Balloon Atrial Septostomy May Help Hemodynamics, Survival in PAH With Severe RHF

Balloon atrial septostomy (BAS) is associated with significant immediate hemodynamic and clinical improvement and improved survival at 3 years among patients with pulmonary arterial hypertension (PAH) and refractory right heart failure (RHF), according to study findings published in the International Journal of Cardiology.

Researchers retrospectively analyzed and assessed the impact of BAS on clinical hemodynamic variables, cardiac function, and 1-year and 3-year survival in patients with idiopathic PAH with refractory RHF.

A total of 12 patients with severe idiopathic PAH (average [SD] age, 29.9 [10.6] years; 41.7% male) underwent BAS at a hospital in Shanghai, China, from March 2017 to May 2019. All had achieved intermediate-high risk status after adequate medical treatment, including triple combination therapy of PAH-specific drugs before BAS.

After BAS, all participants had clinical improvement. The mean (SD) final balloon size in the septostomy was 7.8 (2.2 mm) (range, 4-12 mm). A significant decrease in right atrial pressure (RAP) (P <.05), an increase in left atrium pressure (LAP) (P <.05) and cardiac index (CI) (P <.05), and a significant decrease in SaO₂ (P <.05) were observed after the procedure.

At 1 year, the CI (P =.79), SaO₂ (P =.82), and RAP (P =.77) increased, although no significant differences occurred. No significant statistical differences were observed in right atrial transverse diameter (P =.54), right ventricular end-diastolic diameter (P =.82), tricuspid annular plane systolic excursion (P =.93), left atrial anteroposterior diameter (P =.81), and left ventricular end diastolic diameter (P =.72), as detected by echocardiography. Brain natriuretic peptide (BNP) level (P <.05) significantly decreased at 1 year, and World Health Organization (WHO) functional class (P <.05) and 6-minute walking distance (6MWD) (P <.05) improved significantly. In addition, 7 patients were classified as intermediate-low risk status, and the others remained at intermediate-high risk status.

After a mean follow-up of 37.8 (1.7) months (range, 36-41 months), no significant changes were observed in BNP, WHO functional class, and 6MWD. No patients had a lung transplantation, and 2 (16.7%) died at 18 and 20 months after the procedure. The survival rate was 100% at 1 year and 83.3% at 3 years, with no patients experiencing syncope.

Study limitations include the retrospective design, lack of a control group, the relatively small sample size, and use of a single institution. Also, the right heart functional performance could not be evaluated with an echocardiogram or magnetic resonance imaging, and the optimal timing of the procedure remains undefined.

“Given the combination of safety and effectiveness, BAS may be an important additional therapeutic strategy in idiopathic PAH patients with severe RHF,” stated the study authors. “It can improve hemodynamics, which is correlated with cardiac function and clinical benefit. In our cohort, we found that performing BAS at intermediate-high risk stage after maximal medical therapy may reduce procedure-related risks, achieve relatively good results during follow-up, and increase 3-year survival.”