INTER-ATRIAL STENTING —
A LIFE-SAVING THERAPEUTIC OPTION FOR PATIENTS WITH PULMONARY HYPERTENSION
Primary Pulmonary Hypertension is a rare disease with very poor prognosis. More than 50% of patients do not survive for 5 years after diagnosis. These patients die of pulmonary hypertensive crisis and right heart failure.
A 32 year old lady presented with right heart failure and episodes of syncopes. She was on treatment with Sildenefil and Bosentan for 2 years for Primary Pulmonary Hypertension. She was investigated in detail on initial presentation and no cause was identified. There was acute deterioration in her clinical condition, needing hospital admission. She was in NYHA classification stage IV and persistently tachycardic with a heart rate of 120 to 130. An Echocardiogram showed suprasystemic PA pressure, dilated right ventricle with an impaired function and mild pericardial effusion. Syncopal episodes in such a patient suggests an impending danger of sudden collapse and death.
In a pulmonary crisis, no blood flows from pulmonary vascular bed to the left atrium. In such a case, creating a communication between the two atria allows blood flow from the right to the left atrium. This way, cardiac output will be maintained and there is no risk of sudden death. Obviously this will be at the expense of desaturating systemic circulation. However, patients tolerate this reasonably well and their exercise capacity improves because of better cardiac output.
Unfortunately this procedure does not cure the underlying problem, pulmonary hypertension. In this patient, stenting of the atrial septum was performed after considering the pros and cons. The atrial septum was perforated with a transeptal puncture needle. This hole was dilated and kept patent with a metal stent and balloon assembly. An 8 mm size hole was created on the atrial septum and the stent was stretched on either side of the atrial septum creating a dumbbell shape and stabilizing it inside the heart.
Her saturation dropped from 100% to 85% as was expected. Her BP improved significantly after the procedure and her ionotropic supports were weaned off quickly. She was discharged within 2 days of the procedure. She is recovering well, on Sildenefil and Bosentan, and is able to fulfill her entire daily activities well (NYHA stage II ).
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Tagged: Bosentan, case study, Dr Ramakanta Panda, Heart failure, Interatrial septum, Left atrium, New York Heart Association Functional Classification, Pulmonary artery pressure, Pulmonary hypertension, Stent