PURPOSE: Systemic to pulmonary shunts such as patent foramen ovales (PFO) and atrial septal defects (ASD) are associated with cryptogenic stroke, migraine headaches, and arrhythmias. Increasingly percutaneous closure of these lesions with an atrial septal closure device (ASCD) is being performed. We present two cases where closure of an interatrial defect was performed in patients with pulmonary arterial hypertension (PAH), resulting in increased morbidity.
METHODS: Retrospective chart review of 183 cases of PAH followed at our institution. Two cases with a history of ASCD were identified and reported.
RESULTS: Case 1: AB is a 38 year-old female with hereditary hemorrhagic telengectasia who presented with cerebrovascular accident. A PFO was discovered and percutaneously closed. Since, she reported progressive dyspnea. Right heart catheterization revealed: mean pulmonary artery pressure (mPAP) 67 mm Hg, right atrial pressure (RAP) 29 mm Hg, cardiac index (CI) 1.6 L/min/m2. Review of her echocardiogram before PFO closure was consistent with PAH. Case 2: DF is a 43 year-old male who presented to a community hospital with increasing dyspnea. An echocardiogram revealed enlarged right sided chambers, estimated PAP 70 mm Hg, and intracardiac shunt. An ASCD was placed. However, the patient's dyspnea progressed. Subsequent right heart catheterization revealed: mPAP 47 mm Hg, RAP 4 mm Hg, CI 2.1 L/min/m2.
CONCLUSION: These are cases in which closure of the patient's interatrial shunt lead to clinical deterioration. Interatrial shunt is associated with complications which may be prevented with the placement of a closure device. However, systemic-to-pulmonary shunt is also associated with PAH. An interatrial defect in a patient with severe PAH allows right-to-left shunting of flow, decompressing the right sided chambers. Thus, it may function as a pressure-release-valve to increase cardiac output and alleviate symptoms of right heart failure.
CLINICAL IMPLICATIONS: Increasingly, ACSDs are placed to prevent complications of interatrial shunt. Currently there are no guidelines for screening for PAH prior to closure. If PAH is confirmed in a patient with interatrial shunt, physicians should carefully consider whether closure is indicated.
DISCLOSURE: Jeremy Strom, None.