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PubMed2005

Hemodynamic effects of inhaled nitric oxide and phosphodiesterase inhibitor (dipyridamole) on secondary pulmonary hypertension following heart valve surgery in adults.

BACKGROUND: Inhaled nitric oxide (iNO) is proposed in the management of pulmonary hypertension (PH) in patients undergoing cardiac surgery. Secondary PH related to a long-standing heart valve disease however may be refractory to iNO. Aim of this prospective study was to determine whether the combination of iNO plus dipyridamole (DP), a cyclic guanosine monophosphate-specific phosphodiesterase inhibitor (PDE5), may enhance and/or prolong the response to iNO in adult patients with secondary valve-related PH undergoing cardiac surgery, and attenuate rebound events related to its discontinuation. METHODS: Responses in 27 patients, 11 male, mean age 72+/-11 years, with PH due to mitral and/or aortic valve disease, were studied in the Intensive Care Unit after cardiac surgery, during sedation and stable hemodynamic conditions. The effect of isolated iNO administration (40 ppm), iNO combined with DP (0.2 mg/kg i.v.), and DP alone (1 mg/kg/24 h) on pulmonary vascular resistance, mean pulmonary artery pressure, cardiac index, mixed venous O2Sat%, and mean arterial pressure were determined. RESULTS: All patients showed at least a 10% decrease in pulmonary vascular resistance vs. baseline after administration of iNO [responders]. Inhaled NO and the combination of iNO/DP produced a reduction of pulmonary vascular resistance and mean pulmonary artery pressure (p<0.05). Cardiac index improved with a significant difference between iNO and the association iNO/DP versus baseline (p<0.05). This significant hemodynamic improvement versus baseline was maintained during isolated DP administration (p<0.05), but not during isolated iNO discontinuation. Mixed venous oxygen saturation showed an overall improvement of 17% (p<0.05). CONCLUSIONS: Inhaled NO and DP infusion might represent a valuable association in the management of PH secondary to a heart valve disease in patients undergoing cardiac surgery. Their beneficial hemodynamic effects might be particularly valuable in the management of patients with associated right ventricular dysfunction.

Administration, Inhalation↗
PubMed2005

Long-term outcome of surgically treated patients with corrected transposition of the great arteries.

OBJECTIVES: The purpose of the study was to examine long-term outcome after traditional surgical treatment of corrected transposition of the great arteries to provide a basis for comparison with new procedures, such as the double-switch or Senning-Rastelli procedures. METHODS: Patient- and procedure-related variables in 123 patients with corrected transposition and 2 functional ventricles operated on between 1963 and 1996 were analyzed. Patients with intracardiac procedures underwent either a traditional 2-ventricle repair or a Fontan procedure. RESULTS: The 1-, 5-, 10-, and 15-year survivals after the operation were 84%, 75%, 68%, and 61%, respectively. Patients requiring tricuspid valve replacement (27 patients) at any time during follow-up had a significantly worse outcome ( P < .001; hazard ratio, 4.4), whereas the best outcome was seen in patients undergoing the Fontan procedure (17 patients, 0 deaths). Right ventricular end-diastolic pressure of greater than 17 mm Hg before the operation ( P < .0001), complete heart block after the operation ( P = .001), subvalvular pulmonary stenosis ( P = .013), Ebstein malformation of the tricuspid valve ( P = .025), and preoperative systemic (right) ventricular dysfunction ( P = .041) were identified as risk factors for death at any time by means of univariate analysis. Ebstein malformation of the tricuspid valve ( P = .036; hazard ratio, 1.5) was identified as a risk factor for death by multivariate analysis. CONCLUSIONS: The long-term outcome of patients with corrected transposition after a classic surgical approach is unsatisfactory. The poorest outcome was seen in patients who required tricuspid valve replacement either at their initial operation or later during follow-up. Alternative surgical approaches, such as the double-switch, Senning-Rastelli, or Fontan procedures, are likely to have better long-term results, especially in the highest risk groups.

Analysis of Variance↗
PubMed2006

Successful resuscitation with thrombolysis of a patient suffering fulminant pulmonary embolism after recent intracerebral haemorrhage.

We report the life-saving administration of thrombolysis during cardiopulmonary resuscitation in a patient with recent intracerebral haemorrhage. A 53-year-old male with intracerebral haemorrhage was admitted to the intensive care unit. On the 24th day of treatment he suffered cardiac arrest with pulseless electrical activity. Transoesophageal echocardiography was performed during ongoing cardiopulmonary resuscitation. Thrombi in the right heart cavities with excessive right ventricular dysfunction confirmed the diagnosis of fulminant pulmonary embolism. Permanent restoration of a spontaneous rhythm was feasible only after administration of systemic thrombolysis with recombinant tissue plasminogen activator. Neurological examination and a computed tomogram of the brain did not show rebleeding. We conclude that under extreme circumstances absolute contraindications to thrombolysis should be weighed against the potential benefit.

