In the Journals

Balloon atrial septostomy potentially beneficial in advanced PAH

Muhammad Shahzeb Khan
Muhammad Shahzeb Khan

Balloon atrial septostomy appears to be safe and is associated with hemodynamic improvements in patients with advanced pulmonary artery hypertension, according to findings published in CHEST.

Pulmonary artery hypertension is a deadly progressive condition with limited effective treatment options. Over the years, as more and more studies investigating the role of balloon atrial septostomy in PAH began to surface, there was an evident need to comprehensively define the body of evidence available in the literature. Hence, we conducted this systematic review and meta-analysis,” Muhammad Shahzeb Khan, MD, from the department of internal medicine at John H. Stroger Jr. Hospital of Cook County in Chicago, wrote in an email to Healio Pulmonology.

For the study, Khan and colleagues evaluated 16 studies published through May 2018 that reported outcomes before and after balloon atrial septostomy, with the exclusion of studies comparing the intervention with other septostomy procedures. In the final analysis, 204 patients (mean age, 35.8 years; 73.1% women) were included.

After balloon atrial septostomy, mean right atrial pressure decreased by 2.77 mm Hg (95% CI, –3.5 to –2.04), cardiac index increased by 0.62 L/min/m2 (95% CI, 0.48-0.75), left atrial pressure increased by 1.86 mm Hg (95% CI, 1.24-2.49) and arterial oxygen saturation decreased by 8.45% (95% CI, –9.93 to –6.97). However, there were no significant changes in mean arterial pressure or mean pulmonary artery pressure after the intervention.

In terms of adverse events, hypoxemia was the most common pooled postprocedural complication (3%), and the pooled incidence of spontaneous septostomy closure was 23.8%.

For mortality, the pooled incidence was 4.8% (95% CI, 1.7-9) for procedure-related deaths, 14.6% (95% CI, 8.6-21.5) for death within 30 days or less and 37.7% (95% CI, 27.9-47.9) for deaths that occurred from 30 days to 46.5 months.

“The pooled results for mortality were surprising, especially considering the current state of PAH treatment options, overall poor prognosis and how infrequently balloon atrial septostomy is used in clinical practice,” Khan said.

In light of these findings, Khan noted that more research in this area is warranted.

“The safety and efficacy of balloon atrial septostomy compared with control groups on medical therapy, as well as balloon atrial septostomy along with concomitant medical therapy, should be studied further,” he said.

Ultimately, Khan said he hopes that this systematic review and meta-analysis will encourage physicians to “rethink the role of balloon atrial septostomy in the current treatment algorithm of PAH, potentially leading to a resurgence in the use of the procedure for select patients with advanced severe PAH.”

“For example, one of the senior authors on this paper, Richard A. Krasuski, MD, is an interventionalist who has worked at two tertiary care centers — Cleveland Clinic and Duke — with the pulmonary hypertension section and has only performed four cases in the last 15 years. I think most interventionalists are afraid of these cases. Maybe our study should change that perception, and we should consider it more often than we do,” he told Healio Pulmonology. – by Melissa Foster

For more information:

Muhammad Shahzeb Khan, MD, can be reached at shahzebkhan@gmail.com; Twitter: @ShahzebKhanMD.

Disclosures: One author reports he receives research funding from and has served as a consultant to Actelion Pharmaceuticals and serves as an investigator for Edwards Lifesciences and as an unfunded scientific advisory board member for Ventripoint. Khan and all other authors report no relevant financial disclosures.

Muhammad Shahzeb Khan
Muhammad Shahzeb Khan

Balloon atrial septostomy appears to be safe and is associated with hemodynamic improvements in patients with advanced pulmonary artery hypertension, according to findings published in CHEST.

Pulmonary artery hypertension is a deadly progressive condition with limited effective treatment options. Over the years, as more and more studies investigating the role of balloon atrial septostomy in PAH began to surface, there was an evident need to comprehensively define the body of evidence available in the literature. Hence, we conducted this systematic review and meta-analysis,” Muhammad Shahzeb Khan, MD, from the department of internal medicine at John H. Stroger Jr. Hospital of Cook County in Chicago, wrote in an email to Healio Pulmonology.

For the study, Khan and colleagues evaluated 16 studies published through May 2018 that reported outcomes before and after balloon atrial septostomy, with the exclusion of studies comparing the intervention with other septostomy procedures. In the final analysis, 204 patients (mean age, 35.8 years; 73.1% women) were included.

After balloon atrial septostomy, mean right atrial pressure decreased by 2.77 mm Hg (95% CI, –3.5 to –2.04), cardiac index increased by 0.62 L/min/m2 (95% CI, 0.48-0.75), left atrial pressure increased by 1.86 mm Hg (95% CI, 1.24-2.49) and arterial oxygen saturation decreased by 8.45% (95% CI, –9.93 to –6.97). However, there were no significant changes in mean arterial pressure or mean pulmonary artery pressure after the intervention.

In terms of adverse events, hypoxemia was the most common pooled postprocedural complication (3%), and the pooled incidence of spontaneous septostomy closure was 23.8%.

For mortality, the pooled incidence was 4.8% (95% CI, 1.7-9) for procedure-related deaths, 14.6% (95% CI, 8.6-21.5) for death within 30 days or less and 37.7% (95% CI, 27.9-47.9) for deaths that occurred from 30 days to 46.5 months.

“The pooled results for mortality were surprising, especially considering the current state of PAH treatment options, overall poor prognosis and how infrequently balloon atrial septostomy is used in clinical practice,” Khan said.

In light of these findings, Khan noted that more research in this area is warranted.

“The safety and efficacy of balloon atrial septostomy compared with control groups on medical therapy, as well as balloon atrial septostomy along with concomitant medical therapy, should be studied further,” he said.

Ultimately, Khan said he hopes that this systematic review and meta-analysis will encourage physicians to “rethink the role of balloon atrial septostomy in the current treatment algorithm of PAH, potentially leading to a resurgence in the use of the procedure for select patients with advanced severe PAH.”

PAGE BREAK

“For example, one of the senior authors on this paper, Richard A. Krasuski, MD, is an interventionalist who has worked at two tertiary care centers — Cleveland Clinic and Duke — with the pulmonary hypertension section and has only performed four cases in the last 15 years. I think most interventionalists are afraid of these cases. Maybe our study should change that perception, and we should consider it more often than we do,” he told Healio Pulmonology. – by Melissa Foster

For more information:

Muhammad Shahzeb Khan, MD, can be reached at shahzebkhan@gmail.com; Twitter: @ShahzebKhanMD.

Disclosures: One author reports he receives research funding from and has served as a consultant to Actelion Pharmaceuticals and serves as an investigator for Edwards Lifesciences and as an unfunded scientific advisory board member for Ventripoint. Khan and all other authors report no relevant financial disclosures.