title: Combination therapy with sildenafil and bosentan reverts severe pulmonary hypertension and allows heart transplantation: case report.
abstract: BACKGROUND
  Severe pulmonary hypertension with no response to vasodilators on an acute hemodynamic study is a contraindication to cardiac transplantation. The development of oral pulmonary vasodilators improves the prognosis in these patients. We present the case of a patient whose admission to the waiting list for cardiac transplantation was possible after 6 months of combination therapy with Sildenafil and Bosentan.
  
  
  METHODS
  The patient was a 50-year-old man with severe dilated alcohol-induced cardiomyopathy. A pretransplantation study, including a right hemodynamic analysis, revealed irreversible pulmonary hypertension, with 59 mm Hg mean pulmonary artery pressure and 6.4 Wood IU pulmonary vascular resistance, with no response to acute vasodilators with nitric oxide or prostacyclin. Initially, heart transplantation was not possible and the patient started treatment with oral Sildenafil. After 6 months there was no improvement in echocardiographic or hemodynamic parameters, and combination therapy with Bosentan was started. With the combination therapy, the patient progressively improved clinically and hemodynamically, the pressures becoming normal at the sixth month, at which time he was included on the waiting list for a heart transplantation. Eight months later he received a graft with a good posttransplantation course, no right ventricular failure in the acute phase, and absence of pulmonary hypertension on echocardiogrphic and invasive studies.
  
  
  CONCLUSIONS
  Combinations of an oral pulmonary vasodilator with diverse action mechanisms may represent an alternative for patients with irreversible pulmonary hypertension who do not respond to monotherapy.
authors.affiliation: Department of Cardiology and Cardiac Surgery, Hospital Virgen del Rocío, Seville, Spain. mvmogjim@hotmail.com
authors.forename: M V
authors.initials: MV
authors.lastname: Mogollón
authors.forename: E
authors.initials: E
authors.lastname: Lage
authors.forename: S
authors.initials: S
authors.lastname: Cabezón
authors.forename: R
authors.initials: R
authors.lastname: Hinojosa
authors.forename: S
authors.initials: S
authors.lastname: Ballesteros
authors.forename: A
authors.initials: A
authors.lastname: Aranda
authors.forename: J M
authors.initials: JM
authors.lastname: Sobrino
authors.forename: A
authors.initials: A
authors.lastname: Ordóñez
mesh_terms: D000959:Antihypertensive Agents / Q000627:therapeutic use*; D000077300:Bosentan; D004359:Drug Therapy, Combination; D016027:Heart Transplantation; D006801:Humans; D006976:Hypertension, Pulmonary / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D010879:Piperazines / Q000627:therapeutic use*; D011687:Purines; D000068677:Sildenafil Citrate; D013449:Sulfonamides / Q000627:therapeutic use*; D013450:Sulfones; D016896:Treatment Outcome; D014665:Vasodilator Agents / Q000627:therapeutic use; D014850:Waiting Lists
chemical_list: D000959:Antihypertensive Agents; D010879:Piperazines; D011687:Purines; D013449:Sulfonamides; D013450:Sulfones; D014665:Vasodilator Agents; D000068677:Sildenafil Citrate; D000077300:Bosentan