POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME DUE TO HIGH BLOOD PRESSURE PEAK AFTER HEART TRANSPLANT

Abstract

Objective: Posterior reversible encephalopathy syndrome (PRES) is a reversible subcortical vasogenic cerebral oedema involving parieto-occipital regions in patients with acute neurological symptoms. The aim of this study is to analyse an interesting case of PRES after heart transplant. Design and method: A heart transplant was performed in a 53-years-old woman affected by arrhythmogenic cardiomyopathy. She had history of atrial fibrillation and ventricular fibrillation requiring an implantable cardioverter defibrillator, chronic renal insufficiency with frequent acute episodes, heart failure and stasis hepatopathy. After the transplantation, the patient required femoral extracorporeal membrane oxygenator for three days, mediastinal revision for bleeding, two runs of continuous veno-venous hemofiltration, and a pericardial drainage for effusion. After fifty days the patient was stable, but she suddenly experienced a high blood pressure peak of 180 mmHg and tachycardia, followed by limb stiffening, limb colonies resolved with diazepam, verbal blockade, and sphincter release. Results: A cerebral computer tomography was immediately performed showing a bilateral parieto-occipital oedema suggestive of PRES (Figure 1). The patient was treated by brivaracetam and the immunosuppressive therapy was switched from cyclosporine to tacrolimus. Subsequently, she experienced amelioration of symptoms. Ten days later, electroencephalography did not show any epileptic signs and oedema was regularly evolving on cerebral imaging. PRES usually appears in the setting of blood pressure fluctuations, cytotoxic drugs, and renal failure. In the case presented, the time link between symptoms and typical brain images could show that the high blood pressure peak after heart transplant could have been a trigger for the syndrome in a patient with chronic renal disease treated with cyclosporine, which are both risk factors for PRES. According to literature, PRES syndrome could be due to endothelial injury related to abrupt blood pressure changes, breaking down blood-brain barrier and generating cerebral oedema. Conclusions: This case showed that PRES is a possible complication after heart transplant in patient with predisposing risk factors and blood pressure sudden variations. It is very important to have a good blood pressure control after heart transplant and to choose the property immunosuppressive therapy in these patients.