Abstract 17687: Left Ventricular Unloading in Pulmonary Hypertension With Impella 5.5 as a Bridge to Heart Transplantation

A 59 year-old male with a history of triple-vessel coronary artery bypass graft surgery, ischemic cardiomyopathy with an implantable cardioverter defibrillator, pre- and post-capillary pulmonary hypertension, severe mitral regurgitation, paroxysmal atrial fibrillation, diabetes mellitus, hypertension was referred for transplant evaluation in the setting of cardiogenic shock despite inotropic support. His initial right heart catheterization showed RAP 21 mmHg, RVP 91/9 mmHg, PAP 88/31 mmHg with a mean of 50 mmHg, PCWP 22 mmHg, PVR 6.6 Wood units, SVR 857 dynes, and CO 4.85 l/min/CI 2.59 l/min/m ² by thermodilution. His hospital course was complicated by acute renal failure requiring continuous renal replacement therapy. Inotropic support could not be weaned on multiple attempts, and pulmonary and wedge pressures remained significantly elevated despite a trial of inhaled nitric oxide. The patient underwent Impella 5.5 placement to assess the hemodynamic response of unloading the left ventricle. A repeat right heart catheterization showed a RAP 1 mmHg, RVP 42/1 mmHg, PAP 48/13 mmHg with a mean of 26 mmHg, PVR 2.3 Wood units, SVR 829 dynes, and CO 6.75 l/min/CI 3.74 l/min/m ² by thermodilution. Measurements were obtained with Impella 5.5 at P-8 level, milrinone 0.2 mcg/kg/min, treprostinil 4 ng/kg/min, epoprostenol 1 mg every 6 hours, and sildenafil 10 mg in morning and afternoon and 15 mg in evening. The patient underwent successful heart and kidney transplantation. Post-transplantation right heart catheterization showed persistent pre-capillary pulmonary hypertension with normal filling pressures and CI. His pulmonary hypertension was managed with sildenafil 40 mg three times daily and ambrisentan 10 mg daily. This case demonstrates favorable hemodynamic effects of left ventricular unloading using Impella support with significant reduction in pulmonary vascular pressure to reach candidacy for heart transplantation.