Pulmonary Hypertension Unit

Surgical Options

Atrial septostomy

This is a palliative surgical procedure, which allows an opening to be made through the atrial septum (the muscular wall separating the right and left chambers of the heart). This creates a safety valve, which alleviates the high pressure to which the right heart is subjected in severe disease.
In selected patients it results in an immediate fall in right ventricular end diastolic pressure and systemic oxygen saturations, and is accompanied by an increase in cardiac output.
It may improve survival while awaiting lung transplantation. It is well tolerated despite the fall in systemic oxygen saturations, but it carries a high mortality in critically ill patients.

Recommendations
Atrial septostomy may be considered in severe pulmonary hypertension unchanged by prostaglandin therapy particularly if it is associated by recurrent syncope.
Physicians should only perform Atrial septostomy with experience in performing this procedure and in a specialised pulmonary hypertension centre.

Pulmonary Thromboendartrectomy

clotsA pulmonary Thromboendartrectomy is a cardio thoracic surgical procedure, which removes organised thrombus (clot) formation from the pulmonary arteries.

What is the Length of hospital stay?
The average duration of hospital stay is 2-3 weeks. This includes 2-3 days of evaluative testing where the cardio thoracic surgeon reviews the patient history, and the various diagnostic scans.
A period of 2-5 days will be spent in the surgical intensive care unit. Of course this will depend on the patient’s progress. The patient will remain on the pulmonary ward for 7-10 days for further monitoring. Of course, with complications, the postoperative course can be longer.

What should I expect following surgery?
This is variable for each patient, as the functional improvement postoperatively is related to the amount of pulmonary vascular bed reopened, and to the amount of clot successfully removed. In the vast majority of patients, within several weeks to two months postoperatively there is a dramatic decline in dyspnoea (breathlessness) related to exertion, and an improvement in functional class.
Common symptoms such as chest discomfort, palpations and fluid retention disappear.
Progress will also depend on the condition of the patient before surgery, obviously in sicker patients recovery may take longer. If there is additional heart or lung damage related to another disease process, then some functional limitations may remain
.
How am I referred for surgery?
The patient is reviewed in the pulmonary hypertension unit and following a series of investigations a diagnosis of pulmonary hypertension associated with chronic thromboembolic disease is confirmed.
The consultant will then write a letter of referral, sending copies of the various scans, along with a patient history to a specialist centre, to determine if the clots are accessible through a surgical route.
If it is believed to be a possibility, then the patient will travel over to the centre in question and undergo possible further evaluation and potentially surgery.
The provision of financial support has to be obtained from the relevant health authority before travel can take place.

Lung or heart lung transplantation

Lung or heart lung transplantation improves quality of life and survival in patients with pulmonary hypertension. Rapid expansion of this treatment has been limited by scarcity of donor organs and is limited to approximately 10 pulmonary hypertension patients per annum in the UK.

Pulmonary hypertension accounts for 23.3%of all lung transplants in the USA. The choice of the transplant procedure depends on the underlying disease and on the operating teams experience. Heart lung transplantation may be indicated for patients with primary pulmonary hypertension, valvar heart disease, Eisomengers syndrome with complex cardiac abnormalities, and complex pulmonary artesia. Survival after transplantation is 83% at one year, 70% at three years, and 54% at five years. The main cause of death in the long term remains obliterative bronchiolitis. Pre treatment with prostaglandins improves postoperative survival.

Recommendations

Lung or heart lung transplantation is indicated in patients with pulmonary hypertension with symptomatic progressive disease, which despite optimal medical and/or surgical treatment, leaves the patient in modified functional classes III or IV. The six-minute walk test is a useful tool in the assessment of when to list patients for transplantation. Candidates should meet the internationally recognised guidelines for transplantation.

Pulmonary hypertension without congenital heart disease:
All candidates should be evaluated for vasodilator therapy (including prostaglandins) and other medical or surgical interventions before transplant consideration. It should be considered when treatment with epoprostenol is initiated or failing, or is causing intolerable side effects .

Pulmonary Hypertension secondary to congenital heart disease.
Since predictors of survival are least reliable in this group, the health of patients should have reached an unacceptable level from the patient’s perspective or there should be clear evidence of right heart failure