Use of inhaled epoprostenol in transition to extubation in a patient after implantation of a ventricular assist device.

PULMONARY ARTERY HYPERTENSION (PAH) is a life-threatening condition characterized by an increase in arterial pressure and vascular resistance in the pulmonary circulation. 1 Simonneau G. Galie N. Rubin L.J. et al. Clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2004; 43: 5S-12S Abstract Full Text Full Text PDF PubMed Scopus (1533) Google Scholar It is defined by a mean pulmonary artery pressure (PAP) of more than 25 mmHg at rest or more than 30 mmHg during exercise. 2 Rubin L.J. American College of Chest PhysiciansDiagnosis and management of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest. 2004; 126: 7S-10S Crossref PubMed Scopus (200) Google Scholar PAH may aggravate right-heart failure, which is present in many patients after cardiac surgery requiring cardiopulmonary bypass. This is particularly important in patients who have had placement of a left ventricular assist device (LVAD) as the right ventricle benefits from afterload reduction in the pulmonary circulation. Therefore, in these and other situations, such as orthotopic heart transplant and either single- or double-lung transplant, it is beneficial to lower pulmonary pressures by pharmacologic measures. However, treatment with intravenous (IV) pulmonary vasodilators may reduce systemic blood pressure as well, leading to systemic hypotension and may impair coronary perfusion and right-heart performance. Thus, these patients commonly are treated with inhaled agents such as epoprostenol or nitric oxide postoperatively to reduce pulmonary afterload while avoiding reductions in systemic pressure. To accomplish this, patients must remain intubated until their requirements for inhaled pulmonary vasodilators decrease and can be safely discontinued.