Reversibility of fixed pulmonary hypertension in left ventricular assist device support recipients

Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery (Impact Factor: 3.3). 02/2011; 40(4):971-7. DOI: 10.1016/j.ejcts.2011.01.019
Source: PubMed


Conflicting data still exist concerning the reversibility of secondary severe 'fixed' pulmonary hypertension (PH) by the use of left ventricular assist device (LVAD) support in terms of time necessary to provide a bridge to 'transplantability'.
We retrospectively reviewed 145 patients with heart failure and severe PH treated by LVAD support between 2000 and 2009. There were 133 men (91.7%) and 12 women (8.3%) with a mean age of 52.95±12.01 years. Patients were divided into two groups depending on preoperative PH reversibility. Fixed PH was defined by a mean pulmonary arterial pressure (mPAP) >25 mmHg, a pulmonary vascular resistance (PVR) >2.5 Wood Unit (WU) and a transpulmonary gradient (TPG) >12 mmHg, despite pharmacological treatment.
Fifty-six patients had fixed PH (group A) and 89 reversible PH (group B). Only 27 patients of group A underwent right heart catheterization evaluation during LVAD support; the remaining 29 patients had other contraindications to heart transplantation (HTx). The 27 patients were divided into three subgroups on the basis of examination time during LVAD support: <6 months (11 patients), between 6 and 12 months (six patients) and >12 months (10 patients). The mPAP, PVR, and TPG decreased significantly during LVAD support (mPAP, 37.26±6.35 mmHg vs 21.00±7.51 mmHg, p=0.007; PVR, 3.49±1.47 WU vs 1.53±0.66 WU, p=0.000; and TPG, 15.04±5.22 mmHg vs 7.78±3.21 mmHg, p=0.019). A significant reduction of all parameters was observed during the first 6 months and later on there was no further decrease. There were no significant differences between the three subgroups (mPAP, p=0.680; PVR, p=0.723; and TPG, p=0.679) in terms of time of reversibility. LVAD support allowed 19 patients to be transplanted.
Patients with fixed PH can be treated with LVAD support. Our data suggest that 6 months after LVAD implantation it is possible to observe an important reduction of PH and evaluate the potential transplantability of patients. Longer support does not add any effect of LVAD on PH.

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    • "A ventricular assist device effectively reverses pulmonary hypertension and offers benefits such as unloading of the failing left ventricle as well as improved functional capacity, quality of life and survival. This can allow for cardiac orthotopic transplantation (bridge to heart transplant) in patients who were not initially considered candidates (Mikus et al. 2011; Torre-Amione et al. 2010). This study has clinical relevance for these individuals, suggesting that LVAD and heart transplanted patients may suffer from a subtle and subclinical interoceptive imbalance that may impact their social cognition abilities. "
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    • "There appears to be an expanding role for the LVAD as a bridge to heart transplant in the management of patients with severe left ventricular systolic HF and PH. Several studies in patients with systolic HF and severe PH have demonstrated that an elevated PVR despite pharmacologic therapy is often reduced to <2.5 Wood units over a 6 month time period following LVAD placement [58–62]. Retrospective, observational data analysis has also established that in patients in whom the pulmonary pressure improves with LVAD therapy as bridge to transplant, there is no statistical difference in subsequent posttransplant survival compared to patients without PH [60, 61]. "
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