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Is partially reversible pulmonary hypertension a contraindication for heart transplantation?
Is Partially Reversible Pulmonary Hypertension a Contraindication for Heart Transplantation? A. Baldovinos, A. Kalangos, J. Sierra, M.-J. Licker, and B. Faidutti
H
EART transplantation is in constant evolution, but pulmonary hypertension remains one of the major contraindications for this type of treatment. Demonstration of reversibility of the pulmonary vascular resistance (PVR) is important in pretransplant evaluation to identify those at risk of right ventricle failure after transplantation.1 There is constant dilemma on whether to proceed to heart transplantation alone in the presence of a partially reversible pulmonary hypertension (PRPH). We present our experience with seven patients with PRPH who underwent heart transplantation. MATERIALS AND METHODS Between 1990 and 1997, a total of 53 orthotopic heart transplantations were done in our institution. Seven patients presented with PRPH, at the reversibility test with sodium nitroprusside realized every 6 months while waiting for a graft. The selection criteria for candidates for transplantation are similar to other transplantation centers.2,3 All patients were adults, with mean age of 50 years (range 29 to 62 years). All patients were in NYHA functional class IV; there were six men and one woman. The etiology was idiopathic in four patients and ischemic in three patients. The ischemic mean arrest time was 161 minutes (range 73 to 210 minutes). All patients received an iso-group graft. One patient was transplanted on an urgent basis and six transplanted electively. The weight differences between donors and recipients were similar only was accepted 5% less or 20% more of donor’s body weight in relation to the recipient’s, since undersized organs increases the risk of graft failure.4 The right heart-side catheterization with sodium nitroprusside test was performed routinely every 6 months in patients on the waiting list. The PVR is described in dyn 䡠 s 䡠 cm⫺5. All patients were treated with inhaled nitric oxide (NO), immediately after extracorporeal circulation (ECC) weaning, starting from 1 to 3 ppm, enhancing by steps of 10 ppm every 5 minutes according to the evolution of the pulmonary hypertension, up to a maximum of 80 ppm. In case of no response at this time, we added a right ventricular assistance (RVA), of ABIOMED® BVS 5000. One patient needed a different type of assistance, an intra-aortic balloon pump (IABP), for vasoplegic hypotension.
RESULTS
Results of the pretransplantation reversibility tests are shown in Table 1. In our series three patients were managed 0041-1345/00/$–see front matter PII S0041-1345(99)00820-4 468
Table 1. Results of Pretransplantation Reversibility Tests PVR (dyn 䡠 s 䡠 cm⫺5) Patients
Pretest
Posttest
I II III IV V VI VII
358 370 360 390 401 413 405
220 252 280 295 320 360 343
only with NO, one with NO and IABP for systemic reasons, and three with NO and RVA. The patients managed with NO only presented a mean reduction of the PVR of 97 dyn 䡠 s 䡠 cm⫺5 (89 –107). One patient died 2 years after transplantation for extracardiac causes; at the last catheterization the PVR was 94 dyn 䡠 s 䡠 cm⫺5. The other two patients are alive at 2 years after transplantation with a PVR of 89 and 107 dyn 䡠 s 䡠 cm⫺5. The patient treated with NO and IABP presented a reduction of the PVR to 80 dyn 䡠 s 䡠 cm⫺5 and is alive at 1 year after transplantation. Of the patients receiving NO and RVA, one presented a reduction with the PVR to 130 dyn 䡠 s 䡠 cm⫺5 and is alive at 2 years following transplantation; the other two died of septicemia at the 10th and 15th postoperative day. The patients alive are all in NYHA class I. DISCUSSION
The patients with PRPH who are transplanted benefit from an aggressive treatment of the pulmonary hypertension (PH) soon after weaning from ECC, since managing the right ventricle is one of the keys to a successful heart transplantation. Indeed, the leading cause of perioperative mortality in heart transplant recipients is right ventricular failure because of pulmonary artery hypertension.5 Initially, we manage PRPH in transplanted patients with NO. If PH From the Clinic for Cardiovascular Surgery and Division of Anesthesiology, University Cantonal Hospital of Geneva, Geneva, Switzerland. Address reprint requests to Dr Ary Baldovinos, Clinic for Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland. © 2000 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 32, 468–469 (2000)
REVERSIBLE PULMONARY HYPERTENSION
persists after reaching a maximal dose of NO, we start RVA in the operating room in order to further protect right ventricular function. Even though ventricular assistance devices add morbidity and mortality (infections, bleeding, thromboembolism, failure of the nonassisted ventricle) this is a good means for helping the right ventricle to adapt to a more demanding hemodynamic condition established by a higher vascular resistance. The ABIOMED® BVS 5000 is simple to operate; it requires minimal operator intervention because it automatically adjusts to different hemodynamic conditions of the patient,6 and the cost of utilization remains very low. There is another possibility of treating patients with PRPH, which is that of a heart–lung transplantation. This option has a much higher morbidity and mortality than heart transplantation alone. Moreover, in our country, as in so many other countries, the lack of donors is a big problem, so we tend to use this option in case of fixed PH and spare the lungs for cases of primary pulmonary diseases. Miller et al found that patients presenting a PVR postreversibility test superior to 400 dyn 䡠 s 䡠 cm⫺5 were a contraindication to heart transplantation.7 In our series all cases presented a PVR posttest inferior to 400 dyn 䡠 s 䡠 cm⫺5.
