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Terbutaline for Chronotropic Support in Heart Transplantation

at time of writing, Cardiology Specialty Resident, University of Pittsburgh Medical Center Health System, and Adjunct Instructor of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy; now, Clinical Specialist, Cardiology, Department of Pharmacy, Allegheny General Hospital, Pittsburgh, PA

Michael Shullo, PharmD

Clinical Pharmacist, Cardiology and Transplantation, Coordinator, Ambulatory Care Medicine, University of Pittsburgh Medical Center Health System; Assistant Professor of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh

Kristine Schonder, PharmD

Clinical Pharmacist, Transplantation, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center Health System; Assistant Professor of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh

Robert Kormos, MD

Professor of Surgery, Director, Artificial Heart Program and Cardiothoracic Transplantation, Medical Director, McGowan Institute for Regenerative Medicine, Director, Cardiothoracic Residency Program, University of Pittsburgh Medical Center Health System

Reprints: James C Coons PharmD, Department of Pharmacy, Allegheny General Hospital, 320 E. North Ave., Pittsburgh, PA 15212-4772, fax 412/359-4806, jcoons{at}wpahs.org

OBJECTIVE: To report the use of oral terbutaline for chronotropic support in a patient who had undergone heart transplantation.

CASE SUMMARY: A 54-year-old white man received a heart transplant secondary to ischemic dilated cardiomyopathy. His clinical course was uncomplicated until postoperative day 10, when he became hemodynamically compromised despite inotropic therapy (BP 88/53 mm Hg, mean HR 80 beats/min) secondary to stage IIIa rejection. Although a continuous intravenous infusion of dobutamine was maintained, therapy with oral terbutaline 2.5 mg every 6 hours was initiated. Because the patient remained bradycardic on postoperative day 11 (HR 64 beats/min; mean 75), terbutaline was titrated to a dosage of 5 mg every 8 hours. Subsequently, an improvement in the hemodynamic profile (BP 140/78 mm Hg, mean HR 91 beats/min) was noted. Treatment with terbutaline was continued for 13 days and was well tolerated.

DISCUSSION: As of February 11, 2004, this is the first case, to our knowledge, to describe the use of oral terbutaline therapy for chronotropic support in the setting of acute rejection after heart transplantation. Terbutaline is a ß₂-adrenergic agonist that may mediate its effects via direct ß₂-receptor stimulation, baroreceptor-mediated increases in sympathetic tone, or via presynaptic ß₂-stimulation. Although isoproterenol has been the mainstay of therapy for chronotropic support in this setting, its availability has been an issue in recent years. Terbutaline, therefore, may represent a useful alternative for chronotropic support in the setting of heart transplantation.

CONCLUSIONS: Terbutaline therapy did not appear to be associated with any significant adverse effects and warrants further application and study in this setting.

Key Words: bradycardia, heart transplantation, rejection, terbutaline

Published Online, February 24, 2004. www.theannals.com, DOI 10.1345/aph.1D440