Chest
Volume 126, Issue 1, Supplement, July 2004, Pages 63S-71S
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Surgical Treatments/Interventions for Pulmonary Arterial Hypertension: ACCP Evidence-Based Clinical Practice Guidelines

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While considerable advances have been achieved in the medical treatment of pulmonary arterial hypertension (PAH) over the past decade, surgical and interventional approaches continue to have important roles in those patients for whom medical therapy is unavailable or has been unsuccessful. These techniques include pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension, thoracic transplantation, and atrial septostomy. This chapter will provide evidence-based recommendations for the selection and timing of surgical and interventional treatments of PAH for physicians involved in the care of these complex patients.

Section snippets

Atrial Septostomy (AS)

Patients with IPAH and a patent foramen ovale who were awaiting transplantation were found to have a survival advantage over those without a patent foramen ovale,3 suggesting that the creation of an intra-atrial right-to-left shunt could decompress the right ventricle and increase left ventricular preload, thereby increasing systemic blood flow and improving systemic oxygen transport despite arterial oxygen desaturation. Ideally, the impact of a decline in arterial oxygenation would be further

Pulmonary Thromboendarterectomy (PTE)

PTE may provide a potential surgical cure for PAH resulting from chronic thromboembolic PAH (CTEPH) affecting central pulmonary arteries (main, lobar, segmental). PTE for treatment of CTEPH was first described > 30 years ago.8 Prior to this, CTEPH was an autopsy finding. Since that time, nearly 1,000 PTE cases have been reported in the literature. As with many surgical procedures, published reports of PTE have not been well controlled. The PTE procedure must be distinguished from acute

Lung Transplant and Heart-Lung Transplant (LT and HLT)

LT has been a mainstay of treatment for PH since the 1980s. The first successful LT was a combined HLT performed in a woman with pulmonary vascular disease due to IPAH.1 Since that initial success, LT has been applied to a wide variety of conditions. Guidelines for the selection of candidates for LT have been previously published,40 and readers are referred to that publication for a more comprehensive review of the topic.

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