مقاله انگلیسی استراتژی جدید برای از سرگیری و کاهش اپوپروستنول پس از پیوند ریه برای فشار خون ریوی
Abstract
Introduction
Discussion
Conclusion
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Abstract
Objective The perioperative outcome of lung transplantation (LTx) for patients with severe pulmonary hypertension (PH) remains poor due to the occurrence of primary graft dysfunction (PGD) from left ventricular failure. We hypothesized that tapering pretransplant use of epoprostenol rather than abrupt discontinuation after transplantation might improve perioperative outcomes. Methods We performed 23 LTxs for patients with severe PH who received epoprostenol therapy from 2008 until 2021. In the discontinued group (n=6), epoprostenol was discontinued after the establishment of extracorporeal circulation. In the tapered group (n=17), epoprostenol was discontinued and resumed after reperfusion, and then gradually tapered over the following 2 weeks. We assessed survival, bleeding, blood transfusion, re-opening of the chest, oxygenation, PGD score, extracorporeal membrane oxygenation (ECMO) requirement for recovery after transplantation, and duration of mechanical ventilation. Results The PGD score was signifcantly lower in the tapered group than in the discontinued group at 0 h, 24 h, and 48 h after LTx. In addition, the discontinued group required longer mechanical ventilation than the tapered group. Delayed chest closure and post-transplant ECMO use for recovery occurred signifcantly more frequently in the discontinued group. Conclusions To resume and taper epoprostenol administration after reperfusion in patients with severe PH may be a valuable new strategy associated with better perioperative outcomes.
Introduction
Due to the efective use of various medical therapies for pulmonary arterial hypertension (PAH), lung transplantation (LTx) is performed less frequently for patients with severe pulmonary hypertension (PH); however, it remains an important treatment option for patients who are failing maximal medical therapy. Historically, the early postoperative mortality for patients undergoing LTx for PAH was higher than it was for those with most other end-stage lung diseases due to the occurrence of early graft dysfunction [1]. However, the main cause of primary graft dysfunction (PGD) in these patients was left ventricular failure, rather than residual PH [2]. In addition, Porteous et al. found that diferences in left ventricular diastolic function may contribute to the development of PGD [3]A treatment algorithm for PAH was provided in the 2015 European Society of Cardiology and European Respiratory Society guidelines; the guidelines also indicated that high-risk patients (WHO-FC IV) are recommended to receive initial combination therapy, which includes intravenous prostacyclin [4]. Presently, pretransplant use of epoprostenol is prevalent for patients with end-stage PH; however, it is generally discontinued at the time of transplantation. In our early experience with LTxs for PH, we often encountered severe PGD.