VARIABLE RESPONSE TO INHALED NITRIC OXIDE IN POSTOPERATIVE PATIENTS OF MITRAL STENOSIS WITH PULMONARY HYPERTENSION

Authors

  • Zubia Razzaq
  • Muhammad Aslam
  • M Mazhar Hussain
  • Shahab Naqvi
  • Muhammad Zameer
  • Ahmed Badar

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 resistance

References

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

2009-03-01