Acute Disease↗
PubMed2006

Extracorporeal circulation with low systemic heparinization during lung transplantation.

BACKGROUND: Some lung transplantation (LT) recipients suffer from pulmonary hypertension and right ventricular dysfunction or failure requiring extracorporeal circulation (ECC) to avoid catastrophic complications during surgery. The extracorporeal support usually requires systemic heparinization which is potentially associated with important side effects. We performed eight LT using preheparinized ECC circuits and an oxygenator associated with a lower level of systemic heparinization without evidence of perioperative complications. PATIENTS AND METHODS: From May 2002 to May 2005, 8 patients (5 men and 3 women) of mean age 22.5 +/- 9.5 years underwent bilateral sequential lung transplantation (BSLT) for cystic fibrosis (n = 6) or idiopathic pulmonary fibrosis (n = 2). All procedures were performed with ECC through a femoro-femoral veno-arterial bypass with preheparinized circuits and an oxygenator. RESULTS: No intraoperative mortality occurred. The mean ECC time was 147.8 +/- 31.3 minutes and the mean heparin administered was 3525 +/- 969.16 UI. No coagulopathy or thrombotic events were observed perioperatively. CONCLUSIONS: Our study confirmed the efficacy and safety of prehepanized circuits and oxygenator for femoro-femoral veno-arterial bypass during LT for patients with severe pulmonary hypertension requiring ECC.

Adult↗
PubMed2004

Brain natriuretic peptide predicts right heart failure in patients with acute pulmonary embolism.

BACKGROUND: Plasma levels of brain natriuretic peptide (BNP) are increased in patients with left heart failure. In patients with severe pulmonary embolism (PE), primary right ventricular (RV) dysfunction is frequent. Little is known about BNP secretion in acute RV failure. METHODS: We prospectively studied 50 consecutive patients with confirmed PE (age range, 57 +/- 19 years; 36 men). PE was confirmed with pulmonary angiography, spiral computed tomography, or echocardiography and subsidiary analyses. On admission, echocardiography and BNP measurements were performed in all patients. RESULTS: Patients without RV dysfunction had significantly lower BNP levels than patients with RV dysfunction (55 +/- 69 pg/mL vs 340 +/- 362 pg/mL, P <.001). There was a significant correlation between RV end-diastolic diameter and BNP (r = 0.43, P <.05). BNP discriminated patients with or without RV dysfunction (area under the receiver operating characteristic curve, 0.78; 95% CI, 0.64-0.92). A BNP >90 pg/mL was associated with a risk ratio of 28.4 (95% CI, 3.22-251.12) for the diagnosis of RV dysfunction. All patients without LV systolic dysfunction who had syncope necessitating cardiopulmonary resuscitation had normal BNP levels. Patients with RV dysfunction had significantly more in-hospital complications (cardiogenic shock, inotropic therapy, mechanical ventilation). However, BNP levels were not predictive of mortality or in-hospital complications. CONCLUSIONS: BNP levels are frequently increased in patients with PE who have RV dysfunction, whereas patients without RV dysfunction show reference range BNP levels in the absence of left ventricular dysfunction. In acute PE, BNP elevation is highly predictive of RV dysfunction, but not of in-hospital complications and mortality.

Acute Disease↗
PubMed2001

Aerosolized iloprost for severe pulmonary hypertension as a bridge to heart transplantation.

Preexisting pulmonary hypertension in pediatric patients is associated with poor outcome after cardiac transplantation because of donor right ventricular dysfunction. To avoid a combined heart-lung transplantation in a 17-year-old patient, we used an intensified pretreatment with intravenous prostacyclin and dobutamine combined with an inhalative therapy with the aerosolized prostacyclin-analog Iloprost. With this regimen, the patient was hemodynamically stabilized for the waiting period of 21 days after which an uneventful cardiac transplantation was performed.

Adolescent↗
PubMed2002

Intravenous milrinone in cardiac surgery.

