HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Services Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Sandifer, B. L. Articles by Lawrence, C. Search for Related Content PubMed Articles by Sandifer, B. L. Articles by Lawrence, C.

Pharmacologic Management of Pulmonary Hypertension Associated With Mitral Valve Disease

Emory University, Atlanta, GA

INTRODUCTION: Pulmonary hypertension often complicates mitral valve disease with disabling symptoms. It has been associated with increased perioperative mortality during mitral valve replacement(1,2). Improvement of pulmonary hemodynamics with epoprostenol perioperatively may lead to better surgical outcomes. Though these patients will tend to show improvement in their pulmonary hemodynamics over time after valve replacement, these values rarely return to normal(3). Furthermore, pulmonary artery and capillary endothelin-1 (ET-1) levels have been shown to be elevated in these patients and remain elevated even after valve replacement(4). Since endothelin is known to play a role in the vascular remodeling characteristic of this disease, the ET-1 receptor antagonist bosentan may be useful in the management of these patients after surgery.

CASE PRESENTATION: A 57 year old female with a history of mitral valve regurgitation from rheumatic heart disease was admitted for progressive shortness of breath. Her dyspnea had worsened so that she could no longer perform her activities of daily living. On admission she underwent right heart catheterization which demonstrated pulmonary artery pressures (PAP) at systemic levels. Subsequently epoprostenol therapy was initiated with significant improvement in pulmonary vascular resistance (PVR) and cardiac output (CO) as shown in Table 1
Table 1: Preoperative Hemodynamics

Dose (ng/kg/min) Blood Pressure PAP PVR PCWP CO Pre-op No Therapy NA 119/40 102/32 515 27 4.4 Pre-op On Therapy 10 112/34 55/20 153 20 6.1

PCWP –pulmonary capillary wedge pressure

. She then underwent placement of a St. Jude mechanical valve, was maintained on epoprostenol in the immediate post operative period and then weaned over the next few days. Her post operative course was complicated only by an episode of atrial flutter and she electively underwent cardioversion. After transfer to the floor she was started on bosentan and was discharged. Her response to therapy was followed by serial echocardiographic estimates of right ventricular systolic pressure (RVSP) as shown in Figure 1 . At her three month follow up her symptoms had much improved and she was planning to return to work. Pulse oximetry demonstrated desaturation into the 80’s during a six minute walk test. At her six month visit she was working fulltime and her pulse oximetry dropped barely below 90% during her six minute walk. At one year after valve replacement and initiation of bosentan she was able to perform her activities of daily living without dyspnea.

View larger version (24K): [in this window] [in a new window]

CONCLUSION: Mitral valve disease is often accompanied by significant pulmonary hypertension. This may lead to increased perioperative mortality. The use of epoprostenol to acutely improve pulmonary hemodynamics during this period may lead to better surgical outcomes. The transition to bosentan at discharge may improve long term outcomes.

DISCLOSURE: B.L. Sandifer, None.

REFERENCES

1. Annals of Thoracic Surgery1998;66 :60 –7.
2. European Journal of Cardio-Thoracic Surgery1998;13 :344 –51.
3. Annals of Thoracic Surgery1996;61 :1583 –4.
4. Journal of Thoracic and Cardiovascular Surgery1994;108 :960 –8.