AEROSOLIZED EPOPROSTENOL TO TREAT PULMONARY HYPERTENSION SECONDARY TO MASSIVE PULMONARY EMBOLISM

Abstract

SESSION TITLE: Critical Care 2 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Prostacyclins are potent systemic and pulmonary vasodilators that reduce pulmonary arterial pressure and pulmonary vascular resistance when administered intravenously in pulmonary arterial hypertension, resulting in increased cardiac index and oxygen delivery. Aerosolized prostacyclins are used to treat acute pulmonary hypertension (pHTN) from the acute respiratory distress syndrome and post-cardiac surgery while minimizing systemic hypotension. Very little data exists on the use of aerosolized prostacyclins from another cause of acute pHTN: acute pulmonary embolism (PE). CASE PRESENTATION: A 78 year-old Caucasian male presented to our institution with massive bilateral PE with complete occlusion of his right main pulmonary artery. Bedside transthoracic echocardiogram (TTE) demonstrated right ventricular dilation with moderately reduced function. Immediately following the placement of an ultrasonic thrombolytic catheter system into the right main pulmonary artery, he suffered a cardiac arrest. Aerosolized epoprostenol was administered as salvage therapy via the inspiratory limb of the ventilation circuit at a fixed dose of 160,000 ng/hr. Within 30 minutes of administration, the patient’s oxygen saturation and blood pressure increased from 72% to 91% and 92/59 mmHg to 159/85 mmHg, respectively. The patient’s condition stabilized, and the medication was titrated off 48 hours later. After 6 weeks of hospitalization and inpatient rehabilitation the patient was discharged home. Repeat TTE 2 months post discharge revealed normal right ventricular size and function. DISCUSSION: PE is a common cause of acute pHTN in the critical care setting. Acute right heart failure develops secondary to increased right ventricular filling pressures and stroke work, often leading to obstructive shock and death. In these patients, preserving right heart function via immediate reduction in pulmonary arterial pressures is desired. Embolectomy or thrombolysis are often successful in reducing right ventricular afterload. Aerosolized prostacyclin has been shown in a case report to be transiently beneficial for acute pHTN from PE following systemic thrombolysis. Aerosolized epoprostenol may improve right ventricular function through targeted vasodilation in the pulmonary vasculature and alveolar gas exchange due to increased surface area. In patients with extensive clot burden, there is a theoretical risk of worsening V:Q mismatch by dilating pulmonary capillary beds with proximal emboli. CONCLUSIONS: We present a case of massive PE with cardiac arrest in which the addition of aerosolized epoprostenol following catheter-directed thrombolysis resulted in rapid improvement in pulmonary hemodynamics and gas exchange. Our hope is to establish the potential benefits of aerosolized epoprostenol for patients with refractory right heart failure from PE, although proper patient selection and timing of therapy remains unknown. Reference #1: Webb SA, Stott S, van Heerden PV. The use of inhaled aerosolized prostacyclin in the treatment of pulmonary hypertension secondary to pulmonary embolism. Intensive Care Med. 1996; 22:353-355. Reference #2: Kooter, et al. No effect of epoprostenol on right ventricular diameter in patients with acute pulmonary embolism: a randomized controlled trial. BMC Pulmonary Medicine. 2010; 10:18 DISCLOSURES: No relevant relationships by Tufik Assad, source=Web Response No relevant relationships by Mary Bourget, source=Web Response No relevant relationships by Aaron Milstone, source=Admin input No relevant relationships by Michael Wright, source=Web Response