Sildenafil melhora a função ventricular direita no receptor de transplante cardíaco

Abstract

The use of a female donor for a male recipient is known to have a greater early mortality (OR=1.11, P=0.3), similarly to that of a recipient using vasoactive drugs and waiting in the intensive care unit (OR=2.51, P<0.0001) [13][14][15] .We report the case of a patient undergoing orthotopic cardiac transplantation, who experienced cardiogenic shock due to right ventricular dysfunction secondary to pulmonary hypertension associated with vasoplegia. Because the recipient's clinical condition was critical, a marginal donor was used.In the national literature, we did not find reports of the use of sildenafil for pulmonary hypertension in the postoperative period. The objective of this report is to propose a new and safe manner to treat right ventricular failure secondary to pulmonary hypertension in the postoperative period of cardiac transplantation. Case ReportThe patient was a 33-year-old man with idiopathic dilated cardiomyopathy, who had been in NYHA functional class IV for the preceding 2 years and was hospitalized with low cardiac output and was using catecholamines (dobutamine, 6.6 mcg/kg/min, and dopamine, 8 mcg/kg/min). The patient was hypotensive (blood pressure of 70x40 mmHg), slightly dyspneic at rest, and had hepatomegaly and pulmonary congestion (basal rales in both bases).The patient underwent orthotopic cardiac transplantation on 08/02/2003. Due to his rapid clinical worsening, a marginal organ was used. The marginal donor was a 60-kg female, who had experienced cardiac arrest for 15 minutes 3 days before, was using 12 mcg/kg/min of dopamine, and, on the echocardiogram, had diffuse, mild hypokinesia and preserved overall function.The transplantation was performed according to the bicaval technique with 165 minutes of extracorporeal circulation and 117 minutes of anoxia, under mild hypothermia (32 o C) and use of intermittent anterograde blood cardioplegia. The patient was removed from the extracorporeal circulation after the third attempt and sent to the ICU receiving 0.11 mcg/kg/min of isoproterenol, 0.75 mcg/ kg/min milrinone, and 20mcg/kg/min of dobutamine. His mean blood pressure was 40 mmHg and mean pulmonary arterial pressure was 45 mmHg. His right ventricular contractility was very poor, and he received adrenaline in bolus during transportation and in the first hours at the ICU. Twelve hours after transplantation, the patient was receiving 10mcg/kg/min of dobutamine, 0.96 mcg/kg/min of adrenaline, 0.13 mcg/kg/min of isoproterenol, and 0.41 mcg/kg/ The use of inhaled nitric oxide reduces pulmonary artery pressure, increasing the production of guanosine 3',5'-cyclic monophosphate (GMPc) in the smooth muscle cells of the lung 1 . Specific inhibitors of GMPc phosphodiesterase (PDE5), which hydrolyzes GMPc in vascular smooth muscle, cause pulmonary vasodilation 2-4 .Sildenafil is a specific inhibitor of PDE5 that increases the pulmonary vasodilating effect of inhaled nitric oxide 5-8 , prevents pulmonary hypertensive crises after weaning of nitric oxide in patients with severe pulmonary hypertensio...