ASD With PAH- To Close or Not To

ASD With PAH- to Close or Not To Close

Sudhir Chandra SinhaMD DM FACC FSCAI

Member, European Heart Rhythm AssociationConsultant Cardiologist

Indus Hospitals, Visakhapatnam

Case History

Outcomes in patients with pulmonary hypertension undergoing percutaneous atrial septal defect closureO H Balint, A Samman, K Haberer, L Tobe, P McLaughlin, S C Siu, E Horlick, J Granton, C K SilversidesHeart 2008;94:1189–1193. doi:10.1136/hrt.2006.114660

Patients: Fifty-four patients with moderate (n=34) or severe PAH (n=20) who underwent successful device implantation between 1999 and 2004 were included inthe study. Pulmonary hypertension was classified as moderate (50–59 mm Hg) or severe (>60 mm Hg) according with the right ventricular systolic pressure (RVSP) calculated by echocardiography.

Result: overall mean RVSP decreased at late follow-up, only 43.6% (17/39) ofpatients had normalisation (,40 mm Hg) of the RVSP and 15.4% (6/39) had persistent severe PAH.

Conclusion: Transcatheter closure in patients with secundum ASD and PAH can be successfully performed in selected subjects and is associated with good outcomes.Early improvements in RVSP are seen in patients with moderate or severe PAH undergoing transcatheter ASD closure. Continued improvement in RVSP occurs in late follow-up. Despite decreases in the mean RVSP in late follow-up, many patients do not have complete normalisation of pressures.

Pulmonary Hypertensive Crisis

• Characterized by:

Elevation of PAP/RVSP

Increased PVR

RV failure

Systemic hypotension

Hypoxemia

Death


• Occurs in patients with L-R shunt and Moderate- High PAH, iPAH

• Triggers: Metabolic acidosis, Hypoxemia, CPB, Anemia, hypercarbia, hypothermia, pain and airway manipulations.

• Subsets: TAPVC,Tr Ar,HLH,VSD,TGA,AVCD• During cardiac cath, post-op, post devices• Treatment:

– Epoprostenol, nitric oxide, Milrinone, Sildefanil, ECMO,


• Subsets: TAPVC, Tr Ar, HLH, VSD, TGA, AVCD• May occur with large ASD/PDA with PAH• During cardiac cath, post-op, post devices• Management :

– Epoprostenol infusion– Iloprost aerosol,– Nitric oxide inhalation, – Milrinone nebulisation, – Oral Sildefanil, – Bosentan– ECMO


• Management

Hyperventilation,

Maintaining an alkalotic pH,

Supplemental oxygen,

Low positive end-expiratory pressure

PHC• PULMONARY HYPERTENSION AFTER OPERATIONS FOR CONGENITAL HEART DISEASE:

ANALYSIS OF RISK FACTORS AND MANAGEMENT • Ko Bando, MD, Mark W. Turrentine, MD, Thomas G. Sharp, MD, Yasuo Sekine, MD, Thomas

X. Aufiero, MD, Kyung Sun, MD, Eri Sekine, BS, MPH, John W. Brown, MD From the Section of Cardiothoracic Surgery, James W. Riley Hospital for Children and Indiana University Medical Center, Indianapolis, Ind

J Thorac Cardiovasc Surg 1996;112:1600-1609

Conclusion: Mixed venous saturation monitoring and prophylactic alpha -receptor blockade reduced the incidence of pulmonary

hypertension after operations for congenital heart disease. Early definitive repair reduced morbidity and mortality from postoperative pulmonary hypertension.

Fenestrated Occluders for Treatment of ASD in Elderly Patients with Pulmonary Hypertension and/or Right Heart Failure

LEONHARD BRUCH, M.D. 1 , ANNE WINKELMANN, M.D. 1 , STEFFEN SONNTAG, M.D. 1 , FRANZISKA SCHERF, M.D. 1 , SASCHA RUX, M.D. 1 , MARC O. GRAD, M.D. 1 , and FRANZ X. KLEBER, M.D., F.E.S.C. 1

1 From the Department of Internal Medicine/Cardiology, Unfallkrankenhaus Berlin Academic Teaching Hospital, Berlin,

Germany

we conducted this feasibility trial in 15 ASD patients with pulmonary hypertension and/or right heart failure using a fenestrated Amplatzer septal occluder (AGA Medical Corporation, Golden Valley, MN), allowing an overflow of blood in both directions in case of univentricular diastolic or systolic heart failure. In all patients, the device could be implanted without complications. All symptomatic patients showed an improvement in the New York Heart Association (NYHA) class, and no right or left heart decompensation occurred. On echocardiography, right ventricular end diastolic dimension (RVEDD) and pulmonary artery pressure (PAP) decreased significantly, whereas left ventricular end diastolic dimension (LVEDD) increased. Our series of 15 patients with fenestrated ASD occlusion shows that high-risk ASD occlusion can safely be accomplished with excellent clinical results and without complications by a fenestrated occluder

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ASD With PAH- To Close or Not To