469
CONCLUSIONS
The introduction of NO in the clinic offers a considerable advantage in the management of patients with PRPH. The RVA offers an additional aid for the cases where NO is inefficient, but at the price of higher morbidity and mortality rates. Determining reversibility of pulmonary hypertension associated with postoperative management with NO and RVA shows that PRPH is not a contraindication to heart transplantation in well-selected patients.
REFERENCES 1. Elaine MC, Chau MB, Kent R, et al: Circulation 94(suppl II):XX, 1996 2. Miller LW: Cardiol Clin 13:93, 1995 3. Stevenson LW: Curr Opin Cardiol 11:166, 1996 4. Lund M, Ellis CJ, Coverdale, et al: N Z M J 110:139, 1997 5. Frantz RP, Olso LJ: Am J Med Sci 314(3):139, 1997 6. Jett KG: Ann Thorac Surg 61:301, 1996 7. Miller LW, Kubo SH, Young JB, et al: J Heart Lung Transplant 14:562, 1995
H
EART transplantation is in constant evolution, but pulmonary hypertension remains one of the major contraindications for this type of treatment. Demonstration of reversibility of the pulmonary vascular resistance (PVR) is important in pretransplant evaluation to identify those at risk of right ventricle failure after transplantation.1 There is constant dilemma on whether to proceed to heart transplantation alone in the presence of a partially reversible pulmonary hypertension (PRPH). We present our experience with seven patients with PRPH who underwent heart transplantation. MATERIALS AND METHODS Between 1990 and 1997, a total of 53 orthotopic heart transplantations were done in our institution. Seven patients presented with PRPH, at the reversibility test with sodium nitroprusside realized every 6 months while waiting for a graft. The selection criteria for candidates for transplantation are similar to other transplantation centers.2,3 All patients were adults, with mean age of 50 years (range 29 to 62 years). All patients were in NYHA functional class IV; there were six men and one woman. The etiology was idiopathic in four patients and ischemic in three patients. The ischemic mean arrest time was 161 minutes (range 73 to 210 minutes). All patients received an iso-group graft. One patient was transplanted on an urgent basis and six transplanted electively. The weight differences between donors and recipients were similar only was accepted 5% less or 20% more of donor’s body weight in relation to the recipient’s, since undersized organs increases the risk of graft failure.4 The right heart-side catheterization with sodium nitroprusside test was performed routinely every 6 months in patients on the waiting list. The PVR is described in dyn 䡠 s 䡠 cm⫺5. All patients were treated with inhaled nitric oxide (NO), immediately after extracorporeal circulation (ECC) weaning, starting from 1 to 3 ppm, enhancing by steps of 10 ppm every 5 minutes according to the evolution of the pulmonary hypertension, up to a maximum of 80 ppm. In case of no response at this time, we added a right ventricular assistance (RVA), of ABIOMED® BVS 5000. One patient needed a different type of assistance, an intra-aortic balloon pump (IABP), for vasoplegic hypotension.
