Long-term outcome of percutaneous closure of left-to-right shunts in patients with systemic or near systemic pulmonary artery pressure

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Background: The ESC 2010 guidelines recommend closure of left-to-right (L-R) shunts with Pulmonary Arterial Hypertension (PAH) when Pulmonary Arterial Pressure (PAP) is less than 2/3 of SAP. There is paucity of data on long-term outcome of percutaneous device closure in patients with L-R shunt and PAP >2/3 of SAP. Methods: Between August 2007 and December 2012, we attempted percutaneous closure of 20 ostium Secundum ASD,11 PDA and 3 perimembranous VSD with systemic or near systemic PAP. All patients received pretreatment with sildenafil for 3 weeks to 3 months prior to cath study and device closure. The baseline characteristics are shown in table1. Result: The device closure was successful in all ASD and PDA patients but was unsuccessful in all 3 VSDpatients. Two patient in VSD group died, both due to uncontrolled pulmonary hypertensive crisis, one after unsuccessful procedure and another after surgical closure. Third patient in VSD group had successful surgical closure and PASP was 34 mmHg at the time of discharge. The mean follow-up for ASD is 22.26±9.22 months and 17.89±8.76 months for PDA patients. All patients in ASD and PDA group improved from functional class III to asymptomatic level. In ASD subgroup, 13/19 patients (68.4%) have PASP between 30-45 mmHg and 6/19 (31.6%) have PASP between 45-70 mmHg. In PDA subgroup, 8/9 patient (88.9%) have PASP between 30-45 mmHg, and 1/9 (11.1%) have PASP between 40-60 mmHg. Sildenafil was stopped in all patients when PASP was less than 45 mmHg. No rebound PAH was noted in any patient. View this table: Table 1. Baseline characteristics Conclusion: Percutaneous closure in patients with left to right shunt with Qp/Qs>1.5:1, but systemic or near systemic PAP is safe with good outcomes in ASD and PDA patients.VSD patients probably behave differently from similar ASD and PDA population.