Can we close an ASD in a 25 year old women severe pulmonary hypertension ?
Volumes of literature has been written on the subject.Dedicated cath studies have been done with multiple parameters .
Still , there is a lingering doubt !
Here is a 3 minute practical* solution based on 5 easily available parameters. (* Also referred to as unscientific in medical parlance !)
1. O2 saturation
2. Pulmonary artery diastolic and pulse pressure
3. RV function,
4 .Systemic pressure
5. Functional class
- If O2 saturation is > 90 % consistently there is likely to be significant left to right shunt .Closure is to strongly considered
- If 02 saturation is near 95 % there is absolutely no contraindication at any level of PVR.
- Systolic pulmonary artery pressure derived by TR jet is least useful index.Pulmonary artery diastolic pressure reflects true vascular reactivity of the pulmonary circulation.A wide swinging pulmonary arterial pulse indicates dynamism in circulation and hence operablity.
- If pulmonary artery pulse pressure is wide (>50) , or PA diastolic BP is < 30 one can safely presume irreversible damage to pulmonary vasculature has not occurred and these patients would benefit from surgical closure .
- RV function should be assessed carefully in every patient.This is as important as PVR .Significant RV dysfunction is an absolute contraindication.
- Never close the shunt in patients who is in class 4 symptoms.
- Never close a shunt if the systemic blood pressure is low( 90mmhg)
- Some believe PDA may be closed at any given PVR , while worst outcomes occur with ASD as supra-systemic pulmonary pressure is possible.
Always monitor these patients meticulously especially in the initial days following surgery for deterioration .Most patients will do well if they cross the first 30 days. The RV learns to adopts with new pulmonary hemodynamics !
Dr.S.Venkatesan MD 