VARIABLE RESPONSE TO INHALED NITRIC OXIDE IN POSTOPERATIVE PATIENTS OF MITRAL STENOSIS WITH PULMONARY HYPERTENSION
Abstract
Background: This study was carried out to determine the vasodilator response of inhaled nitric oxidein patients with pulmonary hypertension (PH) after valve replacement surgery for mitral valve disease.Method: This Quesi experimental study was carried out at the intensive care unit of Armed ForcesInstitute of Cardiology (AFIC) in collaboration with Department of Physiology, Army MedicalCollege, Rawalpindi from March 2004 to February 2006. Thirty patients with systolic PulmonaryArtery Pressure (PAP) >50 mmHg on pre-operative echocardiography were inducted. Swan Ganzcatheter was inserted to record baseline pulmonary artery pressure and pulmonary capillary wedgepressure (PCWP), while cardiac output (CO) was recorded through lithium dilution method. PulmonaryVascular Resistance (PVR) was calculated with the help of a formula. Inhaled nitric oxide (iNO) wasadministered after the surgery and the same parameters were recorded again after one hour. Results:The majority of patients were females (73%), while males were only 27%. Out of 30, 21 had isolatedmitral stenosis and 9 had mixed mitral and aortic valve disease. 22 patients responded significantly toiNO therapy with ≥40.0% reduction in their baseline PVR while 8 patients showed insignificantimprovement in their PVR (663±233 dynes.sec.cm-5 to 605±222 dynes.sec.cm-5). Conclusion:Significant improvement in pulmonary vascular resistance in the responders and maintenance of highpressures despite iNO therapy in non-responders indicate that apart from some abnormality in nitricoxide pathway, some other factors may be a contributing in the causation of PH secondary to mitralstenosis in adults, which warrant further studies.Keywords: Nitric Oxide, mitral stenosis, pulmonary hypertension, pulmonary artery pressure,pulmonary vascular resistanceReferences
Moraes D, Loscalzo J. Pulmonary hypertension: newer
concepts in diagnosis and management.Clin Cardiol
;20:676–82.
Loskove JA, Frishman WH. Nitric oxide donors in the
treatment of cardiovascular and pulmonary diseases. Am
Heart J 1995;129:604–13.
McGoon MD. Pulmonary hypertension. In: Murphy JG, ed.
Mayo Clinic Cardiology Review. 2nd ed. Philadelphia:
Lippincott W&W. 2000. p.353–71.
Fullerton DA, Jaggess J, Piedalve F, Grover FL, Mclntyre
RC. Effective control of refractory pulmonary Hypertension
after cardiac operations. J thorac Cardiovasc Sug
;113:363–70.
Pepke-Zaba J, Higenbottam TW, Dinh Xuan AT, Stone D,
Wallwork J. Inhaled nitric oxide as a cause of selective
pulmonary vasodilatation in pulmonary hypertension. Lancet
;338:1173–4.
Rimer S, Gillis CN. Selective pulmonary vasodilation by
inhaled nitric oxide is due to hemoglobin inactivation.
Circulation 1993;88:2884–7.
Rich GF, Murphy GD, Roos CM, Johns RA. Inhaled nitric
oxide: selective pulmonary vasodilator in cardiac surgical
patients.Anesthesiology1993;78:1173–4.
Day RW, Hawkins JA, McGough EC, Crezee’ KL, Orsmond
GS. Randomized controlled study of inhaled nitric oxide after
operation for congenital heart disease. Ann Thorac Surg
;69:1907–13.
Morris K, Beghetti M, Petros A, Adatia I, Bohn D.
Comparison of hyperventilation and inhaled nitric oxide for
pulmonary hypertension after repair of congenital heart
disease. Crit Care Medicine 2000;28(8):2974–8.
Cody R, Haas G, Binkley P. Plasma endothelin correlates
with the extent of pulmonary hypertension in patients with
chronic congestive heart failure. Circulation. 1992;85:504–9.
Dupuis J, Goresky C, Rose C. Endothelin-1 myocardial
clearance, production, and effect on capillary permeability in
vivo. Am J Physiol 1997;273:H1239–45.
Russel, Mohiudeen IA, Maurice S, Finemann, Jeffrey R,
Balea .The effects of inhaled nitric oxide on post-operative
pulmonary hypertension in infants and children undergoing
surgical repair of congenital heart disease. Anesthesia and
Analgesia 1998;87:46–51.
Winberg P, Lundell BP, Gustafsson LE. Effect of inhaled
nitric oxide on raised pulmonary vascular resistance in
children with congenital heart disease. Br Heart J
;71:282–6.
Snow DJ, Gray SJ, Ghosh S, Foubert L, Oduro A, Higen
Bottam TW, et al. Inhaled nitric oxide in patients with
normal and increased pulmonary vascular resistance after
cardiac surgery. B J Anaesth 1994;72:185–9.
Ginns C, Zapol WM, Semigran MJ, Barbara AC, Kacmarek
RM, Fifer MA et al. Comparison of the effects of nitric
oxide, nitroprusside, and nifedipine on hemodynamics and
right ventricular contractility in patients with chronic
pulmonary hypertension Chest.2001;119:128–36.
