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Yan Y, Kamenshchikov N, Zheng Z, Lei C. Inhaled nitric oxide and postoperative outcomes in cardiac surgery with cardiopulmonary bypass: A systematic review and meta-analysis. Nitric Oxide 2024; 146:64-74. [PMID: 38556145 DOI: 10.1016/j.niox.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/06/2024] [Accepted: 03/21/2024] [Indexed: 04/02/2024]
Abstract
Cardiac surgeries under cardiopulmonary bypass (CPB) are complex procedures with high incidence of complications, morbidity and mortality. The inhaled nitric oxide (iNO) has been frequently used as an important composite of perioperative management during cardiac surgery under CPB. We conducted a meta-analysis of published randomized clinical trials (RCTs) to assess the effects of iNO on reducing postoperative complications, including the duration of postoperative mechanical ventilation, length of intensive care unit (ICU) stay, length of hospital stay, mortality, hemodynamic improvement (the composite right ventricular failure, low cardiac output syndrome, pulmonary arterial pressure, and vasoactive inotropic score) and myocardial injury biomarker (postoperative troponin I levels). Subgroup analyses were performed to assess the effect of modification and interaction. These included iNO dosage, the timing and duration of iNO therapy, different populations (children and adults), and comparators (other vasodilators and placebo or standard care). A comprehensive search for iNO and cardiac surgery was performed on online databases. Twenty-seven studies were included after removing the duplicates and irrelevant articles. The results suggested that iNO could reduce the duration of mechanical ventilation, but had no significance in the ICU stay, hospital stay, and mortality. This may be attributed to the small sample size of the most included studies and heterogeneity in timing, dosage and duration of iNO administration. Well-designed, large-scale, multicenter clinical trials are needed to further explore the effect of iNO in improving postoperative prognosis in cardiovascular surgical patients.
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Affiliation(s)
- Yun Yan
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China; Department of Anesthesiology, China-Japan Friendship Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100029, China
| | - Nikolay Kamenshchikov
- Laboratory of Critical Care Medicine, Department of Anesthesiology and Intensive Care, Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk, 634012, Russian Federation
| | - Ziyu Zheng
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China.
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Ko SH, Shim JK, Song JW, Soh S, Kwak YL. Inhaled iloprost in off-pump coronary artery bypass surgery: a randomized controlled trial. Can J Anaesth 2024; 71:479-489. [PMID: 38148468 DOI: 10.1007/s12630-023-02672-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/05/2023] [Accepted: 10/08/2023] [Indexed: 12/28/2023] Open
Abstract
PURPOSE Mechanical cardiac constraint during off-pump coronary artery bypass surgery (OPCAB) causes right ventricle (RV) compression and increased pulmonary artery pressure (PAP), which may further compromise RV dysfunction. We aimed to assess the effect of inhaled iloprost, a potent selective pulmonary vasodilator, on the cardiac index (CI) during mechanical constraint. The secondary aim was to determine the resultant changes in the hemodynamic and respiratory parameters. METHODS A total of 100 adult patients with three-vessel coronary artery disease who had known risk factors for hemodynamic instability (congestive heart failure, mean PAP ≥ 25 mm Hg, RV systolic pressure ≥ 50 mm Hg on preoperative echocardiography, left ventricular ejection fraction < 50%, myocardial infarction within one month of surgery, redo surgery, and left main disease) were enrolled in a randomized controlled trial. The patients were randomly allocated to the control or iloprost groups at a 1:1 ratio, in which saline and iloprost (20 μg) were inhaled for 15 min after internal mammary artery harvesting, respectively. Cardiac index was measured by pulmonary artery catheterization. RESULTS There were no significant intergroup differences in CI during grafting (P = 0.36). The mean PAP had a significant group-time interaction (P = 0.04) and was significantly lower in the iloprost group at circumflex grafting (mean [standard deviation], 26 [3] mm Hg vs 24 [3] mm Hg; P = 0.01). The remaining hemodynamic parameters were similar between the groups. CONCLUSION Inhaled iloprost showed a neutral effect on hemodynamic parameters, including the CI and pulmonary vascular resistance index, during OPCAB. TRIAL REGISTRATION ClinicalTrials.gov (NCT04598191); first submitted 12 October 2020.
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Affiliation(s)
- Seo Hee Ko
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong-Wook Song
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sarah Soh
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Benedetto M, Piccone G, Gottin L, Castelli A, Baiocchi M. Inhaled Pulmonary Vasodilators for the Treatment of Right Ventricular Failure in Cardio-Thoracic Surgery: Is One Better than the Others? J Clin Med 2024; 13:564. [PMID: 38256697 PMCID: PMC10816998 DOI: 10.3390/jcm13020564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
Right ventricular failure (RFV) is a potential complication following cardio-thoracic surgery, with an incidence ranging from 0.1% to 30%. The increase in pulmonary vascular resistance (PVR) is one of the main triggers of perioperative RVF. Inhaled pulmonary vasodilators (IPVs) can reduce PVR and improve right ventricular function with minimal systemic effects. This narrative review aims to assess the efficacy of inhaled nitric oxide and inhaled prostacyclins for the treatment of perioperative RVF. The literature, although statistically limited, supports the clinical similarity between them. However, it failed to demonstrate a clear benefit from the pre-emptive use of inhaled nitric oxide in patients undergoing left ventricular assist device implantation or early administration during heart-lung transplants. Additional concerns are related to cost safety and IPV use in pathologies associated with pulmonary venous congestion. The largest ongoing randomized controlled trial on adults (INSPIRE-FLO) is addressing whether inhaled Epoprostenol and inhaled nitric oxide are similar in preventing RVF after heart transplants and left ventricular assist device placement, and whether they are similar in preventing primary graft dysfunction after lung transplants. The preliminary analysis supports their equivalence. Several key points may be achieved by the present narrative review. When RVF occurs in the setting of elevated PVR, IPV should be the preferred initial treatment and they should be preventively used in patients at high risk of postoperative RVF. If severe refractory postoperative RVF occurs, IPVs should be combined with complementary pharmacology (inotropes and inodilators). If unsuccessful, right ventricular mechanical support should be established.
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Affiliation(s)
- Maria Benedetto
- Cardio-Thoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (M.B.)
| | - Giulia Piccone
- Cardiothoracic and Vascular Intensive Care Unit, Hospital and University Trust of Verona, P. le A. Stefani, 37124 Verona, Italy; (G.P.); (L.G.)
| | - Leonardo Gottin
- Cardiothoracic and Vascular Intensive Care Unit, Hospital and University Trust of Verona, P. le A. Stefani, 37124 Verona, Italy; (G.P.); (L.G.)
| | - Andrea Castelli
- Cardio-Thoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (M.B.)
| | - Massimo Baiocchi
- Cardio-Thoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (A.C.); (M.B.)
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Sardo S, Tripodi VF, Guerzoni F, Musu M, Cortegiani A, Finco G. Pulmonary Vasodilator and Inodilator Drugs in Cardiac Surgery: A Systematic Review With Bayesian Network Meta-Analysis. J Cardiothorac Vasc Anesth 2023; 37:2261-2271. [PMID: 37652847 DOI: 10.1053/j.jvca.2023.07.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/22/2023] [Accepted: 07/30/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE The authors performed a systematic review to evaluate the effect of pharmacologic therapy on pulmonary hypertension in the perioperative setting of elective cardiac surgery (PROSPERO CRD42023321041). DESIGN Systematic review of randomized controlled trials with a Bayesian network meta-analysis. SETTING The authors searched biomedical databases for randomized controlled trials on the perioperative use of inodilators and pulmonary vasodilators in adult cardiac surgery, with in-hospital mortality as the primary outcome and duration of ventilation, length of stay in the intensive care unit, stage 3 acute kidney injury, cardiogenic shock requiring mechanical support, and change in mean pulmonary artery pressure as secondary outcomes. PARTICIPANTS Twenty-eight studies randomizing 1,879 patients were included. INTERVENTIONS Catecholamines and noncatecholamine inodilators, arterial pulmonary vasodilators, vasodilators, or their combination were considered eligible interventions compared with placebo or standard care. MEASUREMENTS AND MAIN RESULTS Ten studies reported in-hospital mortality and assigned 855 patients to 12 interventions. Only inhaled prostacyclin use was supported by a statistically discernible improvement in mortality, with a number-needed-to-treat estimate of at least 3.3, but a wide credible interval (relative risk 1.26 × 10-17 - 0.7). Inhaled prostacyclin and nitric oxide were associated with a reduction in intensive care unit stay, and none of the included interventions reached a statistically evident difference compared to usual care or placebo in the other secondary clinical outcomes. CONCLUSIONS Inhaled prostacyclin was the only pharmacologic intervention whose use is supported by a statistically discernible improvement in mortality in the perioperative cardiac surgery setting as treatment of pulmonary hypertension. However, available evidence has significant limitations, mainly the low number of events and imprecision.
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Affiliation(s)
- Salvatore Sardo
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy.
| | - Vincenzo Francesco Tripodi
- Department of Human Pathology, Unit of Anesthesia and Intensive Care, University Hospital of Messina, Messina, Italy
| | - Filippo Guerzoni
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Mario Musu
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Andrea Cortegiani
- Department of Surgical Oncological and Oral Science, University of Palermo, Palermo, Italy; Department of Anesthesia, Intensive Care, and Emergency, University Hospital "Policlinico Paolo Giaccone", Palermo, Italy
| | - Gabriele Finco
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
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Sato Y, Yanagi A, Kakumoto S, Miyawaki H. Successful Management of Right Ventricular Failure After Emergent Transcatheter Mitral Valve Edge-to-Edge Repair With Inhaled Nitric Oxide: A Case Report. Cureus 2023; 15:e45469. [PMID: 37859894 PMCID: PMC10583858 DOI: 10.7759/cureus.45469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/21/2023] Open
Abstract
Mitral regurgitation (MR) induces left ventricular failure and pulmonary hypertension (PH) and can lead to right ventricular (RV) failure. Inhaled nitric oxide (iNO) decreases pulmonary vessel resistance. iNO has been used in patients with PH and RV failure. We present a case with cardiogenic shock due to severe degenerative MR. The patient underwent emergent transcatheter mitral valve edge-to-edge repair (TEER). Despite TEER had been successfully performed, hemodynamics did not improve due to RV failure. Administration of iNO improved hemodynamics. This case suggests administration of iNO could be an effective option for RV failure after TEER.
