Left atrial shunting devices: why, what, how, and… when?

Left atrial (LA) hypertension is central in the pathophysiology of heart failure (HF) in general and of HF with preserved ejection fraction (HFpEF) in particular. Despite approved treatments, a number of HF patients continue experiencing disabling symptoms due to LA hypertension, causing pulmonary congestion, pulmonary hypertension, and right heart dysfunction, at rest and/or during exercise. LA decompression therapies, i.e., left atrial shunting through a specifically designed device (either implant-based or implant-free), are being studied in various forms of HF to alleviate LA hypertension and patients' symptoms. Despite a solid background and favorable signals from initial non-randomized clinical trials, the quest for the optimal HF candidate for interatrial shunt devices is still an area of active research that at the same time is helping to better elucidate the intricate pathophysiology of HF(pEF).