Interventional and surgical modalities of treatment for pulmonary arterial hypertension
Walter Klepetko, MD*,*,
Eckhard Mayer, MD ,
Julio Sandoval, MD ,
Elbert P. Trulock, MD ,
Jean-Luc Vachiery, MD||,
Phillippe Dartevelle, MD¶,
Joanna Pepke-Zaba, MD,
Stuart W. Jamieson, MD**,
Irene Lang, MD and
Paul Corris, MD
* Department of Cardio-Thoracic Surgery, Vienna University Hospital, Vienna, Austria
Department of Cardio-Thoracic Surgery, Johannes Gutenberg University Hospital, Mainz, Germany
Cardio-Thoracic Department, Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
|| Department of Cardiology, Erasme University Hospital, Brussels, Belgium
¶ Department of Thoracic and Vascular Surgery, Marie Lannelongue Hospital, Paris, France
Department of Respiratory Medicine, Papworth Hospital NHS Trust, Cambridge, United Kingdom
** Division of Cardiovascular and Thoracic Surgery, University of California, San Diego Medical Center, San Diego, California, USA
Department of Cardiology, University Hospital of Vienna, Vienna, Austria
Regional Pulmonary Hypertension Clinic, William Leech Centre for Lung Research, Freeman Hospital, Cambridge, United Kingdom
Manuscript received November 26, 2003;
accepted February 3, 2004.
* Reprint requests and correspondence: Dr. Walter Klepetko, University Hospital of Vienna, Department of Cardio-Thoracic Surgery, Waehringer Guertel 18-20, 1090 Vienna, Austria.
walter.klepetko{at}meduniwien.ac.at
Beyond medical therapy, different interventional and surgical approaches exist for treatment of pulmonary arterial hypertension (PAH). Atrial septostomy has been applied in patients with lack of response to medical therapy in the absence of other surgical treatment options. With growing experience, procedure-related death rates have been reduced to 5.4%, and the most suitable patient group has been identified among patients with a mean right atrial pressure between 10 and 20 mm Hg. Pulmonary endarterectomy is the accepted form of treatment for patients with chronic thromboembolic pulmonary hypertension. Establishing the diagnosis and the classification of the type of lesions by pulmonary angiography is crucial for optimal patient selection. Perioperative mortality rates have been reduced to <10% in experienced centers, and the hemodynamic improvement is dramatic and sustained. Lung and heart-lung transplantation remains the procedure of choice for patients unsuitable for other treatment modalities. Timing of the procedure is difficult because waiting times vary between centers and usually are in a high range. Early referral of patients unresponsive to other treatment forms is therefore of importance to avoid transplantation of patients with established significant comorbidity. The survival rate during the first five years after transplantation for PAH is intermediate among the lung diseases, lower than chronic obstructive pulmonary disease but higher than idiopathic pulmonary fibrosis.
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Abbreviations and Acronyms
| | AS | = atrial septostomy | | BBAS | = blade balloon atrial septostomy | | BDAS | = balloon dilation atrial septostomy | | CTEPH | = chronic thromboembolic pulmonary hypertension | | mRAP | = mean right atrial pressure | | NYHA | = New York Heart Association | | PA | = pulmonary artery | | PAH | = pulmonary arterial hypertension | | PEA | = pulmonary endarterectomy | | PPH | = primary pulmonary hypertension | | PTE | = pulmonary thromboendarterectomy | | PVR | = pulmonary vascular resistance | | RVF | = right ventricular failure | | SOT | = systemic oxygen transport |
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