RESULTS
Results of the pretransplantation reversibility tests are shown in Table 1. In our series three patients were managed 0041-1345/00/$–see front matter PII S0041-1345(99)00820-4 468
Table 1. Results of Pretransplantation Reversibility Tests PVR (dyn 䡠 s 䡠 cm⫺5) Patients
Pretest
Posttest
I II III IV V VI VII
358 370 360 390 401 413 405
220 252 280 295 320 360 343
only with NO, one with NO and IABP for systemic reasons, and three with NO and RVA. The patients managed with NO only presented a mean reduction of the PVR of 97 dyn 䡠 s 䡠 cm⫺5 (89 –107). One patient died 2 years after transplantation for extracardiac causes; at the last catheterization the PVR was 94 dyn 䡠 s 䡠 cm⫺5. The other two patients are alive at 2 years after transplantation with a PVR of 89 and 107 dyn 䡠 s 䡠 cm⫺5. The patient treated with NO and IABP presented a reduction of the PVR to 80 dyn 䡠 s 䡠 cm⫺5 and is alive at 1 year after transplantation. Of the patients receiving NO and RVA, one presented a reduction with the PVR to 130 dyn 䡠 s 䡠 cm⫺5 and is alive at 2 years following transplantation; the other two died of septicemia at the 10th and 15th postoperative day. The patients alive are all in NYHA class I. DISCUSSION
The patients with PRPH who are transplanted benefit from an aggressive treatment of the pulmonary hypertension (PH) soon after weaning from ECC, since managing the right ventricle is one of the keys to a successful heart transplantation. Indeed, the leading cause of perioperative mortality in heart transplant recipients is right ventricular failure because of pulmonary artery hypertension.5 Initially, we manage PRPH in transplanted patients with NO. If PH From the Clinic for Cardiovascular Surgery and Division of Anesthesiology, University Cantonal Hospital of Geneva, Geneva, Switzerland. Address reprint requests to Dr Ary Baldovinos, Clinic for Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland. © 2000 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 32, 468–469 (2000)
REVERSIBLE PULMONARY HYPERTENSION
persists after reaching a maximal dose of NO, we start RVA in the operating room in order to further protect right ventricular function. Even though ventricular assistance devices add morbidity and mortality (infections, bleeding, thromboembolism, failure of the nonassisted ventricle) this is a good means for helping the right ventricle to adapt to a more demanding hemodynamic condition established by a higher vascular resistance. The ABIOMED® BVS 5000 is simple to operate; it requires minimal operator intervention because it automatically adjusts to different hemodynamic conditions of the patient,6 and the cost of utilization remains very low. There is another possibility of treating patients with PRPH, which is that of a heart–lung transplantation. This option has a much higher morbidity and mortality than heart transplantation alone. Moreover, in our country, as in so many other countries, the lack of donors is a big problem, so we tend to use this option in case of fixed PH and spare the lungs for cases of primary pulmonary diseases. Miller et al found that patients presenting a PVR postreversibility test superior to 400 dyn 䡠 s 䡠 cm⫺5 were a contraindication to heart transplantation.7 In our series all cases presented a PVR posttest inferior to 400 dyn 䡠 s 䡠 cm⫺5.
469
CONCLUSIONS
The introduction of NO in the clinic offers a considerable advantage in the management of patients with PRPH. The RVA offers an additional aid for the cases where NO is inefficient, but at the price of higher morbidity and mortality rates. Determining reversibility of pulmonary hypertension associated with postoperative management with NO and RVA shows that PRPH is not a contraindication to heart transplantation in well-selected patients.
REFERENCES 1. Elaine MC, Chau MB, Kent R, et al: Circulation 94(suppl II):XX, 1996 2. Miller LW: Cardiol Clin 13:93, 1995 3. Stevenson LW: Curr Opin Cardiol 11:166, 1996 4. Lund M, Ellis CJ, Coverdale, et al: N Z M J 110:139, 1997 5. Frantz RP, Olso LJ: Am J Med Sci 314(3):139, 1997 6. Jett KG: Ann Thorac Surg 61:301, 1996 7. Miller LW, Kubo SH, Young JB, et al: J Heart Lung Transplant 14:562, 1995