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Review
. 2021 Mar;9(6):522.
doi: 10.21037/atm-20-4710.

Pulmonary vasodilator use in continuous-flow left ventricular assist device management

Preethi Pirlamarla  1 , Eduardo Rame  1 , Charles Hoopes  2 , Indranee Rajapreyar  3
Affiliations
Review

Pulmonary vasodilator use in continuous-flow left ventricular assist device management

Preethi Pirlamarla et al. Ann Transl Med. 2021 Mar.

Abstract

Pulmonary hypertension (PH) due to left heart disease is the most common etiology for PH. PH in patients with heart failure with reduced fraction (HFrEF) is associated with reduced functional capacity and increased mortality. PH-HFrEF can be isolated post-capillary or combined pre- and post-capillary PH. Chronic elevation of left-sided filling pressures may lead to reverse remodeling of the pulmonary vasculature with development of precapillary component of PH. Untreated PH in patients with HFrEF results in predominant right heart failure (RHF) with irreversible end-organ dysfunction. Management of PH-HFrEF includes diuretics, vasodilators like angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers or angiotensin-receptor blocker-neprilysin inhibitors, hydralazine and nitrates. There is no role for pulmonary vasodilator use in patients with PH-HFrEF due to increased mortality in clinical trials. In patients with end-stage HFrEF and fixed PH unresponsive to vasodilator challenge, implantation of continuous-flow left ventricular assist device (cfLVAD) results in marked improvement in pulmonary artery pressures within 6 months due to left ventricular (LV) mechanical unloading. The role of pulmonary vasodilators in management of precapillary component of PH after cfLVAD is not well-defined. The purpose of this review is to discuss the pharmacologic management of PH after cfLVAD implantation.

Keywords: Combined pre and post-capillary pulmonary hypertension; continuous-flow left ventricular assist device (cfLVAD); pulmonary vasodilators; right heart failure (RHF).

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-20-4710). The series “Heart Failure Update and Advances in 2021” was commissioned by the editorial office without any funding or sponsorship. Dr. Rame reports that he is in Actelion Pharmaceuticals (now Jansen Inc): Steering Committee Member for the SoPrANO Trial investigating Macitentan in patients with Pulmonary Hypertension after Left Ventricular Assist Device. The authors have no other conflicts of interest to declare.

Figures

Figure 1
Figure 1
Pathophysiology of Right ventricular failure after continuous flow left ventricular assist device implantation. IVS, interventricular septum; TR, tricuspid regurgitation; MR, mitral regurgitation; LAP, left atrial pressure; PI, pulmonic insufficiency; IAS, interatrial septum; RV, right ventricle; LV, left ventricle; LVAD, left ventricular assist device; CO, cardiac output.
See this image and copyright information in PMC

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