TRANSITION FROM PROSTANOID INFUSION TO ORAL COMBINATION VASODILATOR THERAPY FOR SEVERE PULMONARY ARTERIAL HYPERTENSION – A SINGLE CENTER EXPERIENCE

Abstract

This article may be cited as;  Sidhu MS, Aboulhosn J, Saggar Rajan, Saggar Rajeev, Belperio J, Ardehali A, Ross DJ. Transition from Prostanoid to Combination Oral Therapy for Pulmonary Arterial Hypertension. E-Journal of cardiology 2011;1(1):1-8.

Background:  Experience with transition from parenteral prostanoid (PgI2) to oral therapy for severe, symptomatic NYHA Functional Class (FC) III/IV pulmonary arterial hypertension (PAH) is limited.  Herein, we report our experiences for patients transitioned from PgI2 therapy to oral combination therapy using bosentan and sildenafil.

Methods:  A retrospective review of seven PAH patients determined to be “clinically stable” while on PgI2 during Phase I of our protocol.  In Phase II, bosentan and sildenafil were added as PgI2 was decreased during clinical surveillance with echocardiography, six-minute walk distance (6MWD), FC assessment (I-IV) and measurement of B-type natiuretic peptide (BNP) until PgI2 discontinuation.  During Phase III, monitoring was maintained after discontinuing PgI2 to detect and potentially intervene for clinical worsening.

Results:  For the seven subject group during phase I, the optimal achieved FC were: I (2), II (4), and III (1).  At the end of phase III, the FC were: I (3) and II (4).  One patient experienced right ventricular failure after five months, resulting in requirement of subcutaneous treprostinil and return to “active UNOS listing” for lung transplant.  The mean duration [±SD] for phase I: 15.9±5.1, phase II: 7±3.6, and phase III: 41.3±17.3 months. Survival during over 5 years of therapy and observation, was 86% while predicted 1, 2 and 3 year survival was 86, 80 and 74% per NIH Registry data.  

Conclusions:  Selected patients suffering from severe, symptomatic FC III/IV PAH, may be successfully transitioned from PgI2 therapy and maintained on bosentan and sildenafil, hence often avoiding lung or heart-lung transplantation.