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Affiliation(s)
- Yuma Sato
- Department of Anesthesiology, Kokura Memorial Hospital, Kitakyusyu, JPN
| | - Akio Yanagi
- Department of Anesthesiology, Kokura Memorial Hospital, Kitakyusyu, JPN
| | - Shinichi Kakumoto
- Department of Anesthesiology, Kokura Memorial Hospital, Kitakyusyu, JPN
| | - Hiroshi Miyawaki
- Department of Anesthesiology, Kokura Memorial Hospital, Kitakyusyu, JPN
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Marcus B, Marynen F, Fieuws S, Van Beersel D, Rega F, Rex S. The perioperative use of inhaled prostacyclins in cardiac surgery: a systematic review and meta-analysis. Can J Anaesth 2023; 70:1381-1393. [PMID: 37380903 DOI: 10.1007/s12630-023-02520-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/09/2023] [Accepted: 01/30/2023] [Indexed: 06/30/2023] Open
Abstract
PURPOSE Perioperative pulmonary hypertension (PH) is an independent risk factor for morbidity and mortality in cardiac surgery. While inhaled prostacyclins (iPGI2s) are an established treatment of chronic PH, data on the efficacy of iPGI2s in perioperative PH are scarce. METHODS We searched PubMed, Embase, the Web of Science, CENTRAL, and the grey literature from inception until April 2021. We included randomized controlled trials investigating the use of iPGI2s in adult and pediatric patients undergoing cardiac surgery with an increased risk of perioperative right ventricle failure. We assessed the efficacy and safety of iPGI2s compared with placebo and other inhaled or intravenous vasodilators with random-effect meta-analyses. The primary outcome was mean pulmonary artery pressure (MPAP). Secondary outcomes included other hemodynamic parameters and mortality. RESULTS Thirteen studies were included, comprising 734 patients. Inhaled prostacyclins significantly decreased MPAP compared with placebo (standardized effect size, 0.46; 95% confidence interval [CI], 0.11 to 0.87; P = 0.01) and to intravenous vasodilators (1.26; 95% CI, 0.03 to 2.49; P = 0.045). Inhaled prostacyclins significantly improved the cardiac index compared with intravenous vasodilators (1.53; 95% CI, 0.50 to 2.57; P = 0.004). In contrast, mean arterial pressure was significantly lower in patients treated with iPGI2s vs placebo (-0.39; 95% CI, -0.62 to 0.16; P = 0.001), but higher than in patients treated with intravenous vasodilators (0.81; 95% CI, 0.29 to 1.33; P = 0.002). With respect to hemodynamics, iPGI2s had similar effects as other inhaled vasodilators. Mortality was not affected by iPGI2s. CONCLUSION The results of this systematic review and meta-analysis show that iPGI2s improved pulmonary hemodynamics with similar efficacy as other inhaled vasodilators, but caused a significant small decrease in arterial pressure when compared with placebo, indicating spill-over into the systemic circulation. These effects did not affect clinical outcomes. STUDY REGISTRATION DATE PROSPERO (CRD42021237991); registered 26 May 2021.
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Affiliation(s)
- Berend Marcus
- Department of Anesthesiology, Universitair Ziekenhuis Leuven, Leuven, Belgium
| | - Frederik Marynen
- Department of Anesthesiology, Universitair Ziekenhuis Leuven, Leuven, Belgium
| | - Steffen Fieuws
- Department of Cardiovascular Sciences, Group Biomedical Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
- Leuvens Biostatistiek en Statistische Bioinformatica Centrum, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Dieter Van Beersel
- Department of Anesthesiology, Universitair Ziekenhuis Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Group Biomedical Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiovascular Sciences, Group Biomedical Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Cardiac Surgery, Universitair Ziekenhuis Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Anesthesiology, Universitair Ziekenhuis Leuven, Leuven, Belgium.
- Department of Cardiovascular Sciences, Group Biomedical Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.
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Kamenshchikov NO, Duong N, Berra L. Nitric Oxide in Cardiac Surgery: A Review Article. Biomedicines 2023; 11:biomedicines11041085. [PMID: 37189703 DOI: 10.3390/biomedicines11041085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/26/2023] [Accepted: 03/29/2023] [Indexed: 05/17/2023] Open
Abstract
Perioperative organ injury remains a medical, social and economic problem in cardiac surgery. Patients with postoperative organ dysfunction have increases in morbidity, length of stay, long-term mortality, treatment costs and rehabilitation time. Currently, there are no pharmaceutical technologies or non-pharmacological interventions that can mitigate the continuum of multiple organ dysfunction and improve the outcomes of cardiac surgery. It is essential to identify agents that trigger or mediate an organ-protective phenotype during cardiac surgery. The authors highlight nitric oxide (NO) ability to act as an agent for perioperative protection of organs and tissues, especially in the heart-kidney axis. NO has been delivered in clinical practice at an acceptable cost, and the side effects of its use are known, predictable, reversible and relatively rare. This review presents basic data, physiological research and literature on the clinical application of NO in cardiac surgery. Results support the use of NO as a safe and promising approach in perioperative patient management. Further clinical research is required to define the role of NO as an adjunct therapy that can improve outcomes in cardiac surgery. Clinicians also have to identify cohorts of responders for perioperative NO therapy and the optimal modes for this technology.
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Affiliation(s)
- Nikolay O Kamenshchikov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 634012 Tomsk, Russia
| | - Nicolette Duong
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
- Respiratory Care Service, Patient Care Services, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Lorenzo Berra
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
- Respiratory Care Service, Patient Care Services, Massachusetts General Hospital, Boston, MA 02114, USA
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Ahsan SA, Laird R, Dooley C, Akbar S, Sweeney J, Ohira S, Kai M, Levine A, Gass AL, Frishman WH, Aronow WS, Lanier GM. An Update on the Diagnosis and Management of Acute Right Heart Failure. Cardiol Rev 2023:e000538. [PMID: 36847512 DOI: 10.1097/crd.0000000000000538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Right ventricular (RV) dysfunction and resultant acute right heart failure (ARHF) is a rapidly growing field of interest, driven by increasing appreciation of its contribution to heart failure morbidity and mortality. Understanding of ARHF pathophysiology has advanced dramatically over recent years and can be broadly described as RV dysfunction related to acute changes in RV afterload, contractility, preload, or left ventricular dysfunction. There are several diagnostic clinical signs and symptoms as well as imaging and hemodynamic assessments that can provide insight into the degree of RV dysfunction. Medical management is tailored to the different causative pathologies, and in cases of severe or end-stage dysfunction, mechanical circulatory support can be utilized. In this review, we describe the pathophysiology of ARHF, how its diagnosis is established by clinical signs and symptoms and imaging findings, and provide an overview of treatment options, both medical and mechanical.
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Affiliation(s)
- Syed Adeel Ahsan
- From the Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX
| | - Rachel Laird
- Department of Medicine, Houston Methodist Hospital, Houston, TX
| | - Caroline Dooley
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Sara Akbar
- Department of pulmonary and critical care medicine, Spectrum Health/Michigan State University, Detroit, MI
| | - James Sweeney
- Division of Cardiology, Hackensack Meridian Jersey Shore University Medical Center, Neptune, NJ
| | - Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
| | - Avi Levine
- Departments of Cardiology and Medicine Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Alan L Gass
- Departments of Cardiology and Medicine Westchester Medical Center and New York Medical College, Valhalla, NY
| | - William H Frishman
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- Departments of Cardiology and Medicine Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Gregg M Lanier
- Departments of Cardiology and Medicine Westchester Medical Center and New York Medical College, Valhalla, NY
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Kant S, Banerjee D, Sabe SA, Sellke F, Feng J. Microvascular dysfunction following cardiopulmonary bypass plays a central role in postoperative organ dysfunction. Front Med (Lausanne) 2023; 10:1110532. [PMID: 36865056 PMCID: PMC9971232 DOI: 10.3389/fmed.2023.1110532] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023] Open
Abstract
Despite significant advances in surgical technique and strategies for tissue/organ protection, cardiac surgery involving cardiopulmonary bypass is a profound stressor on the human body and is associated with numerous intraoperative and postoperative collateral effects across different tissues and organ systems. Of note, cardiopulmonary bypass has been shown to induce significant alterations in microvascular reactivity. This involves altered myogenic tone, altered microvascular responsiveness to many endogenous vasoactive agonists, and generalized endothelial dysfunction across multiple vascular beds. This review begins with a survey of in vitro studies that examine the cellular mechanisms of microvascular dysfunction following cardiac surgery involving cardiopulmonary bypass, with a focus on endothelial activation, weakened barrier integrity, altered cell surface receptor expression, and changes in the balance between vasoconstrictive and vasodilatory mediators. Microvascular dysfunction in turn influences postoperative organ dysfunction in complex, poorly understood ways. Hence the second part of this review will highlight in vivo studies examining the effects of cardiac surgery on critical organ systems, notably the heart, brain, renal system, and skin/peripheral tissue vasculature. Clinical implications and possible areas for intervention will be discussed throughout the review.
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Affiliation(s)
| | | | | | | | - Jun Feng
- Cardiothoracic Surgery Research Laboratory, Department of Cardiothoracic Surgery, Rhode Island Hospital, Lifespan, Providence, RI, United States
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10
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Fayad FH, Sellke FW, Feng J. Pulmonary hypertension associated with cardiopulmonary bypass and cardiac surgery. J Card Surg 2022; 37:5269-5287. [PMID: 36378925 DOI: 10.1111/jocs.17160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIM Pulmonary hypertension (PH) is frequently associated with cardiovascular surgery and is a common complication that has been observed after surgery utilizing cardiopulmonary bypass (CPB). The purpose of this review is to explain the characteristics of PH, the mechanisms of PH induced by cardiac surgery and CPB, treatments for postoperative PH, and future directions in treating PH induced by cardiac surgery and CPB using up-to-date findings. METHODS The PubMed database was utilized to find published articles. RESULTS There are many mechanisms that contribute to PH after cardiac surgery and CPB which involve pulmonary vasomotor dysfunction, cyclooxygenase, the thromboxane A2 and prostacyclin pathway, the nitric oxide pathway, inflammation, and oxidative stress. Furthermore, there are several effective treatments for postoperative PH within different types of cardiac surgery. CONCLUSIONS By possessing a deep understanding of the mechanisms that contribute to PH after cardiac surgery and CPB, researchers can develop treatments for clinicians to use which target the mechanisms of PH and ultimately reduce and/or eliminate postoperative PH. Additionally, learning about the most up-to-date studies regarding treatments can allow clinicians to choose the best treatments for patients who are undergoing cardiac surgery and CPB.
