High-Risk Heart Transplant in a Young Patient with Pulmonary Hypertension

Heart Transplant in a 28-Year-Old Male with Dilated Cardiomyopathy and Severe Pulmonary Vascular Resistance

Surgeon: Dr. Vishal Khullar, Director, Cardiothoracic & Vascular Surgery, Heart and Lung Transplant
Hospital: Fortis Hospital Mulund, Mumbai
Procedure: Orthotopic Heart Transplant following Milrinone-tested PVR reversibility assessment

Patient details below are recorded in line with confidentiality conventions for written case studies. Patient identity has been withheld.

Condition

The patient, a young male, was admitted with severe heart failure and was found to have dilated cardiomyopathy, with an echocardiogram showing a severely reduced left ventricular ejection fraction of just 10 to 15%. At this level of function, the heart is barely managing to circulate blood, and medical therapy alone has a limited ceiling. After a period of optimal medical management failed to meaningfully improve his condition, he was formally evaluated for a heart transplant.

Impact on the Patient

At 28, this was not a decision anyone wanted to be facing this early in life, but the numbers left little room for alternatives. His right heart catheterization revealed a pulmonary vascular resistance of 6.5 Wood units, well above the threshold of 4 Wood units that is considered a relative contraindication to transplant, because of the risk of the new donor heart’s right side failing under that resistance immediately after surgery. Rather than close the door on transplant, the team tested whether that resistance was fixed or reversible, working with an experienced cardiac surgeon in Mumbai to interpret what the numbers meant for his specific case.

What Was Assessed During Evaluation

• Echocardiographic confirmation of dilated cardiomyopathy and severely reduced LVEF
• Response to a trial of optimal medical management before proceeding to transplant workup
• Right heart catheterization to quantify pulmonary vascular resistance
• Acute vasoreactivity testing with intravenous Milrinone to assess whether the elevated PVR was reversible
• Overall risk stratification given the combination of young age, severe LV dysfunction, and borderline-high PVR

Why Transplant Was Pursued Despite the High-Risk Profile

• A PVR of 6.5 Wood units carries a real risk of postoperative right heart failure in the donor heart, which made careful reversibility testing essential before listing the patient
• IV Milrinone administration brought the PVR down to below 4 Wood units, demonstrating that the elevated resistance was at least partially reversible rather than fixed pulmonary vascular disease
• With a severely reduced LVEF and no meaningful response to medical therapy, transplantation was recognised as the only viable option for a patient this young
• The patient was accepted for listing with the understanding that he remained a high-risk candidate, requiring close intraoperative and postoperative right heart monitoring

Step-by-Step Surgical Overview

1. Patient listed for transplant; a suitable donor heart was identified in Pune after a two-month wait
2. Donor heart transported by ambulance in 1 hour and 57 minutes
3. Patient prepared and anaesthesia induced; full cardiac monitoring established given the high-risk right heart profile
4. Median sternotomy performed and cardiopulmonary bypass instituted
5. Recipient’s diseased heart excised and donor heart implanted using standard orthotopic technique
6. Total ischemic time from donor retrieval to reperfusion was 3 hours and 45 minutes
7. Patient weaned off bypass on minimal inotropic support
8. Intraoperative transesophageal echocardiogram performed to assess graft function immediately after implantation
9. Chest closed in layered fashion; patient transferred to ICU in stable condition

Procedure Facts

Intraoperative transesophageal echocardiography performed after implantation demonstrated excellent biventricular function on minimal inotropic support — a reassuring sign given the pre-transplant concern around the recipient’s elevated pulmonary vascular resistance. The patient was transferred to the ICU in stable condition and was successfully extubated on postoperative day 1.

Outcomes at a Glance

Families weighing a transplant of this complexity often want a realistic sense of the financial picture as well — our guide on heart transplant cost at Fortis Mumbai breaks down what shapes the total, from donor logistics to ICU stay.

“At just 28, being diagnosed with severe heart failure and learning that I might need a heart transplant was a very difficult experience. I was told that my condition was high-risk because of the pressure in my lungs, but Dr. Vishal Khullar and his team carefully evaluated my condition and found that the pulmonary pressure could be reduced with Milrinone, making transplantation possible. After waiting for a suitable donor heart, I underwent the transplant and was relieved to learn that the new heart was functioning well. I was stable after surgery and was successfully taken off the ventilator the next day. I am grateful to Dr. Khullar and the entire team for giving me this opportunity for a new beginning.”

Patient: 28 years · Male · Identity withheld
Procedure: Heart Transplant · Fortis Hospital Mulund, Mumbai
Surgeon: Dr. Vishal Khullar · Director, Cardiothoracic & Vascular Surgery, Heart and Lung Transplant

Recovery after a high-risk transplant of this kind follows the standard heart transplant pathway, with closer early monitoring for right heart function given the pre-transplant PVR profile. For patients whose heart failure progresses to the point where transplant isn’t immediately achievable, LVAD support is part of the broader mechanical circulatory support program Dr. Khullar’s team offers.

Instructions Provided to the Patient

• Lifelong immunosuppression started immediately post-transplant, with close monitoring for early signs of rejection
• Structured ICU-to-ward step-down with continuous cardiac monitoring
• Graded mobilisation beginning shortly after extubation
• Wound care and infection monitoring
• Scheduled endomyocardial biopsies and echocardiography to track graft function and rejection status

Recovery Timeline

Facing a heart failure diagnosis, or been told you may need a transplant evaluation?

If you or a family member has been advised heart transplant evaluation, Dr. Vishal Khullar and his team are happy to review your reports and walk you through the process.

Dr. Vishal Khullar
Director, Cardiothoracic & Vascular Surgery, Heart and Lung Transplant
Fortis Hospital Mulund, Mumbai | +91-99870 77880 | appointments@drvishalkhullar.com