Phosphodiesterase inhibitors including milrinone produce positive inotropic effects by slowing the hydrolysis of cyclic adenosine monophosphate in the myocardium. With a loading dose of 50 microg/kg followed by an infusion of 0.5 microg x kg(-1) x min(-1), milrinone increases stroke volume index and left ventricular velocity of circumferential fiber shortening after weaning from cardiopulmonary bypass. Milrinone has potential for the treatment and prevention of internal mammary artery spasm because of its vasodilative effect, which is similar to that of papaverine, and is a potent pulmonary vasodilator for patients with right ventricular dysfunction and pulmonary vasoconstriction. Low-dose milrinone may have antiinflammatory properties and potentially can improve splanchnic perfusion.

Cardiac Surgical Procedures↗
PubMed2002

Natriuretic peptides after pulmonary resection.

BACKGROUND: Little is known about alterations in the levels and influence of natriuretic peptide (NP) on cardiopulmonary function after pulmonary resection for lung cancer. This study was designed to investigate the patterns and activity of NP after pulmonary resection. METHODS: We investigated changes in plasma A-type (atrial) NP and B-type (brain) NP (BNP) using radioimmunoassay, in lung cancer patients before and after lobectomy (n = 15) or pneumonectomy (n = 10). Patient characteristics, respiratory function, operative time, blood loss, intraoperative fluid administration, and intraoperative urine output in both groups were also compared. Pulmonary hemodynamic variables were monitored continuously. RESULTS: Plasma concentrations of A-type NP and BNP did not differ between the two groups preoperatively. However, the group undergoing pneumonectomy exhibited higher concentrations of A-type NP and BNP than the group undergoing lobectomy on postoperative days 3 and 7. Alterations in A-type NP and BNP after pulmonary resection therefore differed according to the volume of lung tissue resected. Both mean pulmonary artery pressure and total pulmonary vascular resistance increased significantly in the pneumonectomy group. The total pulmonary vascular resistance on postoperative day 3 correlated with the plasma BNP concentration in the pneumonectomy group. CONCLUSIONS: A-type NP and BNP effectively compensate for the right ventricular dysfunction noted after pulmonary resection, and this is more evident after pneumonectomy than after lobectomy. Changes in ventricular activity associated with changes in plasma BNP and total pulmonary vascular resistance are indicative of cardiopulmonary adjustments after pneumonectomy.

Aged↗
PubMed1997

Coronary artery stenosis in rats affects beta-adrenergic receptor signaling in myocytes.

OBJECTIVE: The purpose of this study was to determine whether the early chronic ischemic cardiomyopathy produced by non-occlusive coronary artery constriction was characterized by alterations in the regulation of beta-adrenoreceptor (beta-AR) signaling. METHODS: Coronary artery narrowing was surgically induced in rats and the animals sacrificed at 7 and 14 days. The changes in the biochemical properties of the multiple components of the beta-AR pathway were examined in enzymatically dissociated myocytes. RESULTS: Coronary stenosis, involving an average 55% reduction in luminal diameter, was associated with left ventricular failure and right ventricular dysfunction at both time intervals. A decrease in the quantity of beta-AR was detected at 7 days and preceded the loss of high-affinity binding sites. This regulatory modification was characterized by a reduction in beta 1 and beta 2 receptors and a shift in the isoproterenol dose response curve indicating a functional correlation between the decrease in beta-AR and attenuated inotropic support of the myocardium. The percentage of beta-AR binding agonist with high affinity decreased significantly at 14 days along with a further reduction in the density of beta 1 and beta 2 receptors. Reconstitution studies with cyc S49 lymphoma cells did not detect an impairment of Gs alpha functional activity, but the quantity of Gi alpha was increased at both intervals. Finally, activation of the catalytic unit of adenylyl cyclase by forskolin and GTP was not altered by coronary stenosis, however, basal cyclic AMP in myocytes was depressed at 14 days. CONCLUSIONS: Coronary stenosis induces distinct and progressive modifications in the beta-AR signaling cascade which may contribute to the impaired ventricular performance in this model of myocardial ischemia.

Adrenergic beta-Agonists↗
PubMed1996

Effective control of pulmonary vascular resistance with inhaled nitric oxide after cardiac operation.

