Overview
Severe pulmonary hypertension (PH) often complicates end-stage heart failure and can pose a major risk for heart transplantation. This case describes a 58-year-old man with refractory heart failure and extreme PH who underwent 62 days of intra-aortic balloon pump (IABP) support. The intervention led to marked hemodynamic improvements and ultimately enabled a successful heart transplant with favorable postoperative recovery.
Initial Presentation and Hemodynamics
The patient, with a long history of coronary artery disease, presented in March 2023 with progressive dyspnea, orthopnea, and edema. Echocardiography showed profound cardiomegaly, severely reduced left ventricular systolic function (LVEF 28%), and extensive valvular disease. Right heart catheterization revealed dangerous PH parameters: PASP 98 mmHg, mPAP 58 mmHg, PCWP 29 mmHg, PVR 9.78 Wood units, consistent with combined pre- and post-capillary PH (CpcPH). The Seattle Heart Failure Model projected very high mortality risks if transplanted under these conditions, underscoring the need for hemodynamic optimization prior to listing for transplant.
Rationale for IABP Support
When medical therapy failed to reduce PH sufficiently, the team employed prolonged IABP support. The goal was to unload the failing left ventricle, improve compliance, and decrease left-sided filling pressures, thereby reducing pulmonary congestion and the pulmonary vascular resistance (PVR). This approach aims to convert potentially reversible PH into a state compatible with successful transplantation.
Course of IABP Therapy
IABP support was initiated on 9 March 2023 and continued for 62 days. Serial imaging (chest CT) on days 15, 25, 34, and 48 showed stable or improving lung infiltrates but no substantial decrease in pulmonary artery width. This finding suggested that the structural burden remained, but functional improvement was achievable with circulatory unloading and optimized medical therapy.
Concurrently, pharmacologic therapy included diuretics, recombinant BNP, macitentan for PA pressure control, and standard anticoagulation. Notably, the pulmonary pressures gradually declined with time. At day 62, hemodynamic measurements via a floating catheter demonstrated a PASP of 31 mmHg, mPAP 24 mmHg, PCWP 10 mmHg, and PVR 4.85 Wood units. These results confirmed reversibility of the PH and feasibility of proceeding to transplant.
Heart Transplantation and Immediate Postoperative Care
The donor heart was procured from a brain-dead donor and transplanted via median sternotomy with cardiopulmonary bypass. Postoperatively, the patient required vasopressor support and inhaled nitric oxide (NO) to manage elevated pulmonary pressures. By postoperative day 1, hemodynamics had improved (BP 108/62 mmHg, PASP 40/25 mmHg), enabling progressive tapering of vasopressors and NO. Inhaled NO was discontinued later, and the patient’s pulmonary pressures stabilized.
Echocardiography at postoperative day 12 showed preserved allograft function (LVEF 68%) with a favorable right heart profile. The patient was discharged on day 19 after surgery and continued to demonstrate stability in follow-up imaging. At the 12-month mark, LVEF remained robust (61%), and estimated PH had normalized to 24 mmHg, reflecting sustained hemodynamic improvement and graft function.
Clinical Significance
This case demonstrates that prolonged IABP support can effectively unload the left ventricle and reduce left-sided filling pressures, thereby reversing severe PH in selected patients with end-stage heart failure. IABP is a relatively simple and readily available mechanical support strategy compared with more complex devices like LVADs or ECMO, particularly when rapid optimization is required or resources are limited.
Key lessons from this case include the importance of careful patient selection, rigorous fluid management, and targeted pharmacologic therapy (e.g., macitentan) to support pulmonary vasculature during the bridge to transplantation. The successful outcome supports consideration of IABP-driven reversibility assessment as part of pre-transplant evaluation in patients with left-heart related PH.
Future Directions
Larger, multi-center studies are needed to validate the generalizability of this approach, define optimal timing and duration for IABP therapy in PH, and compare outcomes with other mechanical circulatory support options. Nonetheless, this case provides actionable insight for centers managing high-risk transplant candidates with concomitant PH.
