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

Palliative interatrial septum stenting with a vascular stent in a chronic thromboembolic pulmonary hypertension patient: Is it beneficial?

BACKGROUND

Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious disease that can progress and lead to a deadly outcome. Despite optimal drug therapy, pulmonary hypertension (PH) remains fatal. Untreatable right heart failure (RHF) from CTEPH is eventually a significant cause of death. However, unloading the right heart and increasing systemic output are the treatment goals in these patients.

CASE PRESENTATION

A 42-year-old female presented to the emergency department with worsening dyspnea experienced for three days before admission. There were also complaints of leg edema, ascites, orthopnea, and palpitation. Physical examination revealed an attenuated second heart sound, abdominal ascites, and bilateral leg edema. She had a history of frequent readmissions due to RHF despite optimal medical therapy and was diagnosed with CTEPH 5 months ago. It was decided that the patient would undergo interatrial septal (IAS) stenting with a vascular stent of 8 mm × 39 mm × 135 cm. The results were good; her symptoms and signs of RHF improved, and she was eventually discharged from the hospital. Four months after the procedure, the patient was able to engage in physical activities without any limitations.

CONCLUSIONS

A palliative IAS stent is one of the choices for intractable RHF management in patients with CTEPH. The vascular stent can be used as an alternative in order to make the interatrial connection more stable and last longer.

Interventional and Surgical Treatments for Pulmonary Arterial Hypertension

Despite significant advancements in pharmacological treatment, interventional and surgical options are still viable treatments for patients with pulmonary arterial hypertension (PAH), particularly idiopathic PAH. Herein, we review the interventional and surgical treatments for PAH. Atrial septostomy and the Potts shunt can be useful bridging tools for lung transplantation (Ltx), which remains the final surgical treatment among patients who are refractory to any other kind of therapy. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) remains the ultimate bridging therapy for patients with severe PAH. More importantly, VA-ECMO plays a crucial role during Ltx and provides necessary left ventricular conditioning during the initial postoperative period. Pulmonary denervation may potentially be a new way to ensure better transplant-free survival among patients with the aforementioned disease. However, high-quality randomized controlled trials are needed. As established, obtaining the Eisenmenger physiology among patients with severe pulmonary hypertension by creating artificial defects is associated with improved survival. However, right-to-left shunting may be harmful after Ltx. Closure of the artificially created defects may carry some risk associated with cardiac surgery, especially among patients with Potts shunts. In conclusion, PAH requires an interdisciplinary approach using pharmacological, interventional, and surgical modalities.