Overview
Severe pulmonary hypertension (PH) linked to end-stage heart failure often complicates heart transplantation planning due to the risk of post-operative right ventricular failure. A recently documented case from Guangdong Provincial People’s Hospital (Guangzhou, China) demonstrates that prolonged intra-aortic balloon pump (IABP) support can reverse severe PH enough to enable successful heart transplantation. The patient, a 58-year-old man with extensive cardiac history, achieved notable hemodynamic and clinical improvements after 62 days of IABP support.
Clinical Background
The patient presented on 8 March 2023 with symptoms of advanced heart failure: orthopnea, marked edema, and progressive dyspnea. Initial investigations revealed a severely dilated and dysfunctional left ventricle (LVEF 28%), significant multivalvular disease (severe mitral and tricuspid regurgitation), and markedly elevated pulmonary pressures (pulmonary artery systolic pressure ~85 mmHg, mean PAP ~66 mmHg). Right heart catheterization (RHC) quantified a high pulmonary vascular resistance (PVR) of 9.78 Wood units and a PVR index around 4.85 Wood units, indicating a mixed pre- and post-capillary PH with a strong pre-capillary contribution. Left atrial pressure was elevated (PCWP 29 mmHg), consistent with left-heart failure-driven PH. The Seattle Heart Failure Model indicated an extremely high short-term mortality risk if transplanted without optimization.
Rationale for IABP Support
Standard pharmacologic therapy offered limited improvement. Given the high risk of post-transplant right ventricular failure from severe PH, the team pursued strategies to unload the left ventricle and reduce pulmonary pressures. When conventional therapy failed, prolonged IABP support was initiated on 9 March 2023 as a bridge-to-transplant strategy. IABP unloads the left ventricle, reduces LV end-diastolic pressure, and improves cardiac output and systemic perfusion, which can translate into decreased pulmonary venous pressure and pulmonary artery pressures over time.
Hemodynamic and Imaging Trajectory
Initial imaging showed persistent pulmonary artery enlargement, patchy lung opacities, and elevated PH parameters. Serial chest CTs on days 15, 25, 34, and 48 of IABP support demonstrated no major changes in pulmonary artery width but did reveal regression of infiltrates, suggesting improved lung perfusion and edema status. Importantly, floating catheter measurements after 62 days of support showed a dramatic reversal: PASP 31 mmHg, PADP 19 mmHg, mPAP 24 mmHg, PCWP 10 mmHg, and PVR 4.85 Wood units. This hemodynamic profile crossed the threshold into a more favorable range for transplantation, indicating reversibility of the PH component and reducing the risk of postop right ventricular dysfunction.
Heart Transplantation and Early Recovery
The donor heart was procured under standard protocols and transplanted via median sternotomy with CPB. Postoperative hemodynamics required high-dose vasopressors and inhaled nitric oxide to manage elevated pressures, but gradually stabilized within the first week. By postoperative day 6, vasopressors were tapered, nitric oxide was discontinued, and echocardiography on day 12 showed excellent graft function (LVEF 68%). The patient was discharged on postoperative day 19 and remained stable on follow-up. A subsequent echocardiogram in February 2024 demonstrated preserved graft function with an estimated pulmonary pressure of 24 mmHg and maintained LV/RV function.
Discussion and Implications
This case supports the concept that prolonged IABP therapy can serve as an effective bridge-to-transplant in selected patients with left-heart-driven PH. The approach allowed for left-ventricular unloading, optimization of hemodynamics, and confirmation of PH reversibility before proceeding with transplantation. IABP, compared with more complex devices like ECMO or LVAD, offers a simpler, rapid, and cost-effective bridge in resource-variable settings while maintaining a favorable safety profile when carefully managed.
Clinical Takeaways
- In patients with end-stage heart failure and severe PH, prolonged IABP can facilitate a reversible PH state suitable for heart transplantation.
- Comprehensive perioperative management—including inhaled NO, vasopressors, and pulmonary vasodilators—supports early graft function and mitigates right-heart strain post-transplant.
- Further multicenter trials are needed to generalize this strategy, optimize timing and duration, and compare with LVAD/ECMO approaches.
Conclusion
Prolonged IABP support proved to be a decisive, effective bridge-to-transplant intervention in a high-risk patient with combined pre- and post-capillary PH. The successful outcome underscores the importance of dynamic hemodynamic assessment and tailored perioperative management in improving transplant candidacy and survival in patients with complex PH profiles.
