Balloon atrial septostomy in pulmonary arterial hypertension: Effect on survival and associated outcomes

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Background

Pulmonary arterial hypertension (PAH) is a progressive disease that, without early identification and treatment, may lead to right heart failure, multi-organ dysfunction and early death. In severe PAH, in addition to maximal medical therapy, balloon atrial septostomy (BAS) may be used for palliation and as a bridge to lung transplantation. We present our contemporary institutional experience utilizing BAS in adult and pediatric patients with severe PAH.

Methods

We performed a retrospective analysis of 46 BASs performed in 32 patients with PAH from 2002 to 2013. Data obtained included vital status, functional class, medications, hemodynamic measurements from right heart catheterizations and biomarkers. Lung transplantation–free and repeat-BAS–free survival was analyzed.

Results

Median age at BAS was 23 (range 1 to 56) years. The most common indications were symptomatic right heart failure (21 of 46 patients) and pre-syncope/syncope (19 of 46 patients); 69% of patients were WHO Functional Class III or IV pre-BAS. There were no procedural complications or deaths. There were no significant differences in biomarkers or hemodynamic findings between pre-BAS and 1 year or latest follow-up. Seven patients were successfully bridged to lung transplantation. Lung transplantation–free and repeat-BAS–free survival at 30 days, 1 year and 5 years was 87%, 61% and 32%, respectively.

Conclusions

In our experienced center, BAS was shown to be safe in patients with severe PAH on maximal medical management, with no procedural deaths or complications. BAS was safely used as a bridge to lung transplantation or to alleviate right heart failure symptoms and/or syncope. Other potential benefits for end-organ function and overall survival remain to be determined.

Section snippets

Methods

Approval for this study was obtained from the institutional review board of Columbia University Medical Center, New York, NY. We identified patients with PAH who had undergone BAS at the New York-Presbyterian/Columbia University Medical Center Pulmonary Hypertension Center from 2002 to 2013. In addition to baseline demographic data, we obtained patient characteristics at 4 points: just before BAS; immediately post-BAS; 1 year post-BAS; and the most recent documented follow-up at the time of the

Results

At our center, from January 1, 2002 to December 31, 2013, 46 BAS were performed in 32 patients (Table 1). Eleven patients required repeat BAS with 3 of these patients requiring a third BAS. There was a female predominance (74%) with a median age at the time of BAS of 23 years (range 1 to 56 years). There were 17 (37%) procedures performed in patients ≤17 years of age. There were 41 procedures with patient World Health Organization (WHO) functional class status documented; 32 (78%) were

Discussion

BAS has been utilized as a palliative measure for almost 30 years in patients with severe PAH on maximal medical therapy. However, it is only offered in experienced centers given the potential hazards of the procedure. There are limited data on outcomes of BAS in large cohorts of PAH patients, although it remains an important management option in the treatment of advanced PAH. These data support the use of BAS in patients with advanced PAH, particularly in the setting of syncope refractory to

Disclosure statement

The authors have no conflicts of interest to disclose.

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