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Affiliation(s)
- Fayez H Fayad
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Program in Liberal Medical Education, Brown University, Providence, Rhode Island, USA
| | - Frank W Sellke
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Division of Cardiothoracic Surgery, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Jun Feng
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Division of Cardiothoracic Surgery, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island, USA
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11
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Henke VG. Inhaled selective pulmonary vasodilator use following cardiac surgery: broader insights from a study describing significant changes in drug utilization and savings after implementation of a guideline favoring inhaled epoprostenol. J Cardiothorac Vasc Anesth 2022; 36:1350-1353. [DOI: 10.1053/j.jvca.2022.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 01/17/2022] [Indexed: 11/11/2022]
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12
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Abstract
Pulmonary arterial hypertension is a rare disease characterized by pulmonary microvasculature remodeling leading to right ventricular failure and death. Medical management of pulmonary hypertension has grown increasingly complex as more therapeutic agents have been developed. Evolving treatment strategies leveraging the endothelin, nitric oxide, and prostacyclin pathways lead to improved exercise capacity and outcomes in patients; however, significant opportunities for advancement remain.
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Affiliation(s)
- Alexander E Sherman
- Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, 650 Charles E. Young Drive South 43-229 CHS, Los Angeles, CA 90095-1690, USA
| | - Rajan Saggar
- Pulmonary Vascular Disease Program, Acute and Chronic Thromboembolic Disease Program, Pulmonary and Critical Care Division, Division of Pulmonary, Critical Care, & Sleep Medicine, David Geffen School of Medicine at UCLA, 650 Charles E. Young Drive South 43-229 CHS, Los Angeles, CA 90095-1690, USA
| | - Richard N Channick
- Pulmonary Vascular Disease Program, Acute and Chronic Thromboembolic Disease Program, Pulmonary and Critical Care Division, Division of Pulmonary, Critical Care, & Sleep Medicine, David Geffen School of Medicine at UCLA, 650 Charles E. Young Drive South 43-229 CHS, Los Angeles, CA 90095-1690, USA.
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13
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Austin DR, Lai Y, Mueller A, Shelton KT. Inhaled Pulmonary Vasodilator Utilization and Cost Following Initiation of a Protocol in a Quaternary Academic Heart Center Intensive Care Unit. J Cardiothorac Vasc Anesth 2021; 36:1343-1349. [DOI: 10.1053/j.jvca.2021.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 10/30/2021] [Accepted: 11/05/2021] [Indexed: 11/11/2022]
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Unexpected Interruptions in the Inhaled Epoprostenol Delivery System: Incidence of Adverse Sequelae and Therapeutic Consequences in Critically Ill Patients. Crit Care Explor 2021; 3:e0548. [PMID: 34671745 PMCID: PMC8522871 DOI: 10.1097/cce.0000000000000548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Inhaled epoprostenol is a continuously delivered selective pulmonary vasodilator that is used in patients with refractory hypoxemia, right heart failure, and postcardiac surgery pulmonary hypertension. Published data suggest that inhaled epoprostenol administration via vibrating mesh nebulizer systems may lead to unexpected interruptions in drug delivery. The frequency of these events is unknown. The objective of this study was to describe the incidence and clinical consequences of unexpected interruption in critically ill patients. DESIGN Retrospective review and analysis. SETTING Stanford University Hospital, a 605-bed tertiary care center. PATIENTS Patients receiving inhaled epoprostenol in 2019. INTERVENTIONS No interventions. MEASUREMENTS AND MAIN RESULTS Clinical indication, duration of inhaled epoprostenol delivery, mode of respiratory support, and documented unexpected interruption. In 2019, there were 493 administrations of inhaled epoprostenol in 433 unique patients. Primary indications for inhaled epoprostenol were right heart dysfunction (n = 394; 79.9%) and hypoxemia (n = 92; 18.7%). Unexpected delivery interruptions occurred in 31 administrations (6.3%). Median duration of therapy prior to unexpected interruption was 2 days (interquartile range, 2-5 d). Respiratory support at the time of unexpected interruption was mechanical ventilation (61.3%), high-flow nasal cannula (35.5%), and noninvasive positive pressure ventilation (3.2%). Adverse sequelae of unexpected interruption included elevated pulmonary artery pressures (n = 12), systemic hypotension (n = 8), hypoxemia (n = 8), elevated central venous pressure (n = 4), and cardiac arrest (n = 1). Therapeutic interventions following unexpected interruption included initiation of inhaled nitric oxide (n = 21), increase in vasoactive medication (n = 2), and increase in respiratory support (n = 2). Most of the adverse events were Common Terminology Criteria for Adverse Events grade 3 and 4 (93.5%). CONCLUSIONS A retrospective review of patients receiving inhaled epoprostenol via vibrating mesh nebulizer in 2019 revealed interruptions in 6.3% of administrations with most of these interruptions requiring therapeutic intervention. The true incidence of unexpected interruption and subsequent rate of unexpected interruption's requiring intervention is unknown due to the reliance on unexpected interruption identification and subsequent documentation in the electronic medical record. Sudden interruption in inhaled epoprostenol delivery can result in severe cardiopulmonary compromise, and on rare occasion, death.
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Hulde N, Koster A, von Dossow V. Perioperative management of patients with undergoing durable mechanical circulatory support. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:830. [PMID: 32793675 PMCID: PMC7396234 DOI: 10.21037/atm-20-2527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Durable mechanical circulatory support (MCS) devices revolutionized the treatment options for patients with end-stage heart failure (HF). Implantation of durable mechanical support has become an integral treatment modality in end-stage HF patients and it is associated with improved quality of life and survival. There is no doubt that this needs an interdisciplinary and interprofessional approach of cardiac surgeons, cardiologists, cardiac anesthesiologists, perfusionists, intensivists, psychologists, assist device coordinators as well as physiotherapists and intensive care. Implantation of durable MCS is a challenging procedure for the anesthesiologist due to the patient’s characteristics and comorbid diseases. It demands comprehensive training, high vigilance and quick response during the acute hemodynamic changes occurring during the surgery. Preoperative risk stratification is of major importance to guide perioperative medical treatment strategies. Most of these patients have several comorbidities and multiple medications. Therefore, to anticipate postoperative end-organ dysfunction such as cognitive dysfunction, pulmonary or renal failure, an interdisciplinary approach is necessary to optimize patient’s prior surgery. Transthoracic and transesophageal echocardiography (TTE and TEE), both play an invaluable role in diagnosing the cause and guiding the management in different unstable clinical situations. Especially prevention of postoperative right HF with subsequent necessity of temporary MCS is important as it is associated with higher mortality. The aim of this review is to provide an overview about the current concepts of perioperative management for durable MCS. A multimodal standard operating procedure supports early recovery after surgery and intensive care stay. Standardized perioperative care helps to ensure optimal medical treatment. This review focusses on several major skills of perioperative management of these high-risk surgical patients.
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Affiliation(s)
- Nikolai Hulde
- Institute of Anesthesiology, Heart and Diabetes Centre North Rhine Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Andreas Koster
- Institute of Anesthesiology, Heart and Diabetes Centre North Rhine Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Vera von Dossow
- Institute of Anesthesiology, Heart and Diabetes Centre North Rhine Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
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Chen SH, Chen LK, Teng TH, Chou WH. Comparison of inhaled nitric oxide with aerosolized prostacyclin or analogues for the postoperative management of pulmonary hypertension: a systematic review and meta-analysis. Ann Med 2020; 52:120-130. [PMID: 32204626 PMCID: PMC7877956 DOI: 10.1080/07853890.2020.1746826] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: This study aims to compare the effectiveness of inhaled prostacyclin or its analoguesversus nitric oxide (NO) in treating pulmonary hypertension (PH) after cardiac or pulmonary surgery remains unclear.Methods: PubMed, Cochrane, and Embase databases were searched for literature published prior to December 2019 using the following keywords: inhaled, nitric oxide, prostacyclin, iloprost, treprostinil, epoprostenol, Tyvaso, flolan, and pulmonary hypertension. Randomized controlled trials and multiple-armed prospective studies that evaluated inhaled NO versus prostacyclin (or analogues) in patients for perioperative and/or postoperative PH after either cardiac or pulmonary surgery were included. Retrospective studies, reviews, letters, comments, editorials, and case reports were excluded.Results: Seven studies with a total of 195 patients were included. No difference in the improvement of mean pulmonary arterial pressure (pooled difference in mean change= -0.10, 95% CI: -3.98 to 3.78, p = .959) or pulmonary vascular resistance (pooled standardized difference in mean change= -0.27, 95% CI: -0.60 to 0.05, p = .099) were found between the two treatments. Similarly, no difference was found in other outcomes between the two treatments or subgroup analysis.Conclusions: Inhaled prostacyclin (or analogues) was comparable to inhaled NO in treating PH after cardiac or pulmonary surgery.Key messagesThis study compared the efficacy of inhaled prostacyclin or its analogues versus inhaled NO to treat PH after surgery. The two types of agent exhibited similar efficacy in managing MPAP, PVR, heart rate, and cardiac output was observed.Inhaled prostacyclin may serve as an alternative treatment option for PH after cardiac or pulmonary surgery.
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Affiliation(s)
- Shih-Hong Chen
- Department of Anesthesiology, National Taiwan University Hospital, Taipei City, Taiwan.,Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan.,Institute of Molecular Medicine, National Tsing Hua University, Hsinchu, Taiwan
| | - Li-Kuei Chen
- Anesthesiology Department of China Medical University, Taichung City, Taiwan.,Anesthesiology Department of China Medical University Hospital, Taichung City, Taiwan
| | - Tsung-Han Teng
- Department of Pathology, St. Martin De Porres Hospital, Chiayi City, Taiwan
| | - Wei-Han Chou
- Department of Anesthesiology, National Taiwan University Hospital, Taipei City, Taiwan
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The Right Ventricle-You May Forget it, but It Will Not Forget You. J Clin Med 2020; 9:jcm9020432. [PMID: 32033368 PMCID: PMC7074056 DOI: 10.3390/jcm9020432] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 01/23/2020] [Accepted: 01/27/2020] [Indexed: 01/21/2023] Open
Abstract
Right ventricular (RV) dysfunction and failure are common and often overlooked causes of perioperative deterioration and adverse outcomes. Due to its unique pathophysiologic underpinnings, RV failure often does not respond to typical therapeutic measures such as volume resuscitation and often worsens when therapy is escalated and mechanical ventilation is begun, with a danger of irreversible cardiovascular collapse and death. The single most important factor in improving outcomes in the context of RV failure is anticipating and recognizing it. Once established, a vicious circle of systemic hypotension, and RV ischemia and dilation is set in motion, rapidly spiraling down into a state of shock culminating in multi-organ failure and ultimately death. Therapy of RV failure must focus on rapidly reestablishing RV coronary perfusion, lowering pulmonary vascular resistance and optimizing volemia. In parallel, underlying reversible causes should be sought and if possible treated. In all stages of diagnostics and therapy, echocardiography plays a central role. In severe cases of RV dysfunction there remains a role for the use of the pulmonary artery catheter. When these mostly simple measures are undertaken in a timely fashion, the spiral of death of RV failure can often be broken or even prevented altogether.
