Successful blade atrial septostomy in a patient with severe primary pulmonary hypertension--a case report

Interventional and surgical therapeutic strategies for pulmonary arterial hypertension: Beyond palliative treatments

Despite significant advances in pharmacological treatments, pulmonary arterial hypertension remains an incurable disease with an unreasonably high morbidity and mortality. Although specific pharmacotherapies have shifted the survival curves of patients and improved exercise endurance as well as quality of life, it is also true that these pharmacological interventions are not always accessible (particularly in developing countries) and, perhaps most importantly, not all patients respond similarly to these drugs. Furthermore, many patients will continue to deteriorate and will eventually require an additional, non-pharmacological, intervention. In this review we analyze the role of atrial septostomy and Potts anastomosis in the management of patients with pulmonary arterial hypertension, we summarize the current worldwide clinical experience (case reports and case series), and discuss why these interventional/surgical strategies might have a therapeutic role beyond that of a "bridge" to transplantation.

Atrial septostomy in patients with pulmonary hypertension: should it be recommended?

Treatment options for patients with advanced pulmonary hypertension (PH) are limited. Iatrogenic creation of an interatrial communication (i.e., atrial septostomy [AS]) has been suggested as a possible treatment option or as a bridge to transplantation in selected patients and has been incorporated into current PH guidelines. Uptake of the procedure has been slow and the worldwide experience with AS is limited to approximately 280 published cases, over a period of more than 25 years. The rationale for creating an AS has been provided by the observation that patients with congenital heart disease, shunt lesions and PH have a better survival compared with patients with idiopathic PH. We review pathophysiologic data and the published clinical experience and discuss the rationale, indication and potential pitfalls of AS in patients with severe PH.

Modified technique of stent fenestration of the atrial septum

OBJECTIVES

To develop a modified technique for stenting the atrial septum in the treatment of patients with a failing Fontan operation or pulmonary hypertension.

SETTING

Two tertiary referral centres.

STUDY DESIGN

Prospective collaborative clinical study.

PATIENTS AND METHODS

A stent was mounted on a standard valvoplasty balloon catheter which was constricted to a predefined diameter by a loop created from a temporary pacing wire. Full balloon inflation created a diabolo shaped stent configuration. The technique was employed in 12 consecutive patients to relieve symptoms of a failing Fontan circulation (n = 6) or severe pulmonary hypertension (n = 6).

RESULTS

Ex vivo studies confirmed that a diabolo shaped stent configuration could be achieved using the above technique. Transcatheter stent implantation was successful in all 12 patients. All six Fontan patients showed significant clinical improvement. Right atrial pressure decreased from (mean (SD)) 16.8 (2.5) to 13.7 (1.9) mm Hg (p < 0.05), and arterial oxygen saturation from 92.8 (1.8)% to 82.7 (3.8)% (p < 0.01). Six patients underwent successful stent fenestration for treatment of pulmonary hypertension. All stents were patent and stable at the most recent follow up (mean 1.75 (1.05) years). No early or late stent related complications were encountered.

CONCLUSIONS

This new technique allows placement of a diabolo shaped stent with a predefined diameter across the atrial septum. The diabolo shape increases stent stability, facilitates recrossing of the stent during future catheter interventions, and ensures medium term stent patency.

Recovery of cardiac function after living-donor lung transplantation in a patient with primary pulmonary hypertension

Legislation for brain death and organ transplantation was passed in Japan in 1997, but there is still a great shortage of brain-death donors. Primary pulmonary hypertension (PPH) is a progressive disease that is usually followed by death within 5 years of diagnosis. Continuous infusion of prostacyclin is effective, but some patients will ultimately require heart-lung or lung transplantation. The first case of bilateral living-donor lobar lung transplantation (LDLLT) for PPH in Japan is reported. The recipient was a 19-year-old woman who was diagnosed as PPH at the age of 14 years and began intravenous prostacyclin therapy. Initially her symptoms improved, but she returned to New York Heart Association class IV in 2000. In January 2001, she underwent bilateral LDLLT. Postoperative echocardiography showed that the right ventricular diameter had decreased and septal wall motion had normalized, resulting in a round-shaped left ventricle. Right heart catheterization demonstrated that cardiac output and pulmonary arterial pressure had normalized. The right ventricular ejection fraction improved from 15% to 77%. The patient was discharged from hospital after 60 days postoperatively. LDLLT will become one of the options in Japan for end-stage PPH.

