Pulmonary artery ablation to treat pulmonary arterial hypertension: a case report
© Kiuchi et al. 2015
Received: 19 October 2015
Accepted: 11 November 2015
Published: 16 December 2015
Idiopathic pulmonary arterial hypertension is defined as a group of diseases characterized by a progressive increase in pulmonary vascular resistance that results in right heart failure and premature death. Although therapies exist to improve hemodynamic instability and symptoms, there is no cure for pulmonary arterial hypertension and it remains a life-threatening condition. A recent study performed in China reported, for the first time, the effect of pulmonary arterial denervation on functional capacity and hemodynamics in patients with refractory idiopathic pulmonary arterial hypertension.
We report a case of a 60-year-old white Brazilian man, with controlled hypertension and stage 2 obesity who complained of progressive fatigue with moderate to light exertion of approximately 1 year’s duration. During this period, he underwent myocardial perfusion scintigraphy without evidence of obstructive ischemic disease. He had no clinical evidence of systolic heart failure. He had undergone biological mitral valve replacement 3 years previously for mitral valve stenosis and ablation of atrioventricular nodal reentry tachycardia 18 months previously. At the time of valve replacement, he had no reported evidence of pulmonary arterial hypertension. His echocardiogram showed normal function of a mitral prosthesis, normal global left ventricular systolic function (left ventricular ejection fraction 62 % measured using the Teichholz method), stage I diastolic dysfunction, and a mean systolic pulmonary arterial blood pressure of 50 mmHg. In the 6-minute walk test, the patient walked 104 meters. Catheterization of his right heart chambers and pulmonary arteries confirmed the diagnosis of pulmonary hypertension. Electroanatomic reconstruction of the right ventricular outflow tract and pulmonary artery was performed under direct fluoroscopic visualization, and a merger was made with a formatted image of cardiac computed tomography angiography. Then we performed irrigated cardiac catheter ablation of the pulmonary trunk.
At the patient’s 3-month follow-up, he showed improvement in functional class for fatigue on major exertion, increased distance walked in the 6-minute walk test, and reductions in pressure of both the right cavities and the pulmonary artery. Currently, with 6 months of clinical follow-up, the patient has maintained his functional classification and is pedaling his bicycle.
KeywordsPulmonary arterial hypertension Catheter ablation Denervation 6-Minute walk test Pulmonary arterial pressure
Idiopathic pulmonary arterial hypertension is defined as a group of diseases characterized by a progressive increase in pulmonary vascular resistance that results in right heart failure and premature death [1–7]. Recent therapeutic advances have improved the treatment options, including prostanoids, endothelin receptor antagonists, and phosphodiesterase type 5 inhibitors [3–6, 8, 9]. The pathogenesis of idiopathic pulmonary arterial hypertension is believed to be due to an imbalance between locally produced vasodilators and vasoconstrictors . Recent studies have demonstrated that vascular wall remodeling also contributes to elevated pulmonary vascular resistance . A meta-analysis of 23 randomized controlled trials demonstrated a reduction in mortality of patients who used targeted therapies approved for use in patients with pulmonary arterial hypertension .
6-Minute walk test results
3 months after ablation
6 months after ablation
Right catheterization and mean systolic blood pressure measurements before and after pulmonary artery ablation
Right pulmonary arterial pressure, mmHg
Left pulmonary arterial pressure, mmHg
Pulmonary artery trunk pressure, mmHg
Right ventricular pressure, mmHg
Right atrial pressure, mmHg
The patient was discharged the next morning. No noteworthy changes before or after the procedure or before discharge in the patient’s radiographic or echocardiographic laboratory parameters were seen. The patient’s blood pressure in both the right heart chambers and the pulmonary artery were determined using catheterization before and at 3 and 6 months after the procedure. The results are shown in Table 2. At the patient’s 3-month follow-up examination, he showed an improvement in functional class for fatigue with major exertion. He also demonstrated an increased distance walked in the 6-minute walk test and reduction of the pressures in both the right cavities and the pulmonary artery. Currently, with 6 months of clinical follow-up, he has maintained his improvement in functional classification and is pedaling his bicycle.
There is no cure for pulmonary arterial hypertension, and it remains a life-threatening disorder, though therapies can improve patients’ symptoms, hemodynamics, and outcomes . A recent study performed in China reported, for the first time, the effect of pulmonary arterial denervation on functional capacity and hemodynamics in patients with refractory idiopathic pulmonary arterial hypertension .