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Gaudard P, Barbanti C, Rozec B, Mauriat P, M'rini M, Cambonie G, Liet JM, Girard C, Leger PL, Assaf Z, Damas P, Loron G, Lecourt L, Amour J, Pouard P. New Modalities for the Administration of Inhaled Nitric Oxide in Intensive Care Units After Cardiac Surgery or for Neonatal Indications: A Prospective Observational Study. Anesth Analg 2019; 126:1234-1240. [PMID: 29341967 DOI: 10.1213/ane.0000000000002813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Nitric oxide (NO) has a well-known efficacy in pulmonary hypertension (PH), with wide use for 20 years in many countries. The objective of this study was to describe the current use of NO in real life and the gap with the guidelines. METHODS This is a multicenter, prospective, observational study on inhaled NO administered through an integrated delivery and monitoring device and indicated for PH according to the market authorizations. The characteristics of NO therapy and ventilation modes were observed. Concomitant pulmonary vasodilator treatments, safety data, and outcome were also collected. Quantitative data are expressed as median (25th, 75th percentile). RESULTS Over 1 year, 236 patients were included from 14 equipped and trained centers: 117 adults and 81 children with PH associated with cardiac surgery and 38 neonates with persistent PH of the newborn. Inhaled NO was initiated before intensive care unit (ICU) admission in 57%, 12.7%, and 38.9% with an initial dose of 10 (10, 15) ppm, 20 (18, 20) ppm, and 17 (11, 20) ppm, and a median duration of administration of 3.9 (1.9, 6.1) days, 3.8 (1.8, 6.8) days, and 3.1 (1.0, 5.7) days, respectively, for the adult population, pediatric cardiac group, and newborns. The treatment was performed using administration synchronized to the mechanical ventilation. The dose was gradually decreased before withdrawal in 86% of the cases according to the usual procedure of each center. Adverse events included rebound effect for 3.4% (95% confidence interval [CI], 0.9%-8.5%) of adults, 1.2% (95% CI, 0.0%-6.7%) of children, and 2.6% (95% CI, 0.1%-13.8%) of neonates and methemoglobinemia exceeded 2.5% for 5 of 62 monitored patients. Other pulmonary vasodilators were associated with NO in 23% of adults, 95% of children, and 23.7% of neonates. ICU stay was respectively 10 (6, 22) days, 7.5 (5.5, 15) days, and 9 (8, 15) days and ICU mortality was 22.2%, 6.2%, and 7.9% for adults, children, and neonates, respectively. CONCLUSIONS This study confirms the safety of NO therapy in the 3 populations with a low rate of rebound effect. Gradual withdrawal of NO combined with pulmonary vasodilators are current practices in this population. The use of last-generation NO devices allowed good compliance with recommendations.
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Affiliation(s)
- Philippe Gaudard
- From the Cardiothoracic Intensive Care Unit, Centre Hospitalier Universitaire de Montpellier, and PhyMedExp, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Claudio Barbanti
- Pediatric Cardiac Intensive Care, Anesthesia and Perfusion Unit, Reference Centre for Complex Congenital Cardiac Disease, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Bertrand Rozec
- Department of Anesthesia and Intensive Care, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Philippe Mauriat
- Congenital Cardiac Surgery Unit, Department of Anesthesia and Intensive Care II, Maison du Haut Lévêque - Groupe Hospitalier Sud, Pessac, France
| | | | - Gilles Cambonie
- Neonatal and pediatric Intensive Care Unit, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Jean Michel Liet
- Pediatric Intensive Care Unit, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Claude Girard
- Cardiovascular Intensive Care Unit, Centre Hospitalier Universitaire Bocage Central, Dijon, France
| | | | - Ziad Assaf
- Pediatric Cardiac Intensive Care, Anesthesia and Perfusion Unit, Reference Centre for Complex Congenital Cardiac Disease, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Pierre Damas
- Intensive Care Unit, Centre Hospitalier Universitaire de Liège, Liège, Belgique
| | - Gauthier Loron
- Neonatal Intensive Care Unit, Centre Hospitalier Universitaire de Reims, Reims, France
| | | | - Julien Amour
- Sorbonne Universités, UPMC Univ Paris 06, UMR INSERM 1166, IHU ICAN, and Department of Anesthesiology and Critical Care Medicine, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Philippe Pouard
- Pediatric Cardiac Intensive Care, Anesthesia and Perfusion Unit, Reference Centre for Complex Congenital Cardiac Disease, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
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Effect of iloprost inhalation on postoperative outcome in high-risk cardiac surgical patients: a prospective randomized-controlled multicentre trial (ILOCARD). Can J Anaesth 2019; 66:907-920. [DOI: 10.1007/s12630-019-01309-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/27/2018] [Accepted: 12/28/2018] [Indexed: 12/13/2022] Open
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Windsor J, Ricci M, Aldoss O, Nakamura Y, Ramakrishna H. Simultaneous Intraoperative Delivery of Inhaled Epoprostenol and Nitric Oxide in a Neonate for Atrial Septal Defect Closure: First Report of a Novel Technique. J Cardiothorac Vasc Anesth 2018; 33:2755-2759. [PMID: 30472016 DOI: 10.1053/j.jvca.2018.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Jimmy Windsor
- Department of Anesthesia, Division of Pediatric Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA.
| | - Marco Ricci
- Department of Surgery, Division of Cardiothoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Osamah Aldoss
- Stead Family Department of Pediatrics, Division of Pediatric Cardiology, University of Iowa Carver College of Medicine,Iowa City, IA
| | - Yuki Nakamura
- Department of Surgery, Division of Cardiothoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic School of Medicine, Scottsdale, AZ
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Fukushima R, Kawaguchi T, Yamada S, Yoshimura A, Hirao D, Oomori T. Effects of cilostazol on the heart rate in healthy dogs. J Vet Med Sci 2018; 80:1707-1715. [PMID: 30249936 PMCID: PMC6261822 DOI: 10.1292/jvms.18-0240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Appropriate dosages of cilostazol have not been studied in veterinary patients, and the degrees of heart rate (HR) increase have not been studied in dogs administered cilostazol. Therefore,
this study aimed to investigate the degrees of HR increase in healthy dogs administered cilostazol. Thirty healthy beagle dogs (15 males and 15 females; age, 5–8 years) were divided into 3
groups of 10 dogs each and orally administered 2.5, 5, or 10 mg/kg cilostazol (twice a day at 8:00 AM and 8:00 PM for 10 days). Higher HR increases were seen in the 5 mg/kg group than in the
2.5 mg/kg group at all time points except 7:00 AM, 9:00 AM, 1:00 PM, and 4:00 PM (P<0.01). Higher HR increases were also observed in the 10 mg/kg group than in the 2.5
mg/kg group at all time points except 4:00 PM (P<0.01). The 10 mg/kg group showed higher HR increases than the 5 mg/kg group at all time points except 6:00 AM, 7:00 AM,
6:00 PM, and 7:00 PM (P<0.05 for 4:00 PM and 5:00 PM; P<0.01 for the other time points). These results together show that the HR of healthy dogs
increased in a dose-dependent manner after cilostazol administration twice a day at doses of 5 to 10 mg/kg. These results provide a useful basis for choosing cilostazol in the treatment of
bradyarrhythmia in dogs.
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Affiliation(s)
- Ryuji Fukushima
- Animal Medical Center, Faculty of Agriculture, Tokyo University of Agriculture and Technology, 3-5-8 Saiwai-cho, Fuchu-shi, Tokyo 183-8509, Japan
| | - Takae Kawaguchi
- Animal Medical Center, Faculty of Agriculture, Tokyo University of Agriculture and Technology, 3-5-8 Saiwai-cho, Fuchu-shi, Tokyo 183-8509, Japan
| | - Shusaku Yamada
- Animal Medical Center, Faculty of Agriculture, Tokyo University of Agriculture and Technology, 3-5-8 Saiwai-cho, Fuchu-shi, Tokyo 183-8509, Japan
| | - Aritada Yoshimura
- Animal Medical Center, Faculty of Agriculture, Tokyo University of Agriculture and Technology, 3-5-8 Saiwai-cho, Fuchu-shi, Tokyo 183-8509, Japan
| | - Daiki Hirao
- Animal Medical Center, Faculty of Agriculture, Tokyo University of Agriculture and Technology, 3-5-8 Saiwai-cho, Fuchu-shi, Tokyo 183-8509, Japan
| | - Takahiro Oomori
- Animal Medical Center, Faculty of Agriculture, Tokyo University of Agriculture and Technology, 3-5-8 Saiwai-cho, Fuchu-shi, Tokyo 183-8509, Japan
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Tremblay JA, Couture ÉJ, Albert M, Beaubien-Souligny W, Elmi-Sarabi M, Lamarche Y, Denault AY. Noninvasive Administration of Inhaled Nitric Oxide and its Hemodynamic Effects in Patients With Acute Right Ventricular Dysfunction. J Cardiothorac Vasc Anesth 2018; 33:642-647. [PMID: 30206010 DOI: 10.1053/j.jvca.2018.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The authors aimed to assess the hemodynamic effects and demonstrate the feasibility of inhaled nitric oxide (iNO) in hemodynamically unstable patients with acute right ventricular (RV) dysfunction and to explore the safety profile of this approach. DESIGN Retrospective cohort study. SETTING Intensive care unit (ICU) of 2 tertiary care centers between January 2013 and 2017. PARTICIPANTS All patients with RV dysfunction in whom iNO was initiated without invasive mechanical ventilation. INTERVENTION Noninvasive administration of iNO. MEASUREMENTS AND MAIN RESULTS Eighteen patients received the intervention during the study period; 8 of these patients had a pulmonary artery catheter and 2 had a pulse contour analysis device. Median (interquartile range) iNO concentration was 20 (20-20) ppm, and therapy duration was 24 (12-46) hours. Most patients received iNO through nasal prongs (66.7%) or a high-flow nasal cannula (27.8%). Within 1 hour, iNO reduced pulmonary vascular resistance from 219.1 to 165.4 dyn•s/cm5 (n = 7; p < 0.001), mean pulmonary artery pressure from 28.4 to 25.3 mmHg (n = 8; p = 0.01), and central venous pressure from 17.5 to 13.1 mmHg (n = 16; p = 0.001). Indexed cardiac output increased from 2.0 to 2.6 L/min/m2 (n = 9; p = 0.004). ICU mortality was 27.78%, and median ICU length of stay was 7 (5-9) days. Two significant bleeding episodes requiring intervention and 1 acute kidney injury occurred during iNO therapy. No headache was reported. CONCLUSION Noninvasively administered iNO was associated with favorable hemodynamic effects in ICU patients with acute RV dysfunction. These results suggest the safety and feasibility of this therapy for which further prospective study is warranted.
