Atrial septostomy

Pulmonary arterial hypertension (PAH) is a severe and rapidly progressive condition, ultimately leading to right heart failure and death. Although medical therapy has improved over the past 15 years, PAH remains incurable and many patients will be in need of lung transplantation. However, very few will eventually be transplanted, due to contraindication precluding listing or unavailability of suitable organs. Therefore, atrial septostomy (AS) is an attractive option for selected patients either as a bridge to transplantation or as destination therapy for patients failing on medical treatment. The physiopathological reasoning in favor of AS is based on the decompression of right heart chambers together with a decrease in the neurohumoral overactivation due to right heart failure. The technique of AS has considerably improved over the years. A stepwise dilation procedure of the interatrial septum together with careful patient selection has led to a significant reduction of procedure- related death, currently as low as 2%. The procedure is indicated in patients remaining in NYHA- FC III/IV despite optimal medical therapy with appropriate oxygenation (saturation on room air =90%) and controlled right heart failure (right atrial pressure 5- 10 years). Finally, the best timing for AS should be redefined, due to the theoretical advantage of earlier intervention.SCOPUS: ch.b