Pulmonary Hypertension Post-LVAD

A 69-year-old male patient with a non-ischemic cardiomyopathy and severe biventricular failure experienced multiple recurrent admissions on home inotrope therapy. His pulmonary artery pressure precluded listing for heart transplantation. The patient had severe mitral regurgitation. He underwent repair of the mitral valve with a 31 mm ring and HVAD (Heartware Inc.; Framingham, MA) implant as destination therapy.

He was transferred to the intensive care unit post-procedure with epoprostenol inhaled, milrinone, and epinephrine. On post-operative day 3, the patient's hemodynamics had not improved significantly, and he remains on dobutamine 2.5 mcg/Kg/min and milrinone 0.375 mcg/Kg/min (Table 1).

Table 1

Right Heart Catheterization

Medications

Right Atrial Pressure

Pulmonary Capillary Wedge Pressure

Pulmonary Artery Pressure

Cardiac Output / Cardiac Index

Blood Pressure

Heart Rate

Pre-operation

Milrinone

6

22

73/30 ~ 46

4.6/2.3

98/68

69

Post-operative Day 3

Milrinone, dobutamine

18

Could not wedge catheter

58/27 ~ 36

5.5/2.7

109/77

110

When the critical care physician asks your opinion on starting the patient on sildenafil, what is your response?

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