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Affiliation(s)
- Jan-Alexis Tremblay
- Department of Medicine, Division of Critical Care, Université de Montréal, Montreal, QC, Canada
| | - Étienne J Couture
- Department of Medicine, Division of Critical Care, Université de Montréal, Montreal, QC, Canada
| | - Martin Albert
- Department of Medicine, Division of Critical Care, Université de Montréal, Montreal, QC, Canada; Department of Medicine and Critical Care, Sacré-Coeur Hospital and Montreal Heart Institute, Montreal, QC, Canada
| | | | - Mahsa Elmi-Sarabi
- Department of Anesthesiology and Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Yoan Lamarche
- Department of Medicine and Critical Care, Sacré-Coeur Hospital and Montreal Heart Institute, Montreal, QC, Canada; Department of Cardiac Surgery Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - André Y Denault
- Department of Anesthesiology and Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada; Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.
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Sardo S, Osawa EA, Finco G, Gomes Galas FRB, de Almeida JP, Cutuli SL, Frassanito C, Landoni G, Hajjar LA. Nitric Oxide in Cardiac Surgery: A Meta-Analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2018; 32:2512-2519. [PMID: 29703580 DOI: 10.1053/j.jvca.2018.02.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To investigate the efficacy and safety of perioperative administration of nitric oxide in cardiac surgery. DESIGN Meta-analysis of randomized controlled trials (RCTs). PARTICIPANTS Cardiac surgery patients. INTERVENTIONS A search of Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and MEDLINE for RCTs that compared nitric oxide with placebo or other comparators. MEASUREMENTS AND MAIN RESULTS The primary outcome was intensive care unit (ICU) stay, and secondary outcomes were mortality, duration of mechanical ventilation, and reduction of mean pulmonary artery pressure. The study included 18 RCTs comprising 958 patients. The authors calculated the pooled odds ratio (OR) and the mean difference (MD) with random-effects model. Quantitative synthesis of data demonstrated a clinically negligible reduction in the length of ICU stay (MD -0.38 days, confidence interval CI [-0.65 to -0.11]; p = 0.005) and mechanical ventilation duration (MD -4.81 hours, CI [-7.79 to -1.83]; p = 0.002) compared with all control interventions with no benefit on mortality. CONCLUSIONS Perioperative delivery of inhaled nitric oxide resulted to be of no or minimal benefit in patients with pulmonary hypertension undergoing cardiac surgery. Large, randomized trials are needed to further assess its effect on major clinical outcomes and its cost-effectiveness.
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Affiliation(s)
- Salvatore Sardo
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Eduardo Atsushi Osawa
- Intensive Care Unit, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Gabriele Finco
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | | | | | - Salvatore Lucio Cutuli
- Department of Anesthesiology and Intensive Care, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University of Milan, Milan, Italy.
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Deshpande SP, Mazzeffi MA, Strauss E, Hollis A, Tanaka KA. Prostacyclins in Cardiac Surgery: Coming of Age. Semin Cardiothorac Vasc Anesth 2017; 22:306-323. [DOI: 10.1177/1089253217749298] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Prostacyclin (prostaglandin I2 [PGI2]) is an eicosanoid lipid mediator produced by the endothelial cells. It plays pivotal roles in vascular homeostasis by virtue of its potent vasodilatory and antithrombotic effects. Stable pharmacological analogues of PGI2 are used for treatment of pulmonary hypertension and right ventricular failure. PGI2 dose dependently inhibits platelet activation induced by adenosine-5′-diphosphate, arachidonic acid, collagen, and low-dose thrombin. This property has led to its use as an alternative to direct thrombin inhibitors in patients with type II heparin-induced thrombocytopenia (HIT) undergoing cardiac surgery. The aims of this review are the following: (1) to review the pharmacology of PGI2 and its derivatives, (2) to present the evidence for their use in pulmonary hypertension and right heart failure, and (3) to discuss their utility in the management of HIT in cardiac surgery.
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Affiliation(s)
| | | | - Erik Strauss
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Allison Hollis
- University of Maryland School of Medicine, Baltimore, MD, USA
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Rao V, Ghadimi K, Keeyapaj W, Parsons CA, Cheung AT. Inhaled Nitric Oxide (iNO) and Inhaled Epoprostenol (iPGI 2) Use in Cardiothoracic Surgical Patients: Is there Sufficient Evidence for Evidence-Based Recommendations? J Cardiothorac Vasc Anesth 2017; 32:1452-1457. [PMID: 29336971 DOI: 10.1053/j.jvca.2017.12.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Vidya Rao
- Department of Anesthesiology, Stanford University, Stanford, CA
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | | | | | - Albert T Cheung
- Department of Anesthesiology, Stanford University, Stanford, CA.
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Newsome AS, Sultan S, Murray B, Jones SW, Pappas A, Schmidt KT, Filteau G, Laux JP, Wolfe A, Williams F, Cairns BA. Effect of inhaled iloprost on gas exchange in inhalation injury. BURNS OPEN 2017. [DOI: 10.1016/j.burnso.2017.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Elmi-Sarabi M, Deschamps A, Delisle S, Ased H, Haddad F, Lamarche Y, Perrault LP, Lambert J, Turgeon AF, Denault AY. Aerosolized Vasodilators for the Treatment of Pulmonary Hypertension in Cardiac Surgical Patients: A Systematic Review and Meta-analysis. Anesth Analg 2017; 125:393-402. [PMID: 28598920 DOI: 10.1213/ane.0000000000002138] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND In cardiac surgery, pulmonary hypertension is an important prognostic factor for which several treatments have been suggested over time. In this systematic review and meta-analysis, we compared the efficacy of inhaled aerosolized vasodilators to intravenously administered agents and to placebo in the treatment of pulmonary hypertension during cardiac surgery. We searched MEDLINE, CENTRAL, EMBASE, Web of Science, and clinicaltrials.gov databases from inception to October 2015. The incidence of mortality was assessed as the primary outcome. Secondary outcomes included length of stay in hospital and in the intensive care unit, and evaluation of the hemodynamic profile. METHODS Of the 2897 citations identified, 10 studies were included comprising a total of 434 patients. RESULTS Inhaled aerosolized agents were associated with a significant decrease in pulmonary vascular resistance (-41.36 dyne·s/cm, P= .03) and a significant increase in mean arterial pressure (8.24 mm Hg, P= .02) and right ventricular ejection fraction (7.29%, P< .0001) when compared to intravenously administered agents. No significant hemodynamically meaningful differences were observed between inhaled agents and placebo; however, an increase in length of stay in the intensive care unit was shown with the use of inhaled aerosolized agents (0.66 days, P= .01). No other differences were observed for either comparison. CONCLUSIONS The administration of inhaled aerosolized vasodilators for the treatment of pulmonary hypertension during cardiac surgery is associated with improved right ventricular performance when compared to intravenously administered agents. This review does not support any benefit compared to placebo on major outcomes. Further investigation is warranted in this area of research and should focus on clinically significant outcomes.
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Affiliation(s)
- Mahsa Elmi-Sarabi
- From the Departments of *Anesthesiology and §Cardiac Surgery, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada; †Intensive Care Unit, Hôpital Sacré-Coeur de Montréal, Montreal, Quebec, Canada; ‡Stanford School of Medicine, Stanford, California; ‖Department of Preventive and Social Medicine, Université de Montréal, Montreal, Quebec, Canada; ¶Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec City, Quebec, Canada; #CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Research Unit, Quebec City, Quebec, Canada; and **Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
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Koulova A, Gass AL, Patibandla S, Gupta CA, Aronow WS, Lanier GM. Management of pulmonary hypertension from left heart disease in candidates for orthotopic heart transplantation. J Thorac Dis 2017; 9:2640-2649. [PMID: 28932571 PMCID: PMC5594194 DOI: 10.21037/jtd.2017.07.24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/27/2017] [Indexed: 12/24/2022]
Abstract
Pulmonary hypertension in left heart disease (PH-LHD) commonly complicates prolonged heart failure (HF). When advanced, the PH becomes fixed or out of proportion and is associated with increased morbidity and mortality in patients undergoing orthotopic heart transplant (OHT). To date, the only recommended treatment of out of proportion PH is the treatment of the underlying HF by reducing the pulmonary capillary wedge pressure (PCWP) with medications and often along with use of mechanical circulatory support. Medical therapies typically used in the treatment of World Health Organization (WHO) group 1 pulmonary arterial hypertension (PAH) have been employed off-label in the setting of PH-LHD with varying efficacy and often negative outcomes. We will discuss the current standard of care including treating HF and use of mechanical circulatory support. In addition, we will review the studies published to date assessing the efficacy and safety of PAH medications in patients with PH-LHD being considered for OHT.
