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A modelling study of atrial septostomy for pulmonary arterial hypertension, and its effect on the state of tissue oxygenation and systemic blood flow

Published online by Cambridge University Press:  10 February 2010

Gerhard-Paul Diller ,
Astrid E. Lammers ,
Sheila G. Haworth ,
Konstantinos Dimopoulos ,
Graham Derrick ,
Philipp Bonhoeffer ,
Michael A. Gatzoulis  and
Darrel P. Francis
Gerhard-Paul Diller*
Affiliation:
National Heart and Lung Institute, Imperial College of Science and Medicine, London, UK Adult Congenital Heart Unit, Royal Brompton Hospital, London, UK
Astrid E. Lammers
Affiliation:
Paediatric Cardiology, Great Ormond Street Hospital for Children, London, UK Institute of Child Health, University College London, UK
Sheila G. Haworth
Affiliation:
Paediatric Cardiology, Great Ormond Street Hospital for Children, London, UK Institute of Child Health, University College London, UK
Konstantinos Dimopoulos
Affiliation:
National Heart and Lung Institute, Imperial College of Science and Medicine, London, UK Adult Congenital Heart Unit, Royal Brompton Hospital, London, UK
Graham Derrick
Affiliation:
Paediatric Cardiology, Great Ormond Street Hospital for Children, London, UK
Philipp Bonhoeffer
Affiliation:
Paediatric Cardiology, Great Ormond Street Hospital for Children, London, UK
Michael A. Gatzoulis
Affiliation:
National Heart and Lung Institute, Imperial College of Science and Medicine, London, UK Adult Congenital Heart Unit, Royal Brompton Hospital, London, UK
Darrel P. Francis
Affiliation:
National Heart and Lung Institute, Imperial College of Science and Medicine, London, UK International Centre for Circulatory Health, Imperial College of Science and Medicine, London, UK
*
Correspondence to: Dr Gerhard-Paul Diller, Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK. Tel: +44 207 351 8602; Fax: +44 207 351 8629; E-mail: g.diller@imperial.ac.uk
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Abstract

Atrial septostomy is performed in patients with severe pulmonary arterial hypertension, and has been shown to improve symptoms, quality of life and survival. Despite recognized clinical benefits, the underlying pathophysiologic mechanisms are poorly understood. We aimed to assess the effects of right-to-left shunting on arterial delivery of oxygen, mixed venous content of oxygen, and systemic cardiac output in patients with pulmonary arterial hypertension and a fixed flow of blood to the lungs. We formulated equations defining the mandatory relationship between physiologic variables and delivery of oxygen in patients with right-to-left shunting. Using calculus and computer modelling, we considered the simultaneous effects of right-to-left shunting on physiologies with different pulmonary flows, total metabolic rates, and capacities for carrying oxygen. Our study indicates that, when the flow of blood to the lungs is fixed, increasing right-to-left shunting improves systemic cardiac output, arterial blood pressure, and arterial delivery of oxygen. In contrast, the mixed venous content of oxygen, which mirrors the average state of tissue oxygenation, remains unchanged. Our model suggests that increasing the volume of right-to-left shunting cannot compensate for right ventricular failure. Atrial septostomy in the setting of pulmonary arterial hypertension, therefore, increases the arterial delivery of oxygen, but the mixed systemic saturation of oxygen, arguably the most important index of tissue oxygenation, stays constant. Our data suggest that the clinically observed beneficial effects of atrial septostomy are the result of improved flow of blood rather than augmented tissue oxygenation, provided that right ventricular function is adequate.

Keywords

Shuntingcongenital heart diseaseanalytical modelling
Type
Original Articles
Information
Cardiology in the Young , Volume 20 , Issue 1 , February 2010 , pp. 25 - 32
Copyright
Copyright © Cambridge University Press 2010

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Footnotes

*

These authors contributed equally to this manuscript.

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