CONGRESS ABSTRACT

A 41-year-old patient with late graft failure from a cardiac transplant performed 12 years earlier was referred to our unit for heart retransplantation in January 2023. Severe cardiac allograft vasculopathy (ISHLT CAV 3) not amenable to revascularization was diagnosed. Given the patient's history of multiple episodes of worsening heart failure (HF) in the last 12 months, including three episodes of congestion requiring intravenous diuretic therapy, and despite receiving guidelines-directed medical therapy, an off-label use of vericiguat was proposed after achieving a state of euvolemia. Over six weeks, Vericiguat was well tolerated and successfully up-titrated to 10 mg daily. After six months of treatment with 10 mg/day of vericiguat, we repeated a transthoracic echocardiogram, observing improvements in left ventricular ejection fraction and volumes, cardiac output, and an increase in both global longitudinal strain and myocardial work indices. (Figure 1, 2). In addition, there was an increase in the right ventricular free wall longitudinal strain (RVFWS). (Figure 3) For the first time, we report the positive hemodynamic effects of vericiguat in a heart transplant recipient. Vericiguat improved myocardial performance by promoting heart relaxation and lowering systemic vascular resistance, which leads to an increase in stroke volume. This is shown by the rise in global constructive work (GCW) and global work efficiency (GWE). Interestingly, the increase in GCW (from 479 to 599 mmHg%) and global work index (GWI) (from 340 to 486 mmHg%) values exceeded those of the cut-offs reported as predictors of death from any cause and cardiac transplantation. Furthermore, the reduction in pulmonary pressure values that vericiguat induces may contribute to an improvement in right ventricular-pulmonary artery coupling, leading to the reported increase in RVFWS. Noteworthy, the improvements on both functional and structural echocardiographic parameters translated into significant clinical benefits; in fact, our patient did not experience  any further episodes of worsening HF and is currently in good hemodynamic condition awaiting cardiac retransplantation. Although the use of recommended HF medications has not been rigorously validated in HTx recipients, and since heart retransplantation is not devoid or risks, Vericiguat may be a useful therapeutic option in case of refractory, symptomatic HF.