Intravenous sildenafil in right ventricular dysfunction with pulmonary hypertension following a heart transplant

Abstract

The objective of the present work is to describe the experience with intravenous (IV) sildenafil in heart transplant (HT) patients with reactive pulmonary hypertension (PH) who developed right ventricular dysfunction (RVD) in the immediate postoperative period. The first 5 patients who received IV sildenafil followinga HT are presented. The HTs took place between March 2011 and September 2012 in patients aged 37 to 64 years; all patients were male. Prior to the HT, mean pulmonary artery pressure (mPAP) was 32-56 mmHg. In all cases, the hemodynamic study demonstrated PH reactivity (positive vasodilator test with nitric oxide). All 5 patients developed RVD with hemodynamic instability immediately after the HT, despite the administration of nitric oxide from the time of intubation prior to the implant, optimal medical treatment in all cases, and a ventricular assist in 2 cases. In all patients, IV sildenafil was initiated at 10 mg/8 h for 48 h and was subsequently increased to 20 mg/8 h. in its oral formulation until discharge from the hospital. The change in pulmonary pressure was assessed using a Swan-Ganz catheter. Ventricular function was assessed using echocardiography. Length of stay in the Resuscitation Unit and mid-term survival were also assessed. Average time of extracorporeal circulation was 200 ± 110 min and organ ischemic time was 210 ± 95 min. All of the patients demonstrated pulmonary and systemic hemodynamic improvement, as well as recovery of right ventricular function after completing the treatment with IV sildenafil. The stay in the Resuscitation Unit lasted 3-25 days. All the patients were discharged from hospital with no mortality to date. Intravenous sildenafil improves right ventricle hemodynamics associated with pulmonary hypertension post-HT. Prophylactic prevention with this drug could be indicated for patients with reactive PH who are about to receive a transplant.

Keywords: Cardiac transplant; Intravenous sildenafil; PDE-5 inhibitor; Pulmonary hypertension; Right ventricular dysfunction.

Fig. 1 -

Values prior to the heart transplant. mPAP = mean pulmonary artery pressure; PCP = pulmonary capillary pressure; TPG = trans-pulmonary gradient; HT = heart transplant.

Fig. 2 -

Time of extracorporeal circulation and organ ischemic time.

Fig. 3 -

Postoperative TAPSE values after intravenous sildenafil. CVS = cardiovascular surgery; TAPSE = tricuspid annular plane systolic excursion.

Fig. 4 -

Mean pulmonary artery pressure after intravenous sildenafil. mPAP = mean pulmonary artery pressure; HT = heart transplant.