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

doi:10.1016/S0002-9149(99)00416-6

The American Journal of Cardiology

Volume 84, Issue 6, 15 September 1999, Pages 682-686

https://doi.org/10.1016/S0002-9149(99)00416-6 Get rights and content

Abstract

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 patients 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.

Section snippets

Patients

From December 1990 to May 1998, 12 patients with advanced pulmonary hypertension were catheterized to create an ASD. Informed consent was obtained in each case. There were 10 women and 2 men. Mean age was 37 ± 12 years (range 13 to 56), and mean weight was 62 ± 12 kg (range 51 to 92). All patients were in New York Heart Association class III or IV; 6 had had severe syncopal episodes, 7 had severe ascites, and 5 patients had experienced clinical deterioration while on continuous intravenous

Results

Demographic data, procedural information, and results are summarized in TABLE I, TABLE II. The mean baseline mixed venous oxygen saturation was 49 ± 13%, whereas the mean baseline indexed pulmonary vascular resistance was 46 ± 23 Wood units. Each patient had successful creation of an ASD (Figure 1). The largest balloon size used was 8 mm in 1 patient, 12 mm in 10 patients, and 14 mm in 1 patient. The mean right atrial pressure decreased from 23 ± 8 to 18 ± 5 mm Hg (p = 0.002). The mean left

Discussion

Despite the first description of its use >15 years ago,6 transcatheter ASD creation in patients with severe pulmonary hypertension has been reported in a very limited number of patients.7, 8, 9, 10 Nihill et al7 created an ASD in 14 patients; 9 had long-term clinical improvement, 2 died acutely, and 3 died at follow-up. Kerstein et al8 performed atrial septostomy in 15 patients; 11 showed initial clinical improvement, 2 had no clinical change, and 2 died acutely. Rich et al9 performed blade

Acknowledgements

We thank Dr. Lewis J. Rubin for his helpful comments.

References (19)

A.R. Glanville et al.
Primary pulmonary hypertensionlength of survival in patients referred for heart-lung transplantation
Chest
(1987)
D. Young et al.
Fate of the patient with the Eisenmenger syndrome
Am J Cardiol
(1971)
W.G. Austen et al.
Experimental studies of the surgical treatment of primary pulmonary hypertension
J Thorac Cardiovasc Surg
(1964)
S. Rich et al.
Atrial septostomy as palliative therapy for refractory primary pulmonary hypertension
Am J Cardiol
(1983)
S. Rich et al.
Usefulness of atrial septostomy as a treatment for primary pulmonary hypertension and guidelines for its application
Am J Cardiol
(1997)
J. Sandoval et al.
Graded balloon dilation atrial septostomy in severe primary pulmonary hypertensiona therapeutic alternative for patients nonresponsive to vasodilator treatment
J Am Coll Cardiol
(1998)
T.J. Collins et al.
Atrial septostomy for pulmonary hypertension
Am Heart J
(1988)
M.J. Hausknecht et al.
Successful palliation of primary pulmonary hypertension by atrial septostomy
Am J Cardiol
(1990)
A. Rothman et al.
Graded balloon dilation atrial septostomy as a bridge to lung transplantation in pulmonary hypertension
Am Heart J
(1993)

There are more references available in the full text version of this article.

Cited by (113)

