1197-153 - MANAGEMENT OF RIGHT HEART FAILURE IN COMBINED PRE AND POST-CAPILLARY PULMONARY HYPERTENSION AFTER LEFT VENTRICULAR ASSIST DEVICE PLACEMENT

View session detail

Author Block: Shyla McMurtry, Michael Pascoe, Vasili Katsadouros, Maya Ignaszewski, Andrew Kolodziej, Department of Internal Medicine, University of Kentucky, Lexington, KY, USA, Department of Cardiology, University of Kentucky, Lexington, KY, USA
Background: We present a patient with heart failure with reduced ejection fraction (HFrEF) and WHO group 2 pulmonary hypertension (PH) with elevated pulmonary vascular resistance (PVR) before left ventricular assist device (LVAD) placement with concern for RV failure.
Case: A 57yo female with WHO group 2 PH, HFrEF due to ischemic cardiomyopathy evaluated for LVAD. Pre-operative right heart catheterization (RHC) showed left heart failure with low cardiac index (CI) of 1.5L/min/m2 by thermodilution and Fick while on milrinone 0.25mcg/kg/min, elevated right heart pressures (RA 15, RV 77/9, PA 82/34, PCWP 29), and PVR of 8.7 WU. While CI and PCWP improved with nitroprusside (CI 2.2 -2.3; PCWP 7), PVR remained elevated at 6 WU. Treated as combined pre- and post-capillary PH with sildenafil and selexipag followed by BiVAD placement. During RVAD removal, patient developed hypotension, low flows, and a rise in central venous pressure (CVP) to 15mmHg concerning for right heart failure. LVAD settings at before inhaled epoprostenol (iNO) at speed 5000 rpm, flow 4.0 lpm, pulsatility index (PI) 4.0, and power of 3.3W. Repeat RHC showed mixed etiology PH (RA 23, RV 51/14, PA 59/29, PCWP 19) and continued elevated PVR to 6WU, thus started on sildenafil and iNO along with pre-existent milrinone. Right heart dysfunction stabilized allowing for weaning of inotropic support. LVAD readings after iNO discontinuation stabilized to speed of 5100 rpm, flow of 3.8 lpm, PI of 5.4, and power of 3.4W and ultimately discharged on sildenafil only.
Decision‐making: Long-term left heart failure leading to WHO group2 PH can develop elevated PVR and histological changes reminiscent of PAH. Few studies evaluating PAH medications in WHO group 2 PH have been associated with increased mortality, especially in the Flolan International Randomized Survival Trial treating HFrEF with epoprostenol. Phosphodiesterase type 5 inhibitors have been shown to improve right heart hemodynamics with improving cardiac output and facilitating weaning of iNO especially after LVAD placement.
Conclusion: While studies are needed to evaluate using PAH medications in WHO group 2 PH, we highlight their use in managing right heart failure during LVAD placement.