropic support, except the one who had atrial septal defect closure before the Potts shunt. One of the three cyanotic patients died. Two patients with left‐to‐right shunt before the Potts shunt had an uncomplicated postoperative course.

Conclusions

Shunt physiology is only partially predictable after the Potts shunt in children with PAH and atrial septal defect. Abrupt drop in left ventricle preload while the right ventricle is decompressed can potentially be prevented by atrial septal defect closure prior to the Potts shunt.

Use of prostaglandin E1 to treat pulmonary hypertension in congenital diaphragmatic hernia

BACKGROUND/PURPOSE

Prostaglandin E1 (PGE) has been used to maintain ductus arteriosus patency and unload the suprasystemic right ventricle (RV) in neonates with congenital diaphragmatic hernia (CDH) and severe pulmonary hypertension (PH). Here we evaluate the PH response in neonates with CDH and severe PH treated with PGE.

METHODS

We performed a retrospective chart review of CDH infants treated at our center between 2011 and 2016. In a subset, PGE was initiated for echocardiographic evidence of severe PH, metabolic acidosis, or hypoxemia. To assess PH response, we evaluated laboratory data, including B-type natriuretic peptide (BNP) and echocardiograms before and after PGE treatment. Categorical and continuous data were analyzed with Fisher's exact tests and Mann-Whitney t-tests, respectively.

RESULTS

Fifty-seven infants were treated with PGE a mean 17 ± 2 days. BNP levels declined after 1.4 ± 0.2 days of treatment and again after 5.2 ± 0.6 days. After 6 ± 0.8 days of treatment, echocardiographic estimates of severe PH by tricuspid regurgitation jet velocity, ductus arteriosus direction, and ventricular septum position also improved significantly. Treatment was not associated with postductal hypoxemia or systemic hypoperfusion.

CONCLUSIONS

In patients with CDH and severe PH, PGE is well tolerated and associated with improved BNP and echocardiographic indices of PH, suggesting successful unloading of the RV.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.