(1507) Intravenous Prostacyclin Therapy for Nonoperative Salvage of Shock due to Right Ventricular Failure

Introduction: Pulmonary arterial hypertension (PAH) is caused by increased pulmonary vascular resistance and right ventricular (RV) afterload from luminal obliteration of the distal pulmonary arterioles. The main cause of death for PAH patients is right ventricular failure (RVF). The management of patients with severe RVF is challenging due to limited therapeutic options, lack of available mechanical RV support devices, and scarcity of pulmonary vascular disease expertise. We present a case of PAH induced acute RVF that was rescued utilizing intravenous (IV) prostacyclin therapy after extracorporeal membrane oxygenation (ECMO) was not an option.

Description: A 59-year-old female with PAH due to amphetamine abuse was admitted to the ICU with acute mesenteric ischemia. Vasopressor and inotropic support were initiated but multisystem organ failure (MSOF) developed. Right Heart Catheterization (RHC) confirmed impaired cardiac output due to RVF with significant fluid overload. She was not a candidate for RV mechanical support or transplant due to ongoing methamphetamine use. IV Treprostinil was titrated to 20ng/kg/min and aggressive volume removal via continuous renal replacement. Inotropes were weaned and patient successfully transitioned from IV to oral Treprostinil. Patient was discharged home on Treprostinil, Sildenafil, and Ambresentan.

Discussion: According to the ASPIRE registry, the in-hospital mortality rate can be as high as 50% in patients with RVF leading to MSOF. Acute strategies include identifying the underlying cause and optimizing preload, afterload, and cardiac contractility. In critical illness, cardiac mechanical support is considered depending on reversibility of the underlying cause and candidacy for lung transplantation. The use of continuous prostacyclin therapy in decompensating patients is complex given the balance of RV afterload reduction and unintentional peripheral vasoplegia. They should be avoided in patients with evidence of combined severe distributive shock. Guideline recommendations and evidence for use in this setting are minimal.

This case highlights prostacyclin agents as an alternative in appropriate nonoperative patients and the importance of early recognition and transfer of RVF patients to a center with expertise in PAH management and advanced cardiac support.