Management of pulmonary hypertension from left heart disease in candidates for orthotopic heart transplantation (original) (raw)
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Physiological research / Academia Scientiarum Bohemoslovaca, 2011
Pulmonary hypertension (PH) unresponsive to pharmacological intervention is considered a contraindication for orthotopic heart transplantation (OHTX) due to risk of postoperative right-heart failure. In this prospective study, we describe our experience with a treatment strategy of improving severe PH in heart transplant candidates by means of ventricular assist device (VAD) implantation and subsequent OHTX. In 11 heart transplantation candidates with severe PH unresponsive to pharmacological intervention we implanted VAD with the aim of achieving PH to values acceptable for OHTX. In all patients we observed significant drop in pulmonary pressures, PVR and TPG (p < 0.001 for all) 3 months after VAD implantation to values sufficient to allow OHTX. Seven patients underwent transplantation (mean duration of support 216 days) while none of patients suffered right-side heart failure in postoperative period. Two patients died after transplantation and five patients are living in very g...
The Journal of Heart and Lung Transplantation, 2012
Pulmonary hypertension associated with left heart disease is the most common form of pulmonary hypertension encountered in clinical practice today. Although frequently a target of therapy, its pathophysiology remains poorly understood and its treatment remains undefined. Pulmonary hypertension in the context of left heart disease is a marker of worse prognosis and disease severity, but whether its primary treatment is beneficial or harmful is unknown. An important step to the future study of this important clinical problem will be to standardize definitions across disciplines to facilitate an evidence base that is interpretable and applicable to clinical practice. In this current statement, we provide an extensive review and interpretation of the current available literature to guide current practice and future investigation. At the request of the Pulmonary Hypertension (PH) Council of the International Society for Heart and Lung Transplantation (ISHLT), a writing group was assembled and tasked to put forth this document as described above. The review process was facilitated through the peer review process of the Journal of Heart and Lung Transplantation and ultimately endorsed by the leadership of the ISHLT PH Council.
Physiological research / Academia Scientiarum Bohemoslovaca
Pulmonary hypertension (PH) unresponsive to pharmacological intervention is considered a contraindication for orthotopic heart transplantation (OHTX) due to risk of postoperative right-heart failure. In this prospective study, we describe our experience with a treatment strategy of improving severe PH in heart transplant candidates by means of ventricular assist device (VAD) implantation and subsequent OHTX. In 11 heart transplantation candidates with severe PH unresponsive to pharmacological intervention we implanted VAD with the aim of achieving PH to values acceptable for OHTX. In all patients we observed significant drop in pulmonary pressures, PVR and TPG (p<0.001 for all) 3 months after VAD implantation to values sufficient to allow OHTX. Seven patients underwent transplantation (mean duration of support 216 days) while none of patients suffered right-side heart failure in postoperative period. Two patients died after transplantation and five patients are living in very goo...
Reversible Pulmonary Hypertension in Heart Transplant Candidates: To Transplant or Not to Transplant
The Annals of Thoracic Surgery, 2006
Background. Pulmonary hypertension (PHT), defined as a pulmonary vascular resistance (PVR) greater than 2.5 Wood units [WU] and(or) transpulmonary gradient (TPG) greater than 12 mm Hg, is a risk factor for mortality in cardiac transplantation due to elevated postoperative right heart failure. Orthotopic heart transplantation is possible if PVR could be reversed below 2.5 WU and TPG below 12 mm Hg. We show the Muenster experience from the last 10 years. Methods. From April 1996 to December 2005 all cardiac transplant recipients separated into patients with and without PHT were included. All patients with PHT had successful reduction (PVR < 2.5 WU and TPG < 12 mm Hg) using prostaglandin I 2 or E 1. Posttransplant early and late mortality and incidence of right heart failure were studied. Results. Two hundred seventeen patients were included in this study. Of these, 168 had normal pulmonary pressures (non-PHT group), 49 (22.6%) had reversible PHT (rev-PHT group). Mean PVR was 1.6 ؎ 1.1 WU vs 2.1 ؎ 1.1 WU (p < 0.01; non-PHT vs rev-PHT) and mean TPG 8.0 ؎ 1.9 mm Hg vs 10.6 ؎ 4.1 mm Hg (p ؍ not significant [NS]). Thirty-day survival after orthotopic cardiac transplantation was 85% vs 78% (p ؍ 0.150) and 10 year survival 63% vs 61% (p ؍ NS). Right heart failure during the first 30 days after transplantation occurred in 27% in the non-PHT group and in 64% in the rev-PHT group (p ؍ 0.035). However, in patients transplanted after 2001 it did not appear. Conclusions. Cardiac transplant candidates with reversible PHT have still significantly elevated pulmonary pressures compared with patients without PHT. Despite a significantly higher risk of right heart failure, long-term survival after orthotopic cardiac transplantation was not affected.
