Preoperative pharmacological management of a patient with ASD II and pulmonary hypertension forcardiac surgery

Abstract

The article presents the case of a 36-year-old woman referred to the Clinic of Cardiology at the Pomeranian Medical University with exertional dyspnoea that had been increasing for 2 years. Upon examination, the patient was diagnosed with an atrial septal defect type II (ASD II) with a left-to-right shunt and pulmonary hypertension. Echocardiography revealed a defect of 4.3 cm in diameter, right ventricular systolic pressure (RSVP) 80 mm Hg, tricuspid regurgitation. Right heart catheterization (RHC) revealed: mean pulmonary arterial pressure (mPAP) 59 mm Hg, pulmonary vascular resistance 10.22 Wood units (WU) and a negative vasoreactivity test. Following a cardiosurgical consultation, the patient was qualified for preliminary pharmacological treatment and re-examination. Sildenafil was included in the treatment, followed by macitentan. Improvement in exercise tolerance was observed [in the 6-minute walk test — from 440 to 526 m; clinically from New York Heart Association (NYHA) III to NYHA I/II] as well as a decrease in N-terminal pro-B-type natriuretic peptide concentration (from 250 to 170 pg/mL). Echocardiography showed a decrease in RVSP to 60 mm Hg. In RHC performed after one year of treatment, mPAP decreased to 40 mm Hg, PVR decreased to 3.25 WU, and cardiac output increased from 5.57 to 10.44 L/min. Mixed venous oxygen saturation increased from 64.5% to 72.5%. After another cardiosurgical consultation, the patient was qualified for surgery. Closure of ASD II was performed with a pericardial patch and completed with tricuspid valve plasty. The peri-and postoperative period was uneventful, and the clinical and echocardiographic follow-up confirmed the positive effects of the treatment.