The Creation of an Interatrial Right-To-Left Shunt in Patients with Severe, Irreversible Pulmonary Hypertension: Rationale, Devices, Outcomes.

PURPOSE OF THE REVIEW: Targeted pharmacotherapies did improve survival rates, exercise capacity, and quality of life (QoL) of PAH patients. However, these pharmacological interventions are expensive and not always accessible. In addition, not all patients do respond similarly to these medications and many will continue to deteriorate. This review aims to discuss the beneficial role of an artificial right-to-left shunt and highlights current interventional devices and outcomes.

RECENT FINDINGS: Since patients with preexisting atrial shunts or patients with Eisenmenger's disease show better survival rates, improved exercise capacity, and QoL, PAH patients clinically do benefit from an atrial septostomy by reducing signs of right heart failure, improving left heart filling, cardiac output, and systemic oxygen transport despite hypoxia. However, an uncontrolled septostomy with unrestricted right-to-left shunt bears the risk of acute severe desaturation and death. The Atrial Flow Regulator (AFR device, Occlutech®, Sweden) provides an adjustable shunt size with restricted flow and excellent short-term outcomes. Interventional strategies for PAH palliation are on the rise. The novel AFR device provides a durable and safe option for a controlled right-to-left shunting, thus enabling an individualized management.