J Ayub Med Coll Abbottabad 2009;21(1)
http://www.ayubmed.edu.pk/JAMC/PAST/21-1/Zubia.pdf
Mahoney PD, Evan Loh E, Blitz LR, Herrmann HC.
Hemodynamic effects of inhaled nitric oxide in women with
mitral stenosis and pulmonary hypertension. Am J Cardiol
;87:188–92.
Vincens JJ, Temizer D, Post JR, Edmunds HL, Herrkajj HC.
Long term outcome of cardiac surgery in patients with mitral
stenosis and severe pulmonary hypertension. Circulation
;92:137–42.
Scott WC, Miller DC, Haverich A, Mitchell RS, Oyer PE,
Stinson EB, et al. Operative risk of mitral valve surgery:
discriminant analysis of 1329 procedure. Circulation
;72:108–19.
Krishnamoorthy KM, Radhakrishnan S, Shrivastava S. Left
atrial and pulmonary artery wedge pressure monitoring
during balloon mitral valvuloplasty. J Assoc Physicians India
;49:614–6.
Gerlach H, Keh D, Semmerow A, Busch T, Lewandowski K,
Pappert DM, Rossaint R, Falke KJ. Dose response
characteristics during long time inhalation of nitric oxide in
patients with severe acute respiratory distress syndrome. A
prospective, randomized, controlled study. Am J Resp Crit
Care Med 2003;167:1008–15.
Solina AR, Cody RP, Ginsberg SH, Papp D, Grubb WR,
Scholz PM, et al. Dose response to nitric oxide in adult
cardiac surgery patients. J Clin Anesth 2001;13(4): 281–6.
Keiler-Jensen N, Ricksten SE, Lundin S. Vasodilator therapy
after heart transplantation: effects of inhaled nitric oxide and
intravenous prostacyclin, prostaglandin E1 and sodium
nitroprusside.J Heart Lung Transplant 1995;14:436–43.
Girard C, Lehott JJ, Pannetier JC, Filley S, French P,
Estanove S. Inhaled nitric oxide after mitral valve
replacement in patients with chronic pulmonary artery
hypertension Anesthesiology 1992;77(5):880–3.
Rawczynska-Englert I, Korewicki J, Purzycki Z, Abramczuk
E, Sitkowski W, Sliwinski M. Analysis of remission of
pulmonary hypertension after mitral valve replacement.
Przegl Lek 1992;49(9):302–5.
Balzer DT, Kort HW, Day RW, Corneli HM, Kovalchin JP,
Cannon BC, et al. Inhaled Nitric Oxide as a preoperative test
(INOP Test 1).The INOP Test Study Group.
Circulation.2002;106(suppl 1):176–81.
Curran RD, Mavroudis C, Backer CL, Sautel M, Zales VR,
Wessel DL. Inhaled nitric oxide for children withcongenital
heart disease and pulmonary hypertension. Annuls of Thorac
Surg 1995;60:1765–71.
Fullerton DA, Jaggers J, Piedalue F, Grover FL, Mclntyre RC
Jr. Effective control of refractory pulmonary Hypertension
after cardiac operations. J thorac Cardiovasc Sug
;111(4):753–63.
Fullerton DA, Jiggers J, Wollmering MM, Piedalue F,
Grover FL, Mclntyre RC Jr. Variable response to inhaled
nitric oxide after cardiac surgery. Ann Thorac Surg.
;63(5):1251–6.
Fattouch K, Sbraga F, Bianco G, Speziale G, Gucciardo M,
Sampognaro R, Ruvolo G. Inhaled prostacyclin, nitric oxide,
and nitroprusside in pulmonary hypertension after mitral
valve replacement. J Card Surg 2005;20:171–6.
Published
Issue
Section
License
Journal of Ayub Medical College, Abbottabad is an OPEN ACCESS JOURNAL which means that all content is FREELY available without charge to all users whether registered with the journal or not. The work published by J Ayub Med Coll Abbottabad is licensed and distributed under the creative commons License CC BY ND Attribution-NoDerivs. Material printed in this journal is OPEN to access, and are FREE for use in academic and research work with proper citation. J Ayub Med Coll Abbottabad accepts only original material for publication with the understanding that except for abstracts, no part of the data has been published or will be submitted for publication elsewhere before appearing in J Ayub Med Coll Abbottabad. The Editorial Board of J Ayub Med Coll Abbottabad makes every effort to ensure the accuracy and authenticity of material printed in J Ayub Med Coll Abbottabad. However, conclusions and statements expressed are views of the authors and do not reflect the opinion/policy of J Ayub Med Coll Abbottabad or the Editorial Board.
USERS are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles, or use them for any other lawful purpose, without asking prior permission from the publisher or the author. This is in accordance with the BOAI definition of open access.
AUTHORS retain the rights of free downloading/unlimited e-print of full text and sharing/disseminating the article without any restriction, by any means including twitter, scholarly collaboration networks such as ResearchGate, Academia.eu, and social media sites such as Twitter, LinkedIn, Google Scholar and any other professional or academic networking site.