Outcomes of atrial septostomy and effect on long-term survival in patients with idiopathic pulmonary arterial hypertension: A single-center cohort
2023, International Journal of Cardiology
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%.
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.
The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: The use of mechanical circulatory support in lung transplantation
2023, Journal of Thoracic and Cardiovascular Surgery
The use of mechanical circulatory support (MCS) in lung transplantation has been steadily increasing over the prior decade, with evolving strategies for incorporating support in the preoperative, intraoperative, and postoperative settings. There is significant practice variability in the use of these techniques, however, and relatively limited data to help establish institutional protocols. The objective of the AATS Clinical Practice Standards Committee (CPSC) expert panel was to review the existing literature and establish recommendations about the use of MCS before, during, and after lung transplantation.
The AATS CPSC assembled an expert panel of 16 lung transplantation physicians who developed a consensus document of recommendations. The panel was broken into subgroups focused on preoperative, intraoperative, and postoperative support, and each subgroup performed a focused literature review. These subgroups formulated recommendation statements for each subtopic, which were evaluated by the entire group. The statements were then developed via discussion among the panel and refined until consensus was achieved on each statement.
The expert panel achieved consensus on 36 recommendations for how and when to use MCS in lung transplantation. These recommendations included the use of veno-venous extracorporeal membrane oxygenation (ECMO) as a bridging strategy in the preoperative setting, a preference for central veno-arterial ECMO over traditional cardiopulmonary bypass during the transplantation procedure, and the benefit of supporting selected patients with MCS postoperatively.
Achieving optimal results in lung transplantation requires the use of a wide range of strategies. MCS provides an important mechanism for helping these critically ill patients through the peritransplantation period. Despite the complex nature of the decision making process in the treatment of these patients, the expert panel was able to achieve consensus on 36 recommendations. These recommendations should provide guidance for professionals involved in the care of end-stage lung disease patients considered for transplantation.
Advanced Circulatory Support and Lung Transplantation in Pulmonary Hypertension
2022, Cardiology Clinics
Citation Excerpt :
Atrial septostomy has been used to palliate severe pulmonary hypertension, and in select cases bridge patients to lung transplant. Rothman and colleagues reported a series of 12 technically successful atrial septostomies from 1990 to 1998 for either primary or secondary hypertension, with systemic oxygen saturation decrease ranging from 5% to 10%.50 Half had clinical improvement with 5 of 6 eventually bridged to lung transplant; 6 others had no clinical improvement.
Lung Transplantation for Pulmonary Hypertension
2021, Encyclopedia of Respiratory Medicine, Second Edition
Pulmonary arterial hypertension is one condition where great strides have been made with multiple treatment options emerging over the last two to three decades. While the need for lung transplantation as the final safety net for these patients has diminished, it remains a viable treatment option for select patients who have failed medical therapy. The emergence of ECMO as a bridge both before and after lung transplantation has also furthered management options. This article will provide details on nuanced aspects of lung transplantation in patients with all forms of pulmonary hypertension, with a focus on idiopathic pulmonary arterial hypertension.
Use of Balloon Atrial Septostomy in Patients With Advanced Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis
2019, Chest
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.
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.
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.
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.
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.
Effect of Patent Foramen Ovale in Patients With Pulmonary Hypertension
2018, American Journal of Cardiology
Septostomy reduces right ventricular (RV) workload at the expense of hypoxemia in patients with advanced pulmonary hypertension (PH). A patent foramen ovale (PFO) may serve as a “natural” septostomy, but the incidence and impact of a PFO in PH remains uncertain. We prospectively examined echocardiograms in 404 PH patients referred for initial hemodynamic assessment. Patients included had saline bubble injection and if negative repeatinjection after Valsalva maneuver. Echocardiographic and hemodynamic data were examined. Survival was modeled using Kaplan–Meier method. Eisenmenger syndrome or known atrial shunts other than PFO were excluded: 292 patients met entry criteria. A PFO was identified in 16.8% of the entire cohort, 22.9% of pulmonary arterial hypertension (PAH) patients, and 8.6% of Dana Point group 2 PH patients. Right atrial to pulmonary capillary wedge pressure difference was lowest in the latter group (−7.9 ± 7.1 vs −1.7 ± 5.5 mm Hg for all others, p <0.01). Patients with a PFO were younger (53.9 vs 58.6 years, p = 0.02). A PFO was more often present with moderately or severely dilated (p = 0.01) or dysfunctional (p = 0.03) RVs. Six year survival was unchanged by PFO presence for all patients, including those with PAH. Proportional hazards analysis found only age and functional class independently predicted survival (p <0.01). A PFO is identified less often in Dana Point group 2 PH, likely due to inability of Valsalva maneuver to overcome right atrial to pulmonary capillary wedge pressure difference. In conclusion, the incidence of a PFO in the PH population increases with more dilated and dysfunctional RVs, suggesting that the PFO may be stretched open rather than congenital. The presence of a PFO does not impact survival in PH or PAH.

View all citing articles on Scopus

View full text

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

Abstract

Section snippets

Patients

Results

Discussion

Acknowledgements

Chest

Am J Cardiol

J Thorac Cardiovasc Surg

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

Am J Cardiol

Am Heart J

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