Management of pulmonary hypertension from left heart disease in candidates for orthotopic heart transplantation

Abstract

Pulmonary hypertension in left heart disease (PH-LHD) commonly complicates prolonged heart failure (HF). When advanced, the PH becomes fixed or out of proportion and is associated with increased morbidity and mortality in patients undergoing orthotopic heart transplant (OHT). To date, the only recommended treatment of out of proportion PH is the treatment of the underlying HF by reducing the pulmonary capillary wedge pressure (PCWP) with medications and often along with use of mechanical circulatory support. Medical therapies typically used in the treatment of World Health Organization (WHO) group 1 pulmonary arterial hypertension (PAH) have been employed off-label in the setting of PH-LHD with varying efficacy and often negative outcomes. We will discuss the current standard of care including treating HF and use of mechanical circulatory support. In addition, we will review the studies published to date assessing the efficacy and safety of PAH medications in patients with PH-LHD being considered for OHT.

Effect of Pulmonary Hypertension on Transplant Outcomes in Patients With Ventricular Assist Devices

“…PCWP, mm Hg 18 (12,24) 21 (15,26) 23 (17,28) <.001 15 (9,20) 19 (10,27) 23 ( Continuous data are presented as the median (25th, 75th percentile) and categorical data as number (%).…”

“…In addition, although in the early 1990s pulmonary dilators, such as sodium nitroprusside, had already been considered to be effective in reducing pretransplant PVR for HTx candidacy, 3 there have been dramatic developments since the 2000s in other pulmonary dilation therapies. [7][8][9] We could speculate that recent post-HTx management with such highly effective dilators might have mitigated a negative impact of PVR on HTx outcomes, especially in the non-LVAD cohort. In the LVAD cohort, however, such dilator therapies might not be as effective as expected because their high PVR values were already fixed, which were not reversible even with LV unloading by LVADs.…”

“…2 In its renewed recommendation in 2016, there was no clear statement regarding an eligibility criterion for PVR. 6 This is likely because expert consensus acknowledges recent advances in the prevention and management of RHF or pulmonary hypertension (PH) [7][8][9] has enabled transplant programs to successfully perform transplantation in patients previously considered ineligible for transplant on the basis of high PVR.…”

ISHLT consensus statement: Perioperative management of patients with pulmonary hypertension and right heart failure undergoing surgery

“…Management of PH in AHF remains challenging (259)(260)(261)(262). As combined post-and precapillary PH (CpcPH) may be characterized by superimposed arterial vasoconstriction ± vascular arterial and venous remodelling above and beyond venous congestion, it has been suggested that pulmonary vasodilator therapy utilized for PAH, might be of value in PH due to LHD including LHF.…”

Anaesthesia for heart transplantation

“…pulmonary vasodilators. 14 The operating theatre teamdincluding the senior surgeon and perfusionistdshould be immediately available when anaesthesia is induced. For patients with an LVAD, a practitioner trained in managing the device should remain in the operating theatre until the device is explanted.…”