Atrial septostomy for pulmonary hypertension

Atrial septostomy represents an additional, promising strategy in the treatment of severe PPH. Experience with this procedure still is limited; however, based on analyses of the worldwide experience, several general conclusions and recommendations can be made. 1. Atrial septostomy can be performed successfully in selected patients with advanced pulmonary vascular disease. 2. Patients with primary pulmonary hypertension who have undergone successful AS have shown: a significant clinical improvement beneficial and long-lasting hemodynamic effects at rest a trend toward improved survival 3. The procedure-related mortality of the collective experience is high (16%). Several recommendations can be made to minimize the risk: [figure: see text] Atrial septostomy should be attempted only in institutions with an established track record in the treatment of advanced pulmonary hypertension, where septostomy is performed with low morbidity. Atrial septostomy should not be performed in patients in whom death is impending or who have severe right ventricular failure and are on maximal cardiorespiratory support. An mRAP greater than 20 mm Hg, PVR index greater than 55 u/m2, and a predicted 1-year survival less than 40% are significant predictors of procedure-related death. Before cardiac catheterization, patients should have an acceptable baseline systemic oxygen saturation (> 90% in room air) and optimized cardiac function (adequate right heart filling pressure, additional inotropic support if necessary). During cardiac catheterization, the following are mandatory: Supplemental oxygen Mild sedation to prevent anxiety Careful monitoring of variables (left atrial pressure, SaO2, and mRAP) Step by step procedure After AS, it is important to optimize oxygen delivery. Transfusion of packed red blood cells or erythropoietin (before and following the procedure, if needed) may be necessary to increase oxygen content. 4. Because the disease process in PPH is unaffected by the procedure (late deaths), the long-term effects of an AS must be considered to be palliative. 5. Despite its risk, AS may represent a viable alternative for selected patients with severe PPH. Indications for the procedure may include: Recurrent syncope or right ventricular failure, despite maximal medical therapy, including oral calcium-channel blockers or continuous intravenous prostacyclin (Fig. 11) As a bridge to transplantation When no other option exists.

Atrial septostomy as a bridge to lung transplantation in patients with severe pulmonary hypertension

Long waiting times for lung transplantation have limited the survival of patients with advanced pulmonary hypertension. Atrial septostomy has been used in this group of patients in an attempt to prolong survival. We evaluated the results of atrial septostomy in 12 patients using the static graded balloon dilation technique. Between December 1990 and May 1998, 10 women and 2 men (ages 13 to 56 years, mean 37 years) underwent atrial septostomy. Nine patients had primary and 3 patents had secondary pulmonary hypertension. Five patients deteriorated despite long-term intravenous prostacyclin infusions. The atrial septum was crossed with a Brockenbrough needle, followed by an 0.035-J exchange wire and progressively larger catheter balloons for atrial septal dilation, until systemic oxygen saturation decreased 5% to 10%. An atrial septal defect was successfully created in each patient. The mean right atrial pressure decreased from 23 to 18 mm Hg and the mean systemic oxygen saturation decreased from 93% to 85%. The mean cardiac index increased from 1.7 to 2.1 L/min/m2 and the mean systemic oxygen transport increased from 268 to 317 ml/min/m2. Complications occurred in 3 patients: transient hypotension during transesophageal echocardiography, a femoral pseudoaneurysm, and a femoral arteriovenous fistula. After septostomy, 6 patients had clinical improvement (resolution of ascites, edema, and no further episodes of syncope); 5 of these 6 patients underwent lung transplantation a mean of 6.1 months after septostomy. Six patients did not have clinical improvement after septostomy. Atrial septostomy improves the hemodynamic status and may be useful as a bridge to lung transplantation in selected patients with pulmonary hypertension.