Pharmacologic Bridging With Prostaglandin E1 Before Heart Transplantation - A New Chance for an Old Drug
Journal of Clinical and Basic Cardiology 2002; 5 (2): 171-177
Keywords: Bridging-Therapie, Endpunkt, Herztransplantation, prostaglandin E1, refraktäre Herzinsuffizienz, bridging therapy, heart transplantation, Outcome, prostaglandin E1, refractory heart failure
In everyday practice, physicians consider heart failure refractory when intractable signs and symptoms (oedema, pulmonary congestion, dyspnoea, fatigue) occur although vigorous attempts have been made to adjust oral heart failure therapy. This condition is present in about 15 to 20 % of heart failure patients and is associated with high mortality unless heart transplantation (HTx) is performed. However, during the waiting period, decompensation is frequent and need of hospitalisation increases steeply. In this population, intravenous infusions with inotropes or vasodilators, such as prostaglandin E1 (PGE1), elicit similar dramatic effects when given acutely. Patients who face a longer wait on the HTx list, may be considered for long-term intravenous PGE1 therapy in an attempt to facilitate hospital discharge. As a rule, to qualify for bridging with PGE1 patients must be receiving maximum tailored therapy with digoxin, diuretics, and ACE-inhibitors (or analogous drugs) while hospitalised. Further, a positive haemodynamic response to PGE1 during right heart catheterization is required. PGE1 ambulatory infusions are easily administered with a pump through central venous tunnelled access lines and can be given after a brief period of instruction with few readmissions or significant complications. A prospective randomized trial suggested increased freedom from worsening heart failure in patients bridged with PGE1 as opposed to prostacyclin or dobutamine. Finally, patients bridged with PGE1 appear to have similar 1-year-survival rates after HTx as patients receiving oral heart failure medications only.