Increased pulmonary vascular resistance may greatly complicate the perioperative management of cardiac surgical patients. Inhaled nitric oxide may be a promising new therapy to selectively lower pulmonary vascular resistance. The purpose of this study was to examine the effects of inhaled nitric oxide on pulmonary and systemic hemodynamics in cardiac surgical patients. Twenty patients (age 57 +/- 6 years) were studied in the operating room after weaning from cardiopulmonary bypass. Mean pulmonary artery pressure, pulmonary vascular resistance, systemic vascular resistance, and mean aortic pressure were determined at four points of data collection: before nitric oxide, with 20 ppm nitric oxide, with 40 ppm nitric oxide, and after nitric oxide. Statistical analysis was by analysis of variance; significance was accepted for p < 0.05. Inhaled nitric oxide produced selective pulmonary vasorelaxation. Pulmonary vascular resistance was lowered from 343 +/- 30 before nitric oxide to 233 +/- 25 dynes.sec-1.cm-5 with 20 ppm nitric oxide. Pulmonary vascular resistance was not further lowered by 40 ppm nitric oxide (p < 0.05). Mean pulmonary arterial pressure was 29 +/- 1 mm Hg before nitric oxide and was lowered to 22 +/- 1 mm Hg by 20 ppm nitric oxide and 21 +/- 1 mm Hg by 40 ppm nitric oxide (p < 0.05). Both pulmonary vascular resistance and mean pulmonary arterial pressure returned to baseline after withdrawal of inhaled nitric oxide. Inhaled nitric oxide produced no changes in either systemic vascular resistance or mean aortic pressure. We conclude that nitric oxide may be used as an effective pulmonary vasodilator after cardiac operations. It may be particularly valuable for selectively lowering right ventricular afterload in patients with right ventricular dysfunction.

Administration, Inhalation↗
PubMed2004

Pulmonary embolism.

Pulmonary embolism (PE) is a common illness that can cause death and disability. It is difficult to detect because patients present with a wide array of symptoms and signs. The clinical setting can raise suspicion, and certain inherited and acquired risk factors predispose susceptible individuals. D-dimer concentration in blood is the best laboratory screening test, and chest CT has become the most widespread imaging test. Treatment requires rapid and accurate risk stratification before haemodynamic decompensation and the development of cardiogenic shock. Anticoagulation is the foundation of therapy. Right-ventricular dysfunction on echocardiography and higher than normal concentrations of troponin identify high-risk patients who might need escalation of therapy with thrombolysis or embolectomy even if the blood pressure is normal on presentation. When patients are admitted to medical wards or when patients undergo surgery, their physicians should prescribe prophylactic measures to prevent PE. After hospital discharge, prophylaxis should continue for about a month for patients at high risk of thromboembolism.

Humans↗
PubMed2003

Local and systemic thrombolytic therapy for acute venous thromboembolism.

Thrombolytic therapy unquestionably leads to more rapid and complete clot lysis with a significantly higher risk of bleeding when compared with anticoagulation. The most definite indication for thrombolytic therapy in patients with VTE is massive PE associated with hemodynamic instability. Other potential indications, although not widely accepted or proven, include PE-related respiratory failure with severe hypoxemia and massive iliofemoral thrombosis with the risk of phlegmasia cerulea dolens. Routine use of thrombolytic therapy in all other cases of PE and DVT cannot be justified. Future research using randomized controlled studies should focus on the following key questions: Do hemodynamically stable patients with PE and right ventricular dysfunction benefit from thrombolysis, and, if so, is there a subset of patients within this group who are most likely to benefit? Does thrombolytic therapy improve long-term outcomes of DVT with a favorable risk-to-benefit ratio, and, if so, which patients are most likely to benefit long-term? What is the precise role of catheter-directed thrombolysis in the treatment of VTE, particularly the use of a low-dose thrombolytic agent in conjunction with mechanical clot disruption to minimize bleeding in patients at high risk? Until these questions are answered, clinicians must approach decision-making regarding the use of thrombolytic therapy in PE and DVT with careful consideration of the potential risks and benefits for the patient within the framework of currently available data.

Acute Disease↗
PubMed2002

Transposition complexes in the adult: a changing perspective.

This study has shown the heterogeneous group of patients with discordant ventricular arterial relations, their management and problems encountered during follow up. Patients after surgery for transposition are still relatively young by cardiology standards and their problems continue to evolve; nevertheless the future is becoming clearer. However there are still important lessons to be learnt by continued and diligent observation and systematic, multicenter research. It is important to maintain a low threshold for thorough re-evaluation of patients whenever new symptoms are discovered. Indeed, patients should undergo regular detailed investigations at timely intervals. It is vital that this evolving group of adult patients, as with most patients emerging from a childhood with other congenital heart malformations, is managed by cardiologists fully trained in congenital heart disease.

Adult↗
PubMed1983

An epidemic of pulmonary hypertension after toxic rapeseed oil ingestion in Spain.

