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STATE-OF-THE-ART PAPER

Interventional and Surgical Modalities of Treatment in Pulmonary Hypertension

Anne M. Keogh, MBBS, PhD^_*,_*, Eckhard Mayer, MD, Raymond L. Benza, MD, Paul Corris, MD, Philippe G. Dartevelle, MD^||, Adaani E. Frost, MD^¶, Nick H. Kim, MD^#, Irene M. Lang, MD^_**, Joanna Pepke-Zaba, PhD and Julio Sandoval, MD

^_* St. Vincent's Hospital, Sydney, Australia
Catholic Academic Hospital, Mainz, Germany
Drexel University College of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
Freeman Hospital, Newcastle upon Tyne, United Kingdom
^|| Marie Lannelongue Hospital, Le Plessis Robinson, France
^¶ Baylor College of Medicine, Houston, Texas
^# University of California, San Diego, School of Medicine, La Jolla, California
^_** Medical University of Vienna, Vienna, Austria
Papworth Hospital, Papworth Everard, Cambridge, United Kingdom
National Institute of Cardiology, Mexico City, Mexico

Manuscript received April 13, 2009; accepted April 15, 2009.

^_* Reprint requests and correspondence: Prof. Anne M. Keogh, St. Vincent's Hospital, Victoria Street, Darlinghurst 2010, Sydney NSW, Australia (Email: amkeogh{at}stvincents.com.au).

Most patients with chronic thromboembolic pulmonary hypertension are operable, and pulmonary endarterectomy is the treatment of choice. Pulmonary endarterectomy should not be delayed for medical therapy, and risk stratification helps to define patients likely to achieve the best outcome. Inoperable patients should be referred for trials of medical agents. Atrial septostomy is promising but underutilized, although better ways of ensuring an adequate, lasting septostomy still need to be determined. Indications for the procedure are unchanged, and it should be considered more frequently. Bilateral sequential lung or heart–lung transplantation is an important option for selected patients, and potential candidates who are class IV or III but not improving should be referred early to a transplantation center. Currently, there is a need for right ventricular assist devices with flow characteristics suited to the circulation of patients with pulmonary arterial hypertension. Right ventricular synchronization therapy has not yet been tested. Novel shunts (e.g., Potts anastomosis) also hold promise. All surgery for pulmonary hypertension should be performed in centers with experience in these techniques.

Key Words: surgical modalities • treatment in PAH • interventional modalities

Abbreviations and Acronyms   AS = atrial septostomy   BLTx = bilateral lung transplantation   CI = cardiac index   CO = cardiac output   CTEPH = chronic thromboembolic pulmonary hypertension   DHCA = deep hypothermic circulatory arrest   ECLS = extracorporeal life support   ECMO = extracorporeal membrane oxygenation   HLTx = heart–lung transplantation   IPAH = idiopathic pulmonary arterial hypertension   IVC = inferior vena cava   LV = left ventricle/ventricular   mPAP = mean pulmonary arterial pressure   mRAP = mean right atrial pressure   NYHA = New York Heart Association   PAH = pulmonary arterial hypertension   PEA = pulmonary endarterectomy   PH = pulmonary hypertension   PVR = pulmonary vascular resistance   RAP = right atrial pressure   RV = right ventricular   6MWD = six-min walk distance   SOT = systemic arterial oxygen saturation

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