Atrial Septostomy for Severe Pulmonary Arterial Hypertension With Decreased Cardiac Output: An Underused Procedure

Abstract

PURPOSE: Severe pulmonary arterial hypertension (PAH) leads to a low flow state through the pulmonary circulation, which causes biventricular failure. Patients present with fatigue, shortness of breath, syncope and chest pain. Atrial septostomy (AS) increases blood flow into the left ventricle and cardiac output. METHODS: A retrospective chart review was performed looking at all AS performed at Tampa General Hospital from June 2007 until December 2012. We identified 15 cases of AS for PAH in total of 14 patients. There were 10 females and 4 males, aged between 28 and 80. Indications included right heart failure, chest pain and syncope. Patients were on optimal medical therapy at the time of the procedure, with combination therapy. Right heart catheterization showed severe PAH and a depressed cardiac index. AS was performed using either a trans-esophageal or an intracardiac ultrasound and fluoroscopic guidance. Major PAH Florida centers were polled for the regular use of this procedure. RESULTS: Eleven patients had successful treatment via AS and lived at least one year following the procedure. Quality of life improved significantly as evidenced by an increase in six minute walk distance upon follow up. Oxygenation decreased following AS. Three patients died within weeks from intractable right heart failure. Two patients were discharged on long-term dobutamine infusion and are both alive at 1 year with improved quality of life. Ours was the only major center in Florida routinely performing AS when indicated. CONCLUSIONS: AS increases cardiac output at the expense of about a 10-15% decrease in arterial saturation. This is reflected by a significant increase in 6-minute walk distance. AS should be performed in patients with symptoms of decreased cardiac output despite medical therapy (chest pain, near syncope, fatigue and difficulty in breathing) and should be avoided in patients with very severe right heart failure.