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Use of Balloon Atrial Septostomy in Patients With Advanced Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis.

ABSTRACT: BACKGROUND:Despite the use and purported benefits of balloon atrial septostomy (BAS), its safety, efficacy, and therapeutic role in the setting of advanced pulmonary arterial hypertension (PAH) are not well defined. OBJECTIVE:The goal of this study was to conduct a systematic review and meta-analysis to better determine the evidence supporting the use of BAS in PAH. METHODS:MEDLINE, Scopus, Cochrane Library, and Clinicaltrials.gov were searched from inception through May 2018 for original studies reporting outcomes with PAH prior to and following BAS. Studies comparing BAS vs other septostomy procedures were excluded. Weighted mean differences and 95% CIs were pooled by using a random effects model. RESULTS:Sixteen studies comprising 204 patients (mean age, 35.8 years; 73.1% women) were included. Meta-analysis revealed significant reductions in right atrial pressure (-2.77 mm Hg [95% CI, -3.50, -2.04]; P < .001) and increases in cardiac index (0.62 L/min/m2 [95% CI, 0.48, 0.75]; P < .001) and left atrial pressure (1.86 mm Hg [95% CI, 1.24, 2.49]; P < .001) following BAS, along with a significant reduction in arterial oxygen saturation (-8.45% [95% CI, -9.93, -6.97]; P < .001). The pooled incidence of procedure-related (48 h), short-term (? 30 day), and long-term (> 30 days up to a mean follow-up of 46.5 months) mortality was 4.8% (95% CI, 1.7%, 9.0%), 14.6% (95% CI, 8.6%, 21.5%), and 37.7% (95% CI, 27.9%, 47.9%), respectively. CONCLUSIONS:The present analysis suggests that BAS is relatively safe in advanced PAH, with beneficial hemodynamic effects. The relatively high postprocedural and short-term survival with less impressive long-term survival suggest a bridging role for BAS; its contribution to this change needs to be verified by using a comparator group.

SUBMITTER: Khan MS

PROVIDER: S-EPMC7403752 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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Use of Balloon Atrial Septostomy in Patients With Advanced Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis.

Khan Muhammad Shahzeb MS Memon Muhammad Mustafa MM Amin Emaan E Yamani Naser N Khan Safi U SU Figueredo Vincent M VM Deo Salil S Rich Jonathan D JD Benza Raymond L RL Krasuski Richard A RA

Chest 20190323 1

<h4>Background</h4>Despite the use and purported benefits of balloon atrial septostomy (BAS), its safety, efficacy, and therapeutic role in the setting of advanced pulmonary arterial hypertension (PAH) are not well defined.<h4>Objective</h4>The goal of this study was to conduct a systematic review and meta-analysis to better determine the evidence supporting the use of BAS in PAH.<h4>Methods</h4>MEDLINE, Scopus, Cochrane Library, and Clinicaltrials.gov were searched from inception through May 20 ...[more]

PMID: 30910639

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Project description:BackgroundPrevious meta-analyses of treatments for pulmonary arterial hypertension (PAH) have not shown mortality benefit from any individual class of medication.MethodsMEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from inception through November 2009 for randomized trials that evaluated any pharmacotherapy in the treatment of PAH. Reference lists from included articles and recent review articles were also searched. Analysis included randomized placebo controlled trials of at least eight weeks duration and studies comparing intravenous medication to an unblinded control group.Results1541 unique studies were identified and twenty-four articles with 3758 patients were included in the meta-analysis. Studies were reviewed and data extracted regarding study characteristics and outcomes. Data was pooled for three classes of medication: prostanoids, endothelin-receptor antagonists (ERAs), and phosphodiesterase type 5 (PDE5) inhibitors. Pooled relative risks (RRs) and 95% confidence intervals (CIs) were calculated for mortality, 6-minute walk distance, dyspnea scores, hemodynamic parameters, and adverse effects. Mortality in the control arms was a combined 4.2% over the mean study length of 14.9 weeks. There was significant mortality benefit with prostanoid treatment (RR 0.49, CI 0.29 to 0.82), particularly comparing intravenous agents to control (RR 0.30, CI 0.14 to 0.63). Mortality benefit was not observed for ERAs (RR 0.58, CI 0.21 to 1.60) or PDE5 inhibitors (RR 0.30, CI 0.08 to 1.08). All three classes of medication improved other clinical and hemodynamic endpoints. Adverse effects that were increased in treatment arms include jaw pain, diarrhea, peripheral edema, headache, and nausea in prostanoids; and visual disturbance, dyspepsia, flushing, headache, and limb pain in PDE5 inhibitors. No adverse events were significantly associated with ERA treatment.ConclusionsTreatment of PAH with prostanoids reduces mortality and improves multiple other clinical and hemodynamic outcomes. ERAs and PDE5 inhibitors improve clinical and hemodynamic outcomes, but have no proven effect on mortality. The long-term effects of all PAH treatment requires further study.

Dataset Information

Use of Balloon Atrial Septostomy in Patients With Advanced Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis.

Publications

Use of Balloon Atrial Septostomy in Patients With Advanced Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis.

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