Current and future therapy for pulmonary hypertension in patients with right and left heart failure
Expert Review of Cardiovascular Therapy, 2010
Pulmonary hypertension (PH) is a devastating condition that without proper management can deteriorate progressively. Elevated pulmonary artery pressure without an identifiable etiology is called IPAH. PH resulting from a specific disease is referred to as secondary PH; left-sided cardiac disease can lead to an increase in pulmonary artery pressure resulting in increased vascular resistance and subsequent structural remodeling. If left-sided failure progresses to right-sided failure with high pulmonary artery pressure, the outcome is ominous. It has been clearly proven that early diagnosis and effective medical therapy can markedly decrease morbidity and mortality. In this review, we discuss the current treatment modalities and their limitations for PH secondary to heart failure. Conventional therapy in patients with pulmonary arterial hypertension as well as recent advances in the medical management of PH in general, are also described. Last, the surgical management of these patients and other promising interventional modalities are reviewed.
Right ventricle–sparing heart transplantation effective against iatrogenic pulmonary hypertension
The Journal of Heart and Lung Transplantation, 2004
Right heart failure is the predominant cause of death following heart transplantation, occurring with disturbingly high frequency in patients with severe antecedent pulmonary hypertension. We have recently reported a novel technique of heart transplantation that spares the recipient right ventricle, excising only the recipient left ventricle. The resulting model has 2 right hearts and 1 left heart. The aim is to preserve the recipient's right ventricle, which is already conditioned to pulmonary hypertension. The hope is that, in this way, death due to right heart failure can be prevented in humans. Our prior report was a feasibility study in normal dogs. This study challenges this new technique by creating iatrogenic pulmonary hypertension in the recipient animals.
The Journal of Heart and Lung Transplantation, 2010
The prognostic impact of pulmonary hypertension (PH) before and after heart transplantation (HTx) is debated. We investigated: (i) the significance of pre-operative reversible PH on postoperative survival; (ii) the value of recatheterization while on the waiting list; (iii) the evolution of right heart hemodynamics (RHH) after HTx; and (iv) the prognostic impact of PH at 1 year after HTx. METHODS: We reviewed the records of 500 HTx recipients transplanted between 1983 and 2007. Preoperatively, a non-PH group (Group 1, n ϭ 365) fulfilled directly our RHH criteria for HTx, while a PH group (Group 2, n ϭ 135) was accepted after reversibility of PH by acute vasodilatory testing. Recatheterization was performed every third month while on the waiting list and repeatedly after transplantation. RESULTS: With a follow-up of 6.8 Ϯ 5.1 years and a 50% survival rate of 12.1 Ϯ 5.4 years, our main findings were as follows: (i) Patients with reversible PH on vasodilatory testing had a survival rate similar to that of patients without PH (11.7 Ϯ 0.8 vs 12.1 Ϯ 0.5 years, p ϭ 0.80). (ii) Pre-operative recatheterization was of limited value as RHH remained stable. Five percent of patients died while on the waiting list and 2 improved clinically and were removed. (iii) Mean pulmonary artery pressure (MAP) was reduced from 28 Ϯ 9 and 40 Ϯ 8 mm Hg pre-operatively to 21 Ϯ 7 and 24 Ϯ 6 mm Hg after 2 weeks and 16 Ϯ 7 and 18 Ϯ 8 mm Hg at 3 years in Groups 1 and 2, respectively. (iv) Recipients with MAP Ͼ20 mm Hg at 1 year post-HTx had significantly lower survival than those with MAP Յ20 mm Hg (11.5 Ϯ 0.7 vs 15.6 Ϯ 0.6 years, p Ͻ 0.001). CONCLUSIONS: Elevated pulmonary pressure 1 year after HTx provides significant prognostic information regarding long-term outcome, whereas pre-operative reversible PH in this group does not influence survival.