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Affiliation(s)
- Anna Koulova
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Alan L. Gass
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | | | - Chhaya Aggarwal Gupta
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Wilbert S. Aronow
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Gregg M. Lanier
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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Sabato LA, Salerno DM, Moretz JD, Jennings DL. Inhaled Pulmonary Vasodilator Therapy for Management of Right Ventricular Dysfunction after Left Ventricular Assist Device Placement and Cardiac Transplantation. Pharmacotherapy 2017; 37:944-955. [DOI: 10.1002/phar.1959] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Leah A. Sabato
- Heart Failure and Cardiac Transplantation; Department of Pharmacy; UC Health-University of Cincinnati Medical Center; Cincinnati Ohio
| | - David M. Salerno
- Solid Organ Transplantation; Department of Pharmacy; NewYork-Presbyterian Hospital - Weill Cornell Medical Center; New York New York
| | - Jeremy D. Moretz
- Ventricular Assist Devices; Department of Pharmacy; Vanderbilt University Medical Center; Nashville Tennessee
| | - Douglas L. Jennings
- Heart Transplant and Mechanical Circulatory Support; Department of Pharmacy; New York-Presbyterian Hospital - Columbia University Medical Center; New York NY
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Inhaled Treprostinil Drug Delivery During Mechanical Ventilation and Spontaneous Breathing Using Two Different Nebulizers. Pediatr Crit Care Med 2017; 18:e253-e260. [PMID: 28441181 PMCID: PMC5478389 DOI: 10.1097/pcc.0000000000001188] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To determine the feasibility of delivering inhaled treprostinil during mechanical ventilation and spontaneous unassisted ventilation using the Tyvaso Inhalation System and the vibrating mesh nebulizer. We sought to compare differences in fine particle fraction, and absolute inhaled treprostinil mass delivered to neonatal, pediatric, and adult models affixed with a face mask, conventional, and high-frequency ventilation between Tyvaso Inhalation System and with different nebulizer locations between Tyvaso Inhalation System and vibrating mesh nebulizer. DESIGN Fine particle fraction was first determined via impaction with both the Tyvaso Inhalation System and vibrating mesh nebulizer. Next, a test lung configured with neonatal, pediatric, and adult mechanics and a filter to capture medication was attached to a realistic face model during spontaneous breathing or an endotracheal tube during conventional ventilation and high-frequency oscillator ventilator. Inhaled treprostinil was then nebulized with both the Tyvaso Inhalation System and vibrating mesh nebulizer, and the filter was analyzed via high-performance liquid chromatography. Testing was done in triplicate. Independent two-sample t tests were used to compare mean fine particle fraction and inhaled mass between devices. Analysis of variance with Tukey post hoc tests were used to compare within device differences. SETTING Academic children's hospital aerosol research laboratory. MEASUREMENTS AND MAIN RESULTS Fine particle fraction was not different between the Tyvaso Inhalation System and vibrating mesh nebulizer (0.78 ± 0.04 vs 0.77 ± 0.08, respectively; p = 0.79). The vibrating mesh nebulizer delivered the same or greater inhaled treprostinil than the Tyvaso Inhalation System in every simulated model and condition. When using the vibrating mesh nebulizer, delivery was highest when using high-frequency oscillator ventilator in the neonatal and pediatric models, and with the nebulizer in the distal position in the adult model. CONCLUSIONS The vibrating mesh nebulizer is a suitable alternative to the Tyvaso Inhalation System for inhaled treprostinil delivery. Fine particle fraction is similar between devices, and vibrating mesh nebulizer delivery meets or exceeds delivery of the Tyvaso Inhalation System. Delivery for infants and children during high-frequency oscillator ventilator with the vibrating mesh nebulizer may result in higher than expected dosages.
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Goya S, Wada T, Shimada K, Hirao D, Fukushima R, Yamagishi N, Shimizu M, Tanaka R. Effects of postural change on transesophageal echocardiography views and parameters in healthy dogs. J Vet Med Sci 2017; 79:380-386. [PMID: 27980234 PMCID: PMC5326945 DOI: 10.1292/jvms.16-0323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The purpose of the present study is to investigate the effect of postural change on
transesophageal echocardiography (TEE) views and parameters of interest anesthesia
monitoring in healthy dogs. Twelve Beagle dogs were anesthetized and randomly positioned
in one of four postures: right lateral-recumbency, left lateral-recumbency, supine
position and prone position. After examinations in one posture, the same examination was
demonstrated in another posture and repeated in all postures. In each posture, several
standard TEE views were demonstrated: longitudinal cranial-esophageal aorta
long-axis-view, transverse middle-esophageal mitral valve long-axis-view and transgastric
middle short-axis-view. Additionally, echocardiographic parameters were attempted to
measure, and direct blood pressure monitoring was performed in each view. As a result,
oriented views, except for transgastric middle short-axis-view, could be obtained in all
postures. Stroke volume and peak early diastolic velocity of mitral inflow were lower in
supine position compared with those in right and left lateral-recumbency. Heart rate (HR)
and systemic vascular resistance were higher in supine position compared with those in
right and left lateral-recumbency. Left ventricular pre-ejection period/left ventricular
ejection time corrected and uncorrected by HR were higher in supine position compared with
those in right and left lateral-recumbency. In conclusion, longitudinal cranial-esophageal
aorta long-axis-view and transverse middle-esophageal mitral valve long-axis-view provide
useful information of interest anesthesia monitoring, because of their views enable to
certainly obtain TEE parameters in various postures. Furthermore, TEE parameters allow to
detect the changes of preload, afterload and HR that occur in supine position dogs.
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Affiliation(s)
- Seijirow Goya
- Department of Veterinary Surgery, Faculty of Veterinary Medicine, Tokyo University of Agriculture and Technology, 3-5-8 Saiwai-cho, Fuchu-shi, Tokyo 183-0052, Japan
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Estrada VHN, Franco DLM, Moreno AAV, Gambasica JAR, Nunez CCC. Postoperative Right Ventricular Failure in Cardiac Surgery. Cardiol Res 2016; 7:185-195. [PMID: 28197291 PMCID: PMC5295509 DOI: 10.14740/cr500e] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2016] [Indexed: 12/11/2022] Open
Abstract
Two cases of patients that developed right ventricular failure (RVF) after cardiac valve surgery are presented with a narrative revision of the literature. RVF involves a great challenge due to the severity of this condition; it has a low incidence among non-congenital cardiac surgery patients, is more likely associated with cardiovascular and pulmonary complications related to cardiopulmonary bypass (CPB), and is a cause of acute graft failure and of a higher early mortality in cardiac transplant. The morphologic and hemodynamic characteristics of the right ventricle and some specific factors that breed pulmonary hypertension after cardiac surgery are in favor of the onset of RVF. Due to the possibility of complications after cardiac valve repair or replacement, measures as appropriate hemodynamic monitoring, to manage oxygenation, ventilation, sedation, acid base equilibrium and perfusion goals are a requirement, as well as a normal circulating volume, and the prevention of a disproportionate rise in the afterload, to preserve the free wall of the right ventricle (RV) and the septum's contribution to the right ventricular global function and geometry. If there is no response to these basic measures, the use of advanced therapy with inotropics, intravenous or inhaled pulmonary vasodilation agents is recommended; the use of mechanical ventricular assistance stands as a last resource.
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Is Administration of Nitric Oxide During Extracorporeal Membrane Oxygenation Associated With Improved Patient Survival? Pediatr Crit Care Med 2016; 17:1080-1087. [PMID: 27632059 DOI: 10.1097/pcc.0000000000000939] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the outcomes associated with the use of inhaled nitric oxide during extracorporeal membrane oxygenation. DESIGN Post hoc analysis of data from an existing administrative national database, Pediatric Health Information system (2004-2014). Multivariable logistic regression models were fitted to study the effect of inhaled nitric oxide during extracorporeal membrane oxygenation on study outcomes. SETTING Forty-two children's hospitals across the United States. PATIENTS Patients in the age group from 1 day through 18 years admitted to an ICU who received extracorporeal membrane oxygenation during their hospital stay were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 6,419 patients qualified for inclusion. Of these, inhaled nitric oxide was used among 3,629 patients during extracorporeal membrane oxygenation run. Approximately one half of the study patients received inhaled nitric oxide at extracorporeal membrane oxygenation initiation. The proportion of patients receiving inhaled nitric oxide during extracorporeal membrane oxygenation decreased with increasing duration of extracorporeal membrane oxygenation. After adjusting for patient characteristics and center variables, use of inhaled nitric oxide was not associated with any survival benefit. However, higher proportion of patients receiving inhaled nitric oxide were associated with prolonged hospital length of stay and prolonged duration of extracorporeal membrane oxygenation. In adjusted models, the hospital charges were higher in the inhaled nitric oxide group. The median hospital costs among patients receiving inhaled nitric oxide were higher by $39,732 (95% CI, $31,074-48,390) as compared to the patients who did not receive inhaled nitric oxide, after adjusting for patient (including hospital length of stay) and center level variables. As the duration of inhaled nitric oxide therapy increased, proportion of patients with prolonged duration of extracorporeal membrane oxygenation and prolonged hospital length of stay increased. CONCLUSIONS This large observational analysis of use of nitric oxide during extracorporeal membrane oxygenation calls into question the benefits of inhaled nitric oxide among patients receiving extracorporeal membrane oxygenation for pulmonary or cardiac failure. Given our inability to determine type of extracorporeal membrane oxygenation and control for severity of illness, these findings should be interpreted as exploratory.
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Abe S, Ishida K, Masuda M, Ueda H, Kohno H, Matsuura K, Tamura Y, Watanabe M, Matsumiya G. A prospective, randomized study of inhaled prostacyclin versus nitric oxide in patients with residual pulmonary hypertension after pulmonary endarterectomy. Gen Thorac Cardiovasc Surg 2016; 65:153-159. [PMID: 27783213 PMCID: PMC5331109 DOI: 10.1007/s11748-016-0724-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 10/18/2016] [Indexed: 11/26/2022]
Abstract
Objectives Pulmonary endarterectomy (PEA) is an effective treatment for chronic thromboembolic pulmonary hypertension (CTEPH), but postoperative residual hypertension leads to in-hospital mortality. Inhaled epoprostenol sodium (PGI2) and NO are administered for pulmonary hypertension after cardiothoracic surgery. This prospective study provides the first comparative evaluation of the effects of inhaled PGI2 and NO on pulmonary hemodynamics, systemic hemodynamics, and gas exchange in patients developing residual pulmonary hypertension after PEA. Methods Thirteen patients were randomized to receive either NO (n = 6) or PGI2 (n = 7) inhalation when pulmonary hypertension persisted after weaning from cardiopulmonary bypass. Hemodynamic and respiratory variables were measured before inhalation of the agent (T0); 30 min (T1), 3 h (T2), and 6 h after inhalation (T3); and the next morning (T4). The NO dose was started at 20 ppm and gradually tapered until extubation, and PGI2 was administered at a dose of 10 ng kg−1 min−1. Results In both groups, mean pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) significantly decreased over time until T4 (mean PAP: p < 0.0001; PVR: p = 0.003), while mean systemic arterial blood pressure significantly increased (p = 0.028). There were no significant between-group differences in patient characteristics, cardiac index, left atrial pressure, or ratio of arterial oxygen tension to fraction of inspired oxygen. There were no in-hospital deaths. Conclusions Both inhaled PGI2 and NO significantly reduced PAP and PVR without adverse effects on systemic hemodynamics in patients who developed residual pulmonary hypertension after PEA. Inhaled PGI2 can be offered as alternative treatment option for residual pulmonary hypertension.