The cardiac profile of 38 patients readmitted to the hospital with the clinical and radiologic findings of pulmonary artery hypertension and right ventricular failure 2 months after ingestion of toxic rapeseed oil was determined with M-mode and two-dimensional echocardiography, pulsed Doppler flow studies and right and left heart catheterization and ventriculography. The echocardiogram and pulsed Doppler recordings revealed right ventricular enlargement in 84% of the patients, indirect evidence of pulmonary artery hypertension in 76% and tricuspid insufficiency in 13%. At cardiac catheterization (n = 11) the mean (+/- standard deviation) pulmonary artery pressure was 40 +/- 9 mm Hg, mean pulmonary systemic vascular resistance ratio was 0.45 +/- 0.12 and mean right ventricular end-diastolic pressure was 13 +/- 4 mm Hg. Pulmonary artery hypertension was sustained after the acute administration of 100% oxygen and persisted in six patients who were restudied within 6 months. Cardiac index and left heart pressures were normal in all but one patient. The contrast ventriculographic studies revealed right ventricular dilation in all patients, tricuspid regurgitation in three patients and a normal left ventricular contraction pattern in all but one patient. The data confirm that symptomatic pulmonary artery hypertension and associated right ventricular dysfunction can complicate toxic rapeseed oil ingestion and that these findings persist for at least 6 months.

Acetanilides↗
PubMed2002

[Inhaled nitric oxide in the peroperative period and recovery].

OBJECTIVE: To analyse the current knowledge concerning use of inhaled NO (iNO) in anaesthesia and intensive care. DATA SOURCE: References were obtained from Medline, recent review articles, the library of the department and personal files. STUDY SELECTION: All categories of articles on this topic have been selected. DATA EXTRACTION: Articles have been analysed for history, biochemistry, pharmacology, toxicity and clinical use of iNO. DATA SYNTHESIS: Nitric oxide (NO) is a potent endothelium-dependent vasodilator. Because of its selective action on pulmonary circulation and the lack of effect on the systemic circulation due to its inactivation by haemoglobin, iNO has been presented as a new therapeutic agent in most diseases with pulmonary hypertension. During heart transplantation or surgical correction of congenital heart disease, iNO decreases pulmonary hypertension and improves altered right ventricular function. Studies included however small numbers of patients. Preliminary pharmacological studies demonstrated that iNO was able to decrease pulmonary hypertension and improve systemic oxygenation in adult respiratory distress syndrome. To date, none of the three multicentric studies performed was able to show any significant effect on duration of mechanical ventilation, morbidity or mortality. Finally, the sole demonstrated indication for iNO which remains is the persistent pulmonary hypertension of the newborn. Two multicentric studies have evidenced an improvement in systemic oxygenation and a reduced need for extracorporeal membrane oxygenation. In these two studies global mortality was however unchanged. CONCLUSION: Persistent pulmonary hypertension is the sole demonstrated indication for iNO. Inhaled nitric oxide may be efficient in pulmonary hypertension, right ventricular dysfunction and severe hypoxemia. Inhaled nitric oxide must be considered as a rescue therapy or needs to be part of research protocols.

Administration, Inhalation↗
PubMed1986

[Hemodynamic aspect of adiastole in oxprenolol poisoning].

Self-poisoning with beta-blockers is uncommon but often life-threatening. A 59 year old man was admitted to the ICU after having ingested an estimated dose of 2 g of oxprenolol. Circulatory collapse occurred without pre-existing cardiac failure. Right ventricular haemodynamic data showed adiastole which responded to massive doses of isoprenaline and dopamine. Subsequently the patient recovered normal haemodynamic parameters. This report suggests that right ventricular dysfunction may complicate beta-blocker overdose.

Diastole↗
PubMed2005

[Treatment of venous thromboembolic disease].

Adequate initial anticoagulant treatment is required to prevent thrombus growth and recurrence. Intravenous unfractionated heparin is being replaced by low-molecular-weight heparin as the anticoagulant of choice for initial treatment of venous thromboembolism. Vitamin K antagonists remain the only oral anticoagulant available (target international normalized ratio: 2.5). The duration of therapy should be individualized according to the risk of recurrence and the risk of bleeding. Three months of treatment is usually adequate if thrombosis was provoked by a reversible risk factor such as surgery. For patients with unprovoked ("idiopathic") thrombosis, anticoagulant treatment for at least 6 months is indicated. For patients with a recurrence of venous thromboembolism or with an irreversible risk factor such as cancer, indefinite anticoagulant therapy is recommended. Long-term treatment with low-molecular-weight heparin is usually preferable for patients with active cancer. Systemic thrombolysis is indicated for patients with massive pulmonary embolism but controversy persists for those with isolated right ventricular dysfunction.

Anticoagulants↗