Elevation in left atrial (LA) pressure is the pathognomonic finding that defines the presence of heart failure with preserved ejection fraction (HFpEF). High LA pressure during exertion is associated with dynamic pulmonary congestion, exertional dyspnoea and poor quality of life.1 2 Although medical therapy such as sodium glucose cotransporter 2 inhibitors can reduce rest and exercise LA hypertension3 with improved quality of life, there remains substantial residual symptom burden and LA hypertension among patients with HFpEF.
One approach to address this LA hypertension is the creation of an interatrial shunt as a mechanical approach to offload the LA. By establishing a functional communication between the two atria and shunting blood from the LA to the right atrium, single-arm studies and a sham-controlled trial have confirmed a reduction in exercise pulmonary capillary wedge pressure (PCWP).4 Despite these encouraging haemodynamic findings, the large sham-controlled REDUCE LAP-HF 2 trial found no evidence of clinical benefit with an implantable shunt. There did, however, appear to be heterogeneity of effect, with some HFpEF subsets potentially benefitting from the shunt, whereas others appeared harmed by the additional volume loading on the right heart.5 As a result of this uncertainty, the optimal approach and patient selection for shunt creation remain the subject of active investigation.
Current study results
With the many unanswered questions about shunt efficacy and safety in HFpEF, Yan et al present an important pilot study testing a novel personalised approach to shunt creation guided by haemodynamics.6 As opposed to current approaches that use an implantable ‘one-size-fits-all’ shunt approach, the …
