Rapid peri-operative transition between oral and intravenous treprostinil was safely achieved without invasive monitoring in a low-risk patient with pulmonary arterial hypertension.
Case Report (n=1)
Can oral treprostinil be safely transitioned to intravenous treprostinil peri-operatively without invasive monitoring in low-risk PAH patients?
Rapid peri-operative transition between oral and intravenous treprostinil can be safely achieved without invasive monitoring in carefully selected low-risk PAH patients.
Abstract Introduction Pulmonary arterial hypertension (PAH) is associated with high peri-operative morbidity and mortality, and peri-operative management of PAH-specific therapies is critical to minimize complications. Case Presentation A 29-year-old female with idiopathic PAH presented with abdominal pain. Right heart catheterization one year prior revealed RA 10 mmHg, PA 94/41 (63) mmHg, PCWP 9 mmHg, Fick Cardiac Output 4.11 L/min, Fick Cardiac Index 2.43 L/min/m2, PA saturation 63% and PVR 11.4 Woods Units. Transthoracic echocardiogram six months prior showed a mildly dilated right ventricle with preserved systolic function and no pericardial effusion. She remained WHO functional class I and low risk per REVEAL 2.0 and ESC/ERS stratification. She had been maintained on macitentan, tadalafil, and oral treprostinil 10mg TID, and subcutaneous sotatercept was added following this testing. On admission, abdominal computed tomography confirmed a recurrent tubo-ovarian abscess complicated by left hydronephrosis. She had failed prior antibiotic treatment, therefore surgical intervention was recommended. Tadalafil and macitentan were continued perioperatively. Given her NPO status for surgery, oral treprostinil was planned to transition to equivalent dose intravenous treprostinil 40ng/kg/min with dosing weight 95 kg without invasive hemodynamic monitoring (table 1). The day prior to the surgery, intravenous treprostinil was initiated at 20 ng/kg/min with the mid-day dose of oral treprostinil and infusion rate was increased to 40 ng/kg/min with the evening dose of oral prior to oral discontinuation. She underwent robotic assisted left salpingo-oophorectomy, lysis of adhesions, and ureteral stent placement. After surgical clearance for diet initiation, oral treprostinil 10 mg TID was resumed in the afternoon on postoperative day 1, and intravenous treprostinil was decreased to 20 ng/kg/min, with subsequent discontinuation of the IV infusion after the nighttime oral dose. She recovered uneventfully and was discharged home on postoperative day 3. At follow-up one month later, she remained clinically stable with a low-risk PAH profile. Discussion Abrupt discontinuation of prostacyclin has been shown to result in acute decompensation or death, though there remains a lack of standardized protocols for peri-operative management of oral treprostinil. This case demonstrates that rapid peri-operative transition between oral and intravenous treprostinil can be safely achieved without invasive monitoring in carefully selected low-risk PAH patients, offering a practical strategy when NPO status precludes oral prostacyclin therapy. This abstract is funded by: N/A
Agrawal et al. (Fri,) conducted a case report in Idiopathic pulmonary arterial hypertension (n=1). Transition from oral to intravenous treprostinil was evaluated on Safety and clinical stability during peri-operative transition. Rapid peri-operative transition between oral and intravenous treprostinil was safely achieved without invasive monitoring in a low-risk patient with pulmonary arterial hypertension.