38-year-old Thai male1 wk dyspnea, no orthopnea, no PNDAntiphospholipid syndrome (APS, Lupus anticoagulant (LA) positive), Recurrent Pulmonary emboli, CTEPH s/p Pulmonary endarterectomy
BP 165/119 mmHg, HR 98 bpm, RR 24 bpm, T 36.8°C, O2 sat 92% Cardiac: Normal S1, Lound P2, no murmursLungs: clear lung fields.Extremities: pitting edema 1+ both legs

EKG: NSR at 96 bpm, normal axis + 60 degree, no LV hypertrophy, inverted T at V1-V4, non specific st-t change, no arrhythmias Echocardiogram: LVEF measured at 65%. No RWMAs. RV enlargement, systolic and diastolic D-shaped LV, Moderate TR, severe Pulmonary HT CT pulmonary artery:  Filling defect with eccentric lesions in anterior and posterior basal segment of right interlobar artery, enlarge pulmonary trunk suspected Pulmonary arterial hypertension.  

CAG: Rt dominant, LCA & RCA normal 

Indication for AS: Severe pulmonary hypertension that is refractory to pulmonary endarterectomy and medication Procedural details 1. 8, 6 French sheath were introduced via the right femoral vein (RFV) and artery (RFA) respectively.2. Perform right and left heart catheterization via RFV, RFA3. Using TEE guided transeptal puncture4. Septal puncture with Mullins sheath with Brockenbrough needle5. The dilator was introduced with counter-clock turn to avoid injury to posterior LA surface or roof of LA6. Sheath was introduced over the dilator without pushing the dilator further into LA7. Position of the sheath inside LA was confirmed with TEE8. Brokenbrough needle and dilater were withdrawn9. Turntrac 0.014 x 190 cm wire was passed to LA10. NC balloon 5.0 x 15 mm multiple inflated at atrial septum upto 20 atm 

 1.  Graded Coronary Non Compliant Balloon atrial septostomy maintained the atrial septum to relieved right heart strain and improve left sided filling. The increase in cardiac output offsets the decrease in arterial oxygen concentration. 2.     Balloon atrial septostomy as a palliative therapy for refractory PHT  can bring about significant clinical and hemodynamic improvement.         3. Multimodal approach that combines Pulmonary endarterectomy, Balloon atrial septostomy and drug therapies have also shown effective results.