Use of combination of mitral clip and CGMP-specific phosphodiesterase type 5 inhibitor as bridge for cardiac transplantation

2013 
Introduction Severe mitral regurgitation (MR) and severe pulmonary hypertension (PH) are common consequence of advanced end stage heart failure (HF). Cardiac transplantation is the only available treatment modality with reasonable long term outcome for end stage HF. Presence of severe resistant PH could preclude transplantation. We reported two cases with end stage heart failure and NYHA class III, who have been initially turned down from cardiac transplantation because of severe PH, and we managed to bridge them with mitral clip and Sildenafil to be transplant eligible. Description of the cases. Case 1 First patient is 50 years old gentleman, who is known to have ischemic cardiomyopathy, ejection fraction (EF) of 15%, and severe MR, with significant functional limitation (NYHA class III) despite of maximum medical therapy. His pulmonary arterial systolic pressure (PASP) was 80 mmHg, TPG = 30 mmHg, pulmonary capillary wedge pressure (PCWP) = 33. After full evaluation he underwent successful deployment of mitral clip and started on seldanifl 25 mg three times daily, hoping this will lower the PASP to an acceptable level, to allowlisting for cardiac transplantation. Echocardiographic assessment after one month of treatment showed that estimated PASP of 40 mmHg. Case 2 Second patient is 75 y old, who is known to have ischemic cardiomyopathy, status post three vessels angioplasty, with EF of 25%, and severe MR. He was very symptomatic despite maximum medical therapy. He was deemed not suitable for cardiac transplantation, because of severe pulmonary hypertension; PASP = 85 mmHg, mean PA = 59 mmHg, PCWP = 38 mmHg. He underwent successful deployment of mitral clip and started on sildenafil 25 mg three times daily. At one month follow up PASP went down to 45 mmHg. Conclusion We report for first time a successful use of mitral clip and sildenafil treatment as a bridge to transplant eligibility, for those who have severe MR and PHTN secondary to advances heart failure. These patients may not be otherwise suitable transplant candidate. This case report brings a new hope for selected high risk HF patients, with severe MR and severe PHTN.
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