Ann Thorac Surg 2007;83:1705-1706
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
Paul Hendry, MD
Division of Cardiothoracic Surgery, University of Ottawa Heart Institute, 40 Ruskin St, Room H3404B, Ottawa, Ontario, Canada K1Y 4W7
(Email: phendry{at}ottawaheart.ca).
Pulmonary hypertension is common in end-stage heart failure patients who are being assessed for candidacy for cardiac transplantation. Testing with either milrinone, nitric oxide, or prostaglandins can aid in the determination of reversibility of pulmonary hypertension. The International Society of Heart Lung Transplantation guidelines and Canadian Cardiovascular Society Consensus Conference on Cardiac Transplantation suggest that pulmonary hypertension greater than 50 mm Hg systolic, pulmonary vascular resistance greater than 4 to 5 Wood units, or a transpulmonary gradient greater than 15 to 16 are relative, if not absolute contraindications to cardiac transplantation [1, 2]. Although the medical treatment of advanced heart failure has progressed, increasingly frequent reports of the successful reversal of medically refractory pulmonary hypertension with ventricular assist devices (VADs) gives hope to patients with this condition who would otherwise not be considered as recipients for cardiac transplantation.
Experience with pulsatile VADs during the last few years has shown this to be a reasonable way to bring pulmonary hypertension under control to allow for successful transplantation [3–6]. The report by Etz and colleagues [7] further supports this approach with the use of nonpulsatile VADs. Although not the first report of success using nonpulsatile VADs in the setting of pulmonary hypertension [5, 8], there are important lessons to draw from this experience.
In the article by Etz and colleagues [7], 10 patients were implanted with small, axial flow VADs that were implanted intrapericardially, resulting in less extensive dissection. They also used smaller cannulas, which are not prone to blood extrusion, thereby reducing the risk of postoperative bleeding. The immediate postoperative results indicate absence of intraoperative complications with no bleeding or acute right heart failure, which are testaments to both the excellence in surgical technique, but also the decreased trauma of implanting these devices. This report should help establish confidence in this approach as a step to ultimate cardiac transplantation. Patients were supported for 182 ± 118 days, and pulmonary hypertension had decreased significantly in all patients. However, despite meticulous control of anticoagulation, 3 of 10 patients had significant thromboembolic episodes leading to either death or device replacement. This underscores the current main concern with axial flow devices, which will hopefully be addressed with further refinements in anticoagulation monitoring and therapy and improvements in VAD design. The successfully transplanted patients were followed-up for 18 months, but further information will be required regarding ultimate long-term outcomes of patients treated in this fashion to be able to state with certainty that this approach is durable.
This experience continues to support the successful approach for proactive implantation of VADs in patients with irreversible pulmonary hypertension who are otherwise candidates for cardiac transplantation. It would seem that regardless of the type of VAD used (pulsatile or nonpulsatile), pulmonary hypertension can be reversed with adequate time on VAD support. Although not a low-risk procedure, patients with end-stage heart failure without any other options for hope of any return of quality of life can consequently be given a chance at a reasonable chance of long-term survival with this approach.
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References
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- Mehra MR, Kobashigawa J, Starling R, et al. Listing criteria for heart transplantation: International Society for Heart and Lung Transplantation guidelines for the care of cardiac transplant candidates—2006 J Heart Lung Transplant 2006;25:1024-1042.[Medline]
- Ross H, Hendry P, Dipchand A, et al. 2001 Canadian Cardiovascular Society Consensus Conference on Cardiac Transplantation Can J Cardiol 2003;19:620-654.[Medline]
- Al-Khaldi A, Ergina P, DeVarennes B, Lachappelle K, Cecere R. Left ventricular unloading in a patient with end-stage cardiomyopathy and medically unresponsive pulmonary hypertension Artif Organs 2004;28:158-160.[Medline]
- Choong CK, Pasque MK, Shelton K, et al. The beneficial role of left ventricular assist device destination therapy in the reversal of contraindications to cardiac transplantation J Thorac Cardiovasc Surg 2005;130:879-880.[Free Full Text]
- Martin J, Siegenthaler MP, Friesewinkel O, et al. Implantable left ventricular assist device for treatment of pulmonary hypertension in candidates for orthotopic heart transplantation—a preliminary study Eur J Cardio-thorac Surg 2004;25:971-977.[Abstract/Free Full Text]
- Smedira NG, Massad MG, Navia J, et al. Pulmonary hypertension is not a risk factor for RVAD use and death after left ventricular assist system support ASAIO J 1996;42:M733-M735.[Medline]
- Etz CD, Welp HA, Tjan TDT, et al. Medically refractory pulmonary hypertension: treatment with nonpulsatile left ventricular assist devices Ann Thorac Surg 2007;83:1697-1706.[Abstract/Free Full Text]
- Salzberg SP, Lachat ML, von Harbou K, Zund G, Turina MI. Normalization of high pulmonary vascular resistance with LVAD support in heart transplantation candidates Eur J Cardio-thorac Surg 2005;27:222-225.[Abstract/Free Full Text]
Related Article
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Medically Refractory Pulmonary Hypertension: Treatment With Nonpulsatile Left Ventricular Assist Devices
- Christian D. Etz, Henryk A. Welp, Tony D.T. Tjan, Andreas Hoffmeier, Ernst Weigang, Hans H. Scheld, and Christof Schmid
Ann. Thorac. Surg. 2007 83: 1697-1705.
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