title: Right ventricular assist and prostacyclin infusion for allograft failure in the presence of high pulmonary vascular resistance.
abstract: 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 Over an 18-hour period the patient was weaned and successfully withdrawn from RVA.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.
authors.affiliation: Department of Cardiothoracic Surgery, St. Vincent's Hospital, Darlinghust, Sydney, Australia.
authors.forename: D S
authors.initials: DS
authors.lastname: Esmore
authors.forename: P M
authors.initials: PM
authors.lastname: Spratt
authors.forename: J M
authors.initials: JM
authors.lastname: Branch
authors.forename: A M
authors.initials: AM
authors.lastname: Keogh
authors.forename: R P
authors.initials: RP
authors.lastname: Lee
authors.forename: A E
authors.initials: AE
authors.lastname: Farnsworth
authors.forename: M X
authors.initials: MX
authors.lastname: Shanahan
authors.forename: V P
authors.initials: VP
authors.lastname: Chang
mesh_terms: 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
chemical_list: D011464:Epoprostenol