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Affiliation(s)
- Shinichiro Abe
- Department of Cardiovascular Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-0856, Japan
| | - Keiichi Ishida
- Department of Cardiovascular Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-0856, Japan.
| | - Masahisa Masuda
- Department of Cardiovascular Surgery, Chiba Medical Center, 4-1-2 Tsubakimori, Chuo-ku, Chiba, 260-0042, Japan
| | - Hideki Ueda
- Department of Cardiovascular Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-0856, Japan
| | - Hiroki Kohno
- Department of Cardiovascular Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-0856, Japan
| | - Kaoru Matsuura
- Department of Cardiovascular Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-0856, Japan
| | - Yusaku Tamura
- Department of Cardiovascular Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-0856, Japan
| | - Michiko Watanabe
- Department of Cardiovascular Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-0856, Japan
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-0856, Japan
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Akça B, Dönmez K, Dişli OM, Akgül Erdil F, Çolak MC, Aydemir İK, Battaloğlu B, Erdil N. The effects of pulmonary hypertension on early outcomes inpatients undergoing coronary artery bypass surgery. Turk J Med Sci 2016; 46:1162-7. [PMID: 27513420 DOI: 10.3906/sag-1403-145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 11/03/2015] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND/AIM To investigate the effects of pulmonary hypertension on early clinical variables in patients undergoing coronary artery bypass grafting surgery. MATERIALS AND METHODS The preoperative echocardiographic data of patients who underwent isolated coronary artery bypass surgery were evaluated retrospectively. A total of 1244 patients were included in the study. The patients were divided into two groups: one group consisted of patients with systolic pulmonary artery pressure (SPAP) values equal to or greater than 30 mmHg (Group 1, n = 184), while the other group consisted of patients with SPAP values below 30 mmHg (Group 2, n = 1060). RESULTS Early mortality was similar in both groups (0% in Group 1 and 1.2% in Group 2; P > 0.05). Comparison of postoperative data indicated that Group 1 had a higher need for inotropic agent treatment, a longer average duration of ventilation, and a longer average duration of stay in the intensive care unit (P < 0.05). For the other variables, no significant differences were identified between patients with and without pulmonary hypertension (P > 0.05). CONCLUSION Mild pulmonary hypertension (mean SPAP = 37.7 ± 8.4 mmHg) was not associated with a significant difference in the mortality of patients undergoing coronary artery bypass grafting. For patients undergoing this type of coronary bypass surgery, lower morbidity and mortality rates can be achieved through comprehensive preoperative examinations and effective perioperative medical procedures.
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Affiliation(s)
- Barış Akça
- Department of Cardiovascular Surgery, Faculty of Medicine, İnönü University, Malatya, Turkey
| | - Köksal Dönmez
- Department of Cardiovascular Surgery, Faculty of Medicine, İnönü University, Malatya, Turkey
| | - Olcay Murat Dişli
- Department of Cardiovascular Surgery, Faculty of Medicine, İnönü University, Malatya, Turkey
| | - Feray Akgül Erdil
- Department of Anesthesiology and Reanimation, Faculty of Medicine, İnönü University, Malatya, Turkey
| | - Mehmet Cengiz Çolak
- Department of Cardiovascular Surgery, Faculty of Medicine, İnönü University, Malatya, Turkey
| | - İlhan Koray Aydemir
- Department of Cardiovascular Surgery, Kahramanmaraş State Hospital, Kahramanmaraş, Turkey
| | - Bektaş Battaloğlu
- Department of Cardiovascular Surgery, Faculty of Medicine, İnönü University, Malatya, Turkey
| | - Nevzat Erdil
- Department of Cardiovascular Surgery, Faculty of Medicine, İnönü University, Malatya, Turkey
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Perioperative management of patients with pulmonary hypertension for non-cardiac surgery. Curr Rheumatol Rep 2015; 17:15. [PMID: 25740702 DOI: 10.1007/s11926-014-0490-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pulmonary hypertension (PH) is associated with significant morbidity and mortality. While the advent of disease-modifying therapies in the treatment of PH has dramatically increased the life expectancy of these patients, they remain at high risk for perioperative complications. Outcome studies suggest that patients with PH undergoing non-cardiac surgery have higher morbidity and mortality than those without, independent of severity. Despite these risks, more and more of these patients are presenting for non-cardiac surgery. Patients with rheumatologic disorders in particular often have pulmonary arterial hypertension (PAH), a group that is associated with a poorer prognosis. Yet, these patients invariably develop debilitating joint diseases and not uncommonly present for elective surgery. Preoperatively, patients with PH should be appropriately risk stratified based on functional class, etiology, exercise capacity, pulmonary hemodynamics, and the risk of surgery. If the risks and benefits assessment proves favorable, they should undergo optimization prior to surgery, with any chronic therapy continuing without cessation through the perioperative period. A multidisciplinary approach involving all intraoperative physicians is imperative to forming a safe intraoperative plan based on the inherent physiology underlying the patient's disease. Finally, because complications in this patient population often occur postoperatively, patients should be monitored in an appropriate setting with a goal of preventing right ventricular dysfunction. In this review article, we focus on the evaluation, risk stratification, and optimization of patients with PH undergoing non-cardiac surgery.
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King C, May CW, Williams J, Shlobin OA. Management of right heart failure in the critically ill. Crit Care Clin 2015; 30:475-98. [PMID: 24996606 DOI: 10.1016/j.ccc.2014.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Right ventricular failure complicates several commonly encountered conditions in the intensive care unit. Right ventricular dilation and paradoxic movement of the interventricular septum on echocardiography establishes the diagnosis. Right heart catheterization is useful in establishing the specific cause and aids clinicians in management. Principles of treatment focus on reversal of the underlying cause, optimization of right ventricular preload and contractility, and reduction of right ventricular afterload. Mechanical support with right ventricular assist device or veno-arterial extracorporeal membrane oxygenation can be used in select patients who fail to improve with optimal medical therapy.
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Affiliation(s)
- Christopher King
- Medical Critical Care Service, Inova Fairfax Hospital, 618 South Royal Street, Alexandria, VA 22314, USA.
| | - Christopher W May
- Advanced Heart Failure and Cardiac Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Jeffrey Williams
- Medical Critical Care Service, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Oksana A Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
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Alvarez Escudero J, Calvo Vecino JM, Veiras S, García R, González A. Clinical Practice Guideline (CPG). Recommendations on strategy for reducing risk of heart failure patients requiring noncardiac surgery: reducing risk of heart failure patients in noncardiac surgery. ACTA ACUST UNITED AC 2015; 62:359-419. [PMID: 26164471 DOI: 10.1016/j.redar.2015.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/04/2015] [Indexed: 12/29/2022]
Affiliation(s)
- J Alvarez Escudero
- Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain
| | - J M Calvo Vecino
- Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain; Associated Professor and Head of the Department of Anesthesiology, Infanta Leonor University Hospital, Complutense University of Madrid, Madrid, Spain.
| | - S Veiras
- Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain
| | - R García
- Department of Anesthesiology, Puerta del Mar University Hospital. Cadiz, Spain
| | - A González
- Department of Anesthesiology, Puerta de Hierro University Hospital. Madrid, Spain
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Inhaled nitric oxide in cardiac surgery: Evidence or tradition? Nitric Oxide 2015; 49:67-79. [PMID: 26186889 DOI: 10.1016/j.niox.2015.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/08/2015] [Accepted: 06/25/2015] [Indexed: 12/15/2022]
Abstract
Inhaled nitric oxide (iNO) therapy as a selective pulmonary vasodilator in cardiac surgery has been one of the most significant pharmacological advances in managing pulmonary hemodynamics and life threatening right ventricular dysfunction and failure. However, this remarkable story has experienced a roller-coaster ride with high hopes and nearly universal demonstration of physiological benefits but disappointing translation of these benefits to harder clinical outcomes. Most of our understanding on the iNO field in cardiac surgery stems from small observational or single centre randomised trials and even the very few multicentre trials fail to ascertain strong evidence base. As a consequence, there are only weak clinical practice guidelines on the field and only European expert opinion for the use of iNO in routine and more specialised cardiac surgery such as heart and lung transplantation and left ventricular assist device (LVAD) insertion. In this review the authors from a specialised cardiac centre in the UK with a very high volume of iNO usage provide detailed information on the early observations leading to the European expert recommendations and reflect on the nature and background of these recommendations. We also provide a summary of the progress in each of the cardiac subspecialties for the last decade and initial survey data on the views of senior anaesthetic and intensive care colleagues on these recommendations. We conclude that the combination of high price tag associated with iNO therapy and lack of substantial clinical evidence is not sustainable on the current field and we are risking loosing this promising therapy from our daily practice. Overcoming the status quo will not be easy as there is not much room for controlled trials in heart transplantation or in the current atmosphere of LVAD implantation. However, we call for international cooperation to conduct definite studies to determine the place of iNO therapy in lung transplantation and high risk mitral surgery. This will require new collaboration between the pharmaceutical companies, national grant agencies and the clinical community. Until these trials are realized we should gather multi-institutional experience from large retrospective studies and prospective data from a new international registry. We must step up international efforts if we wish to maintain the iNO modality in the armamentarium of hemodynamic tools for the perioperative management of our high risk cardiac surgical patients.