Kardiologia Polska
HF and is considered one of key contraindications to orthotopic heart transplant (OHT). 2,9 Reversing increased pulmonary capillary pressure represents a therapeutic challenge, which would make OHT-a final resolution of congestive HF-possible. There have been few studies that analyzed the impact of CF-LVAD implantation on pulmonary pressure and resistance. Some authors INTRODUCTION A constant increase in the number of patients with end-stage heart failure (HF) and a shortage of heart donors worldwide implies a wider use of mechanical circulatory support, mainly continuous-flow left ventricular assist devices (CF-LVADs).
The Journal of Thoracic and Cardiovascular Surgery, 2007
Objective: Fixed pulmonary hypertension is a contraindication for cardiac transplantation because of the increased risk of donor heart failure. We sought to determine whether left ventricular assist devices improve fixed pulmonary hypertension in cardiac transplant candidates to enable safe cardiac transplantation. Methods: Thirty-five consecutive cardiac transplant candidates (age 56 Ϯ 6 years, 88.5% were men) with fixed pulmonary hypertension (5.1 Ϯ 2.6 Wood units) resistant to medical treatment received a left ventricular assist device as a bridge to transplantation. Three left ventricular assist device systems were used (pulsatile blood flow: Novacor [World Heart Inc, Oakland, Calif] n ϭ 8; continuous blood flow: MicroMed DeBakey [MicroMed Technology Inc, Houston, Tex] n ϭ 24, DuraHeart [Terumo Heart Inc, Ann Arbor, Mich] n ϭ 3). Right-sided heart catheter data were obtained before left ventricular assist device implantation at 3-day and 6-week follow-ups. Clinical data and complications were recorded. Results: Before left ventricular assist device implantation, the pulmonary vascular resistance was 5.1 Ϯ 2.8 Wood units. Values were comparable in patients receiving pulsatile (5.1 Ϯ 3.4 Wood units) or continuous blood flow left ventricular assist devices (5.1 Ϯ 2.7 Wood units, P ϭ .976). Left ventricular assist device implantation decreased pulmonary vascular resistance at 3-day (2.9 Ϯ 1.3 Wood units, P Ͻ .0001) and 6-week (2.0 Ϯ 0.8 Wood units, P Ͻ .0001) follow-ups compared with before implantation. This effect was independent of the type of left ventricular assist device system used (3-day follow-up: pulsatile flow: 3.2 Ϯ 1.3 Wood units vs continuous flow: 2.7 Ϯ 1.2 Wood units; P ϭ .310 and 6-week follow-up: pulsatile flow: 1.9 Ϯ 0.9 Wood units vs continuous flow: 2.1 Ϯ 0.8 Wood units; P ϭ .905). Twenty-four patients had successful bridges to transplantation (69%, mean time on left ventricular assist device 210 Ϯ 83 days), and 11 patients died before transplantation (31%, mean time on left ventricular assist device 67 Ϯ 30 days). The 1-year survival after transplantation was 95%. Conclusion: Left ventricular assist devices decrease fixed pulmonary hypertension in cardiac transplant candidates and allow patients to overcome a contraindication for cardiac transplantation. Therefore, left ventricular assist devices should be considered in all cardiac transplant candidates with fixed pulmonary hypertension. T he prevalence of congestive heart failure is continuously increasing in the Western world. 1 Despite continuous advances of medical therapy for congestive heart failure, cardiac transplantation is the most effective treatment for patients with end-stage heart failure. 2 Pulmonary hypertension (PH) is a risk factor for early and late death after cardiac transplantation. The reason for this is the unacceptably high risk of acute donor right-sided heart failure immediately after implantation. 3-7 There is consensus that the risk of death after cardiac transplantation is increased in patients with pulmonary