Abstract
Severe pulmonary hypertension (PH) in end-stage heart failure poses a critical challenge for heart transplantation. This case documents how prolonged intra-aortic balloon pump (IABP) support reversed high pulmonary pressures, enabling successful transplantation and favorable recovery. The findings underscore the potential of IABP as a bridge-to-transplant strategy in selected patients with left-heart–related PH.
Clinical Presentation
A 58-year-old man with a long-standing history of coronary artery disease presented to Guangdong Provincial People’s Hospital in March 2023 with refractory heart failure. He experienced orthopnea, progressive dyspnea, edema, and a history of chest pain dating back to 2009. Initial investigations revealed dilated cardiac chambers, severely reduced left ventricular function (LVEF 28%), and multivalvular disease with significant mitral and tricuspid regurgitation. Pulmonary artery pressures were markedly elevated (PASP 98 mmHg, mPAP 58 mmHg) with a high pulmonary vascular resistance (PVR 9.78 Wood units). Right heart catheterization confirmed a hemodynamic profile consistent with left heart–related PH with a substantial pre-capillary component (Combined PPH). The Seattle Heart Failure Model indicated high short-term mortality risk (1-year 38%, 5-year 93%).
Initial Management and Rationale for IABP
Despite optimized medical therapy including diuretics, inotropes, and targeted pulmonary vasodilators (macitentan), he remained unsuitable for immediate transplantation due to severe PH. In this context, the multidisciplinary team initiated prolonged IABP support on March 9, 2023, to unload the left ventricle, reduce afterload, and evaluate the reversibility of PH. This approach is supported by ISHLT guidance when severe PH threatens post-transplant right ventricular failure and early mortality.
Supportive Strategy
Alongside IABP, the patient received diuresis, anticoagulation, and targeted therapy to control PH. Serial chest CT scans (days 15, 25, 34, 48) showed persistent pulmonary artery width with decreasing lung infiltrates, suggesting improved pulmonary edema and better cardiopulmonary mechanics. By day 62, invasive hemodynamics demonstrated a dramatic reversal: PASP 31 mmHg, mPAP 24 mmHg, PCWP 10 mmHg, and PVR 4.85 Wood units, meeting criteria indicative of reversibility and suitability for transplantation.
Heart Transplantation and Early Postoperative Course
The donor heart was transplanted successfully via median sternotomy with CPB support. Immediate postoperative challenges included a transient rise in PH (PASP 53 mmHg) and hemodynamic instability requiring vasopressors, inhaled nitric oxide, milrinone, and continued macitentan. Over the ensuing days, pulmonary pressures stabilized as vasopressors were tapered and NO was weaned. By postoperative day 6, hemodynamics normalized with reduced pharmacologic support, allowing removal of the ventilator and steady recovery.
Six days after surgery, echocardiography showed preserved graft function (LVEF 68%), with improvements in chamber sizes and a modest pericardial effusion. The patient was discharged on postoperative day 19 and remained clinically stable in follow-up visits. A later echocardiogram (Feb 27, 2024) demonstrated preserved graft function (LVEF 61%) and normalized estimated PH (24 mmHg).
Discussion
This case demonstrates that prolonged IABP support can unload the failing left ventricle, lower left-sided filling pressures, and reverse many components of secondary PH, thereby converting a high-risk transplant candidate into a suitable recipient. The strategy potentially lowers the risk of post-transplant right ventricular failure and may shorten post-operative recovery when carefully monitored.
Limitations include the single-case nature and the need for larger, prospective multicenter trials to define patient selection criteria, optimal timing, and duration of IABP therapy in the context of PH and transplantation. Nonetheless, the successful outcome observed here supports considering IABP as a bridge-to-transplant option in similar hemodynamic profiles.
Conclusion
In this patient, 62 days of IABP support reversed severe pulmonary hypertension, enabling successful heart transplantation and favorable short-term graft function. This case adds to the growing evidence that reversible PH can be achieved with targeted mechanical unloading and perioperative strategies, expanding transplant accessibility for high-risk patients.
