A42-17 Methamphetamine-induced Combined Pre- and Post-capillary Pulmonary Hypertension in a Patient With Heart Failure and Bicuspid Aortic Valve

Abstract Introduction Methamphetamine use has emerged as a definitive risk factor for pulmonary arterial hypertension (PAH) due to its serotonergic and vasoconstrictive effects on pulmonary vasculature. When coexisting with cardiac disease, such as valvular dysfunction or heart failure, management becomes increasingly complex. This case describes a patient with methamphetamine-associated mixed pre- and post-capillary pulmonary hypertension presenting with cardiovascular collapse during preoperative induction. Case Description A 37-year-old man with a history of bicuspid aortic valve, heart failure with preserved ejection fraction, and pulmonary hypertension was evaluated for aortic valve replacement. Preoperative right heart catheterization revealed mean pulmonary artery pressure (PAP) in the 40s mmHg, pulmonary capillary wedge pressure (PCWP) in the high 20s mmHg, and preserved left ventricular ejection fraction 55%. During induction with propofol, the patient suffered cardiopulmonary arrest requiring resuscitation and initiation of inhaled nitric oxide, epinephrine, and multiple inotropes for cardiogenic shock. He was weaned off mechanical and pharmacologic support within one week, with full neurologic recovery. Further history revealed ongoing methamphetamine use. Repeat echocardiography showed a severely dilated right ventricle with reduced systolic function, and right heart catheterization demonstrated mean PAP 74 mmHg and PCWP 28 mmHg, consistent with combined pre- and post-capillary pulmonary hypertension. He was treated with aggressive diuresis, sildenafil, and stepwise titration of prostacyclin analog therapy. Over time, he achieved clinical compensation and stable outpatient follow-up. Figure 1 presents a transthoracic echocardiogram showing bicuspid aortic valve with severe aortic regurgitation. Discussion This case highlights the diagnostic and therapeutic challenges of methamphetamine-associated pulmonary hypertension in patients with concurrent structural heart disease. The coexistence of elevated PAP and PCWP indicates mixed pulmonary hypertension, requiring cautious titration of vasodilators to avoid precipitating pulmonary congestion. Methamphetamine use accelerates pulmonary vascular remodeling and worsens right heart failure, compounding perioperative risk. Management hinges on stimulant cessation, optimization of volume status, and tailored use of pulmonary vasodilators. This case underscores the importance of substance use screening and multidisciplinary coordination in patients with unexplained or refractory pulmonary hypertension, particularly when cardiac and pulmonary pathophysiology overlap. This abstract is funded by: None