Home Journal Watch A Novel unidirectional Valved shunt approach for end stage pulmonary arterial hypertension: Early experience in adolescents and adults

A Novel unidirectional Valved shunt approach for end stage pulmonary arterial hypertension: Early experience in adolescents and adults

Erika B. Rosenzweig, MD; Ashish Ankola, MD; Usha Krishnan, MD;William Middlesworth, MD; Emile Bacha, MD; Matthew Bacchetta, MD

The Journal of thoracic and cardiovascular surgery. https://doi.org/10.1016/j.jtcvs.2019.10.149

Abstract

http://yorkshirehandbells.co.uk/happy-new-year/?share=twitter Objectives: Despite advances in treatment of idiopathic pulmonary arterial hypertension (IPAH), there remains no medical cure, and patients can experience disease progression leading to right heart failure, progressive exercise intolerance, and death. The reversed Potts shunt (left pulmonary artery to descending aorta) was reintroduced for treatment of end-stage IPAH to permit decompression of the suprasystemic right ventricle by right to left shunting, with preservation of upper body oxygenation. The shunt has the potential to delay the need for lung transplantation and offer a treatment for those who are transplant ineligible. To optimize shunt design and avoid the potential complications of bidirectional shunting, we developed a novel approach using a unidirectional-valved shunt (UVS) in patients with IPAH with suprasystemic pulmonary arterial pressure and poor right ventricular function.

buy provigil pills Methods: A single-center retrospective review was performed of UVS cases done at Columbia University Medical Center–New York Presbyterian between November 1, 2016, and May 1, 2019.

buy cytotec online no prescription Results: Five patients (4 female; ages 12-22 years) underwent UVS. All had suprasystemic pulmonary arterial pressure, poor right ventricular function, and World Health Organization functional class IV symptoms at baseline. All patients are alive and transplant-free at latest follow-up (range 3-33 months; median 6 ± 11 months).

https://tecnos-srl.com/14-cat/dating_17.html Conclusions: The UVS may offer an alternative solution to lung transplantation in adolescents and young adults with IPAH. Longer-term follow-up is needed to determine the ultimate impact of unidirectional unloading of the right ventricle in these patients and to determine whether the UVS will enable a broader approach to the treatment of patients with IPAH.

Full article

Journal Watch Commentary

In the series presented by Rosenzweig et al. the authors use a valved pulmonary to descending aortic conduit, in addition to creation of a small atrial level shunt (ASD). 4 of the 5 patients were supported with veno-venous extracorporeal membrane oxygenator (ECMO), and in combination with an ASD, eases the postoperative transition to the new physiology. The authors have also observed improved RV systolic function over time associated with the reduction in systolic PAP to systemic levels, despite poor preoperative right ventricular functions. The distinct advantage of the UVC is the ability to selectively shunt during supra-systemic PAPs including during exertion and PH crises while preventing systemic to pulmonary shunting at times when not required. This design eliminates bidirectional flow by providing a “pop-off” mechanism. Furthermore, placing a conduit on the main pulmonary artery allows for more uniform RV decompression, particularly given the often-discrepant branch PA sizes. The disadvantages of the procedure are that it is performed under cardiopulmonary bypass support and the post-operative ECMO support which has its own risks. The creation of additional ASD may result in cerebral an upper body desaturation. If the purpose of UVS is for long term palliation, then there will be a concern on the durability of the conduit as they eventually fail, and reintervention may be required. This is owing to the extra-anatomic location and the supra-systemic PAP to which they are exposed. In this instance, a PTFE valved conduit may be good option compared to biological valved conduits to maintain the long-term durability. The early results of the UVS are encouraging and plays a vital role in the management of IPAH as lung transplantation is severely limited by its durability and the need for re-transplantation and the long-term complications of lung transplantation are major concerns, especially in younger patients.

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