Right ventricular assist and prostacyclin infusion for allograft failure in the presence of high pulmonary vascular resistance.
The presence of high pulmonary vascular resistance (PVR) greater than 4 Wood units contributes to significant early posttransplant mortality, and remains a negative predictor of long-term survival. Current trends have been toward exclusion of the recipient with high PVR from the orthotopic procedure; elective heterotopic allograft placement is increasingly advocated. A patient with a PVR of 6 Wood units underwent orthotopic transplantation; the cardiac allograft from a 12 kg heavier donor was implanted after an ischemic time of 115 minutes. Early graft failure at 4 hours and subsequent cardiac arrest were followed by reinstitution of cardiopulmonary bypass, during which time optimal pharmacologic manipulation of the pulmonary vasculature was undertaken, including the use of high-dose prostacyclin. Refractory right heart failure indicated the requirement for right ventricular assistance (RVA) for patient survival. RVA with a Bio-Medicus pump was instituted in association with high-dose prostacyclin; an intraaortic balloon pump was inserted 12 hours later. Maintenance immunosuppression consisted of cyclosporine and azathioprine alone. RVA was maintained for 3 days; during this time the patient was totally pump dependent. Over an 18-hour period the patient was weaned and successfully withdrawn from RVA. Intraaortic balloon pump counterpulsation and the prostacyclin infusion were continued for 6 and 10 days, respectively. The clinical implications of the various interventions that resulted in the patient's survival are discussed.
Esmore
D S
DS
Department of Cardiothoracic Surgery, St. Vincent's Hospital, Darlinghust, Sydney, Australia.
Spratt
P M
PM
Branch
J M
JM
Keogh
A M
AM
Lee
R P
RP
Farnsworth
A E
AE
Shanahan
M X
MX
Chang
V P
VP
D002303:Cardiac Output, Low / Q000209:etiology / Q000628:therapy*; D011464:Epoprostenol / Q000627:therapeutic use*; D016027:Heart Transplantation; D006353:Heart-Assist Devices; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000628:therapy*; D011651:Pulmonary Artery / Q000503:physiopathology*; D014655:Vascular Resistance
D011464:Epoprostenol