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Jentzer JC, Mathier MA. Pulmonary Hypertension in the Intensive Care Unit. J Intensive Care Med 2015; 31:369-85. [PMID: 25944777 DOI: 10.1177/0885066615583652] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 03/16/2015] [Indexed: 12/19/2022]
Abstract
Pulmonary hypertension occurs as the result of disease processes increasing pressure within the pulmonary circulation, eventually leading to right ventricular failure. Patients may become critically ill from complications of pulmonary hypertension and right ventricular failure or may develop pulmonary hypertension as the result of critical illness. Diagnostic testing should evaluate for common causes such as left heart failure, hypoxemic lung disease and pulmonary embolism. Relatively few patients with pulmonary hypertension encountered in clinical practice require specific pharmacologic treatment of pulmonary hypertension targeting the pulmonary vasculature. Management of right ventricular failure involves optimization of preload, maintenance of systemic blood pressure and augmentation of inotropy to restore systemic perfusion. Selected patients may require pharmacologic therapy to reduce right ventricular afterload by directly targeting the pulmonary vasculature, but only after excluding elevated left heart filling pressures and confirming increased pulmonary vascular resistance. Critically-ill patients with pulmonary hypertension remain at high risk of adverse outcomes, requiring a diligent and thoughtful approach to diagnosis and treatment.
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Affiliation(s)
- Jacob C Jentzer
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, PA, USA Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael A Mathier
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, PA, USA
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42
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Santos-Martínez LE, Baranda-Tovar FM, Telona-Fermán E, Barragán-García R, Calderón-Abbo MC. [Inhaled iloprost, a selective pulmonary vasodilator. Clinical evidence from its use in perioperative pulmonary hypertension cardiovascular surgery]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2014; 85:136-44. [PMID: 25450429 DOI: 10.1016/j.acmx.2014.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 07/17/2014] [Accepted: 07/29/2014] [Indexed: 10/24/2022] Open
Abstract
Inhaled iloprost is one of the most recent drugs from prostanoids group's in the treatment of pulmonary arterial hypertension. His place in pulmonary hypertension seen in the perioperative cardiovascular surgery has not been defined. In this review we analyze pulmonary hypertension group's susceptibles of cardiac surgery and its importance, besides the current clinical evidence from drug use in this context.
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Affiliation(s)
- Luis Efren Santos-Martínez
- Departamento de Hipertensión Pulmonar y Función Ventricular Derecha, Unidad Médica de Alta Especialidad (UMAE), Hospital de Cardiología del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), México DF, México; Secretaría de Salubridad y Asistencia (SSA), Departamento de Cuidados Intensivos Posquirúrgicos Cardiovasculares, Instituto Nacional de Cardiología Ignacio Chávez, SSA, México DF, México.
| | - Francisco Martín Baranda-Tovar
- Secretaría de Salubridad y Asistencia (SSA), Departamento de Cuidados Intensivos Posquirúrgicos Cardiovasculares, Instituto Nacional de Cardiología Ignacio Chávez, SSA, México DF, México
| | - Eslí Telona-Fermán
- Secretaría de Salubridad y Asistencia (SSA), Departamento de Anestesiología Cardiovascular, Instituto Nacional de Cardiología Ignacio Chávez, SSA, México DF, México
| | - Rodolfo Barragán-García
- Sub-Dirección de Especialidades Médico-Quirúrgicas, Instituto Nacional de Cardiología Ignacio Chávez, SSA, México DF, México
| | - Moisés Cutiel Calderón-Abbo
- Dirección General, Unidad Médica de Alta Especialidad (UMAE), Hospital de Cardiología del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), México DF, México
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Vorhies EE, Caruthers RL, Rosenberg H, Yu S, Gajarski RJ. Use of inhaled iloprost for the management of postoperative pulmonary hypertension in congenital heart surgery patients: review of a transition protocol. Pediatr Cardiol 2014; 35:1337-43. [PMID: 24872141 DOI: 10.1007/s00246-014-0933-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 05/15/2014] [Indexed: 11/30/2022]
Abstract
Inhaled nitric oxide (iNO) is considered standard therapy for pediatric postcardiac surgical pulmonary hypertension (PH). Limited data suggest that inhaled iloprost (inIlo), an aerosolized prostacyclin, may be a feasible and more affordable therapeutic alternative. The goal of this study was to determine if significant hemodynamic change or adverse events would occur in postoperative congenital heart surgery (CHS) patients with PH after their transition from iNO to inIlo. This retrospective review investigated CHS patients with postoperative PH (mean pulmonary artery pressure [mPAP] >25 mmHg) between January 1, 2010 and December 31, 2011 who transitioned from iNO to inIlo. By protocol, CHS patients receiving stable doses of iNO were gradually transitioned to inIlo. After full transition, the patients received inIlo every 2 h, with a final dosing range of 1.25-5 μg/dose. Both PAP and systemic arterial pressure (SAP) were invasively measured during the transition period. Seven patients ages 10 days to 1.5 years completed the protocol. Measurements of mPAP (p = 0.27) and systolic PAP (p = 0.25) did not differ between iNO and inIlo therapy alone. No serious adverse events or complications (bleeding or thrombocytopenia) occurred. The ratio of systolic PAP to SAP decreased in all patients receiving inIlo alone (p = 0.03). Pulmonary hypertension in postoperative CHS patients can be managed successfully with inIlo, and the measured hemodynamics with this agent are similar to those observed with iNO. For the management of postoperative PH, inIlo may be a reasonable alternative, thus reducing the need for costly iNO. Larger confirmatory studies would more robustly facilitate its integration into standard care.
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Affiliation(s)
- Erika E Vorhies
- Division of Pediatric Cardiology, Department of Pediatrics, University of Calgary, Alberta Children's Hospital, 2888 Shaganappi Trail NW, Calgary, AB, T3B 6A8, Canada,
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44
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Abstract
Perioperative pulmonary hypertension can originate from an established disease or acutely develop within the surgical setting. Patients with increased pulmonary vascular resistance are consequently at greater risk for complications. Despite the various specific therapies available, the ideal therapeutic approach in this patient population is not currently clear. This article describes the basic principles of perioperative pulmonary hypertension and reviews the different classes of agents used to promote pulmonary vasodilation in the surgical setting.
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46
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Perioperative management of pulmonary hypertension during lung transplantation (a lesson for other anaesthesia settings). ACTA ACUST UNITED AC 2014; 61:434-45. [PMID: 25156939 DOI: 10.1016/j.redar.2014.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 04/19/2014] [Accepted: 05/12/2014] [Indexed: 11/21/2022]
Abstract
Patients with pulmonary hypertension are some of the most challenging for an anaesthesiologist to manage. Pulmonary hypertension in patients undergoing surgical procedures is associated with high morbidity and mortality due to right ventricular failure, arrhythmias and ischaemia leading to haemodynamic instability. Lung transplantation is the only therapeutic option for end-stage lung disease. Patients undergoing lung transplantation present a variety of challenges for anaesthesia team, but pulmonary hypertension remains the most important. The purpose of this article is to review the anaesthetic management of pulmonary hypertension during lung transplantation, with particular emphasis on the choice of anaesthesia, pulmonary vasodilator therapy, inotropic and vasopressor therapy, and the most recent intraoperative monitoring recommendations to optimize patient care.
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Tonelli AR, Minai OA. Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Perioperative management in patients with pulmonary hypertension. Ann Thorac Med 2014; 9:S98-S107. [PMID: 25077004 PMCID: PMC4114269 DOI: 10.4103/1817-1737.134048] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 04/05/2014] [Indexed: 01/30/2023] Open
Abstract
Patients with pulmonary hypertension (PH) are being encountered more commonly in the perioperative period and this trend is likely to increase as improvements in the recognition, management, and treatment of the disease continue to occur. Management of these patients is challenging due to their tenuous hemodynamic status. Recent advances in the understanding of the patho-physiology, risk factors, monitoring, and treatment of the disease provide an opportunity to reduce the morbidity and mortality associated with PH in the peri-operative period. Management of these patients requires a multi-disciplinary approach and meticulous care that is best provided in centers with vast experience in PH. In this review, we provide a detailed discussion about oerioperative strategies in PH patients, and give evidence-based recommendations, when applicable.
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Affiliation(s)
- Adriano R Tonelli
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Ohio, USA
| | - Omar A Minai
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Ohio, USA
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48
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Fox DL, Stream AR, Bull T. Perioperative management of the patient with pulmonary hypertension. Semin Cardiothorac Vasc Anesth 2014; 18:310-8. [PMID: 24828282 DOI: 10.1177/1089253214534780] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with pulmonary hypertension are at increased risk for perioperative morbidity and mortality. Elective surgery is generally discouraged in this patient population; however, there are times when surgery is deemed necessary. Currently, there are no guidelines for the preoperative risk assessment or perioperative management of subjects with pulmonary hypertension. The majority of the literature evaluating perioperative risk factors and mortality rates is observational and includes subjects with multiple etiologies of pulmonary hypertension. Subjects with pulmonary arterial hypertension, also referred to as World Health Organization group I pulmonary hypertension, and particularly those receiving pulmonary arterial hypertension-specific therapy may be at increased risk. Perioperative management of these patients requires a solid understanding and careful consideration of the hemodynamic effects of anesthetic agents, positive pressure ventilation and volume shifts associated with surgery in order to prevent acute right ventricular failure. We reviewed the most recent data regarding perioperative morbidity and mortality for subjects with pulmonary hypertension in an effort to better guide preoperative risk assessment and perioperative management by a multidisciplinary team.
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Affiliation(s)
| | - Amanda R Stream
- University of Colorado Health Sciences Center, Aurora, CO, USA
| | - Todd Bull
- University of Colorado Health Sciences Center, Aurora, CO, USA
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Abstract
Due to the increased survival of patients with pulmonary hypertension, even non-cardiac anesthesiologists will see these patients more frequently for anesthesia. The hemodynamic goal in the perioperative period is to avoid an increase in pulmonary vascular resistance (PVR) and to reduce a possibly pre-existing elevated PVR. Acute increases of chronically elevated PVR may result from hypoxia, hypercapnia, acidosis, hypothermia, elevated sympathetic output and also release of endogenous or application of exogenous pulmonary vasoconstrictors. Early recognition and treatment of these changes might be life saving in these patients. Drug interventions to perioperatively reduce PVR include administration of pulmonary vasodilators, such as oxygen, prostacyclines (epoprostenol, iloprost), phosphodiesterase III (milrinone) and V (sildenafil) inhibitors, as well as nitrates and nitric oxide. Along with the concept of selective pulmonary vasodilation inhalative administration of pulmonary vasodilators has benefits compared to intravenous administration. New therapeutic strategies, such as inhalational iloprost, inhalational milrinone and intravenous sildenafil can be introduced without significant technical support even in smaller departments.
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50
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Nonaka DF, Grichnik KP, Whitener GB. Pulmonary Hypertension and Thoracic Surgery: Diagnostics and Advances in Therapy and Intraoperative Management. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0053-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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