Technologies for Treating Left Atrial Decompression in Heart Failure

Dyspnea and exercise intolerance are fundamental clinical features of heart failure that are caused in part by resting or exercise-associated increases in left atrial pressure and consequent pulmonary vascular congestion. Therapies that aim to reduce total body volume and intravascular pressure have been associated with improved outcomes among patients who have heart failure with reduced ejection fraction (HFrEF) (ejection fraction [EF] < 40%), but not heart failure with preserved ejection fraction (HFpEF) (EF > 55%). This may be partly because the latter group is not necessarily total body volume overloaded, but exhibits exertional increases in left atrial pressure. Accordingly, more selective reductions in left atrial pressure, if achievable, may confer symptomatic benefits without the potentially negative sequelae of pharmacologic volume removal and additionally mitigate concerns regarding drug adherence and resistance. Balloon septostomy has been reported in cases of recalcitrant heart failure and hypoxemia, and the utilization of a fenestrated Amplazter Septal Occluder (Abbott Vascular, formerly St. Jude Medical) to maintain a durable Fontan fenestration and interatrial communication was described more than 15 years ago. Mechanical devices that aim to reduce left atrial pressure have been developed and evaluated in HFpEF and HFrEF patients. This article provides an update on three such devices, along with early clinical experience and outlook for the long term