The ablation of the pulmonary artery could be a promising tool in the future for the treatment of pulmonary hypertension.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. The ethics committee (Paola Baars Gomes Moises, Luis Marcelo Rodrigues Paz, Humberto Cesar Tinoco, and Jonny Shogo Takahashi) at our institution approved the execution of the case.
We thank Sérgio Oliveira and Pacemed for their technical support.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Galiè N, Hinderliter AL, Torbicki A, Fourme T, Simonneau G, Pulido T, et al. Effects of the oral endothelin-receptor antagonist bosentan on echocardiographic and Doppler measures in patients with pulmonary arterial hypertension. J Am Coll Cardiol. 2003;41:1380–6.View ArticlePubMedGoogle Scholar
- Galiè N, Seeger W, Naeije R, Simonneau G, Rubin LJ. Comparative analysis of clinical trials and evidence-based treatment algorithm in pulmonary arterial hypertension. J Am Coll Cardiol. 2004;43:81S–8S.View ArticlePubMedGoogle Scholar
- Humbert M, Sitbon O, Simonneau G. Treatment of pulmonary arterial hypertension. N Engl J Med. 2004;351:1425–36.View ArticlePubMedGoogle Scholar
- Galiè N, Humbert M, Vachiery JL, Vizza CD, Kneussl M, Manes A, et al. Effects of beraprost sodium, an oral prostacyclin analogue, in patients with pulmonary arterial hypertension: a randomized, double-blind, placebo-controlled trial. J Am Coll Cardiol. 2002;39:1496–502.View ArticlePubMedGoogle Scholar
- Farber HW, Loscalzo J. Pulmonary arterial hypertension. N Engl J Med. 2004;351:1655–65.View ArticlePubMedGoogle Scholar
- Galiè N, Olschewski H, Oudiz RJ, Torres F, Frost A, Ghofrani HA, et al. Ambrisentan for the treatment of pulmonary arterial hypertension: results of the ambrisentan in pulmonary arterial hypertension, randomized, double-blind, placebo-controlled, multicenter, efficacy (ARIES) study 1 and 2. Circulation. 2008;117:3010–9.View ArticlePubMedGoogle Scholar
- Humbert M, Sitbon O, Chaouat A, Bertocchi M, Habib G, Gressin V, et al. Survival in patients with idiopathic, familial, and anorexigen-associated pulmonary arterial hypertension in the modern management era. Circulation. 2010;122:156–63.View ArticlePubMedGoogle Scholar
- Barst RJ, Ivy DD, Gaitan G, Szatmari A, Rudzinski A, Garcia AE, et al. A randomized, double-blind, placebo-controlled, dose-ranging study of oral sildenafil citrate in treatment-naive children with pulmonary arterial hypertension. Circulation. 2012;125:324–34.View ArticlePubMedGoogle Scholar
- Oudiz RJ, Brundage BH, Galiè N, Ghofrani HA, Simonneau G, Botros FT, et al. Tadalafil for the treatment of pulmonary arterial hypertension: a double-blind 52-week uncontrolled extension study. J Am Coll Cardiol. 2012;60:768–74.View ArticlePubMedGoogle Scholar
- Galiè N, Manes A, Negro L, Palazzini M, Bacchi-Reggiani ML, Branzi A. A meta-analysis of randomized controlled trials in pulmonary arterial hypertension. Eur Heart J. 2009;30:394–403.PubMed CentralView ArticlePubMedGoogle Scholar
- Hoeper MM, Barberia JA, Channick RN, Hassoun PM, Lang IM, Manes A, et al. Diagnosis, assessment, and treatment of non-pulmonary arterial hypertension pulmonary hypertension. J Am Coll Cardiol. 2009;54:S85–96.View ArticlePubMedGoogle Scholar
- Rich S. The value of approved therapies for pulmonary arterial hypertension. Am Heart J. 2007;153:889–90.View ArticlePubMedGoogle Scholar
- Chen SL, Zhang FF, Xu J, Xie DJ, Zhou L, Nguyen T, et al. Pulmonary artery denervation to treat pulmonary arterial hypertension: the single-center, prospective, first-in-man PADN-1 Study (First-in-Man Pulmonary Artery Denervation for Treatment of Pulmonary Artery Hypertension). J Am Coll Cardiol. 2013;62:1092–100.View ArticlePubMedGoogle Scholar