Dramatic improvement of clinical and hemodynamic parameters of a heart transplant candidate with sildenafil treatment

Abstract

Pulmonary hypertension (PHT) is classically defined as an increase in mean pulmonary arterial pressure ≥25 mm Hg at rest as assessed by right heart catheterization (1). It is associated with various clinical conditions. These clinical conditions are classified into five groups. The treatment modalities for group 1 pulmonary hypertension (pulmonary arterialhypertension (PAH)) have diversified enormously in the last de- cade, including prostanoids, endothelin receptor antagonists, and phos- phodiesterase type-5 inhibitors. Unfortunately, therapeutic options for group 2 patients (pulmonary hypertension associated with left-sided heart disease) haven't evolved much and the prognosis for this group still remains poor. However, sildenafil has been recently shown to have some acute beneficial effects in patients with left heart failure (HF) in some trials (2). In this case presentation we discuss a gentleman with advanced left heart failure who showed dramatic clinical and he- modynamic improvement with oral sildenafil treatment. A 55-year-old gentleman was admitted to our clinic for heart failure decompensation. His medical history included coronary artery bypass surgery, an Implantable Cardioverter Defibrillator (ICD) implantation for primary prevention six years later, and an upgrading of his ICD to Cardiac Resynchronization Therapy (CRT) with his ablation due to fre- quent inappropriate ICD shocks as a consequence of atrial fibrillation. His ejection fraction (EF) was calculated as 25% on transthoracic echo- cardiographic examination. His peak VO2 value was measured as 12 ml/kg/min via a cardiopulmonary stress test. Due to frequent hospi- talizations for decompensation and class 4 symptoms refractory to effective medical therapy, the patient was evaluated as a candidate for heart transplantation. A right heart catheterization (RHC) was per- formed to determine the patient's eligibility for transplantation. Pulmo- nary artery pressures and pulmonary vascular resistance were found to be in the ineligible/gray zone (Table 1). Vasoreactivity testing with do- butamine and nasal oxygen was performed to determine the reversibil- ity of the high pulmonary pressures. A partial decrease in pulmonary artery systolic pressure (about 15%) with stable systemic arterial pres- sure was noted. We decided to add oral sildenafil 50 mg (three times a day) to his ongoing treatment, referring to trials showing beneficial pulmonary hemodynamic effects in patients with advanced heart fail- ure. The patient reported dramatic symptomatic improvement and his