Baysal Ayse, Bilsel Serpil, Bulbul Ozlem Gumustekin, Kayacioglu Ilyas, Idiz Mustafa, Yekeler Ibrahim
Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Hospital, Istanbul, Turkey.
Heart Surg Forum. 2006;9(1):E536-42. doi: 10.1532/HSF98.20051161.
Pulmonary hypertension secondary to valvular heart disease is a cause of acute right heart failure during valve replacement operations. This study compares the hemodynamic effects of intravenous use of iloprost and nitroglycerin in patients with pulmonary hypertension undergoing valvular replacement surgery. We sought to determine the acceptable doses of these medications for use in surgery to decrease mean pulmonary artery pressure to <30 mmHg without causing systemic side effects. The plasma nitric oxide levels that were obtained from pulmonary mixed venous blood have been compared to demonstrate the difference in the action mechanism of these drugs.
Eighteen patients undergoing mitral or aortic and mitral valvular replacement with pulmonary hypertension >25 mmHg were included in the study. The 2 groups received iloprost or nitroglycerin via a central pulmonary catheter, and the hemodynamic parameters were evaluated before incision (T1), 10 minutes after chest opening (T2), and 5 minutes and 20 minutes after cardiopulmonary bypass (T3 and T4). The plasma nitric oxide levels were obtained from the mixed venous blood at the T1 and T4 intervals.
The data have been analyzed for each group and for repeated measurements of hemodynamic parameters at T1-T4 time points. The analysis of hemodynamic parameters before (T1 and T2) and after (T3 and T4) bypass showed similar responses depending on the use of either iloprost or nitroglycerin. The administration of iloprost after bypass (T3) at a dosage of 1.25 to 2.5 ng/kg per minute reduced mean pulmonary artery pressure (from 28.8 +/- 7.89 to 20.63 +/- 6.39 mmHg) and pulmonary vascular resistance (from 226.88 +/- 101.93 to 118.00 +/- 82.36 dyn sec cm -5) better than nitroglycerin at a dosage of 0.5 to 1 microg/kg per minute (from 23.20 +/- 5.20 to 18.50 +/- 5.10 mmHg and from 160.80 +/- 39.76 to 137.40 +/- 56.54 dyn sec cm -5, respectively). Iloprost causes significant increase in cardiac output (from 4.91 +/- 0.91 to 5.49 +/- 0.91 L/min) compared to nitroglycerin (from 5.23 +/- 0.80 to 5.27 +/- 0.74 L/min). The plasma nitric oxide levels of the iloprost group did not show an increase from T1 to T4, whereas the nitroglycerin group levels did (P <.05).
Intravenous use of both iloprost and nitroglycerin effectively reduces mean pulmonary artery pressure, although only the iloprost group was accompanied by an increase in cardiac output. During operation, where abrupt management of pulmonary hypertension is required, systemic use of iloprost or nitroglycerin at appropriate doses via a pulmonary artery catheter offers adequate relief of hypertension and is well tolerated without any significant adverse effects. The plasma nitric oxide levels did not rise with the use of iloprost.
瓣膜性心脏病继发的肺动脉高压是瓣膜置换手术期间急性右心衰竭的一个原因。本研究比较了静脉使用伊洛前列素和硝酸甘油对接受瓣膜置换手术的肺动脉高压患者的血流动力学影响。我们试图确定这些药物在手术中的可接受剂量，以将平均肺动脉压降至<30 mmHg且不引起全身副作用。已比较从肺混合静脉血中获得的血浆一氧化氮水平，以证明这些药物作用机制的差异。
18例接受二尖瓣或主动脉瓣及二尖瓣置换且肺动脉高压>25 mmHg的患者纳入本研究。两组通过中心肺动脉导管接受伊洛前列素或硝酸甘油，在切口前（T1）、开胸后10分钟（T2）以及体外循环后5分钟和20分钟（T3和T4）评估血流动力学参数。在T1和T4时间段从混合静脉血中获取血浆一氧化氮水平。
已对每组以及T1 - T4时间点血流动力学参数的重复测量数据进行分析。旁路手术前（T1和T2）和后（T3和T4）血流动力学参数的分析显示，根据伊洛前列素或硝酸甘油的使用情况，反应相似。旁路手术后（T3）以每分钟1.25至2.5 ng/kg的剂量给予伊洛前列素比以每分钟0.5至1 μg/kg的剂量给予硝酸甘油能更好地降低平均肺动脉压（从28.8±7.89降至20.63±6.39 mmHg）和肺血管阻力（从226.88±101.93降至118.00±82.36 dyn sec cm -5）（硝酸甘油组分别从23.20±5.20降至18.50±5.10 mmHg和从160.80±39.76降至137.40±56. (续表 4)
表 4：旁路手术前后血流动力学参数比较
|参数|伊洛前列素组|硝酸甘油组|
|--|--|--|
|平均肺动脉压（mmHg）|术前（T1）：28.8±7.89
术后（T3）：20.63±6.39|术前（T1）：23.20±5.20
术后（T3）：18.50±5.10|
|肺血管阻力（dyn sec cm -5）|术前（T1）：226.88±101.93
术后（T3）：118.00±82.36|术前（T1）：160.80±39.76
术后（T3）：137.40±56.54|
|心输出量（L/min）|术前（T1）：4.91±0.91
术后（T3）：5.49±0.91|术前（T1）：5.23±0.80
术后（T3）：5.27±0.74|
|血浆一氧化氮水平（未提及具体单位）|T1至T4未升高|T1至T4升高（P <.05）|
静脉使用伊洛前列素和硝酸甘油均能有效降低平均肺动脉压，尽管只有伊洛前列素组心输出量增加。在手术期间，当需要紧急处理肺动脉高压时，通过肺动脉导管以适当剂量全身使用伊洛前列素或硝酸甘油可充分缓解高血压，且耐受性良好，无任何明显不良反应。使用伊洛前列素时血浆一氧化氮水平未升高。 54 dyn sec cm -5）。与硝酸甘油（从5.23±0.80升至5.27±0.74 L/min）相比，伊洛前列素使心输出量显著增加（从4.91±0.91升至5.49±0.91 L/min）。伊洛前列素组的血浆一氧化氮水平从T1到T4未升高，而硝酸甘油组升高（P <.05）。
静脉使用伊洛前列素和硝酸甘油均能有效降低平均肺动脉压，尽管只有伊洛前列素组心输出量增加。在手术期间，当需要紧急处理肺动脉高压时，通过肺动脉导管以适当剂量全身使用伊洛前列素或硝酸甘油可充分缓解高血压，且耐受性良好，无任何明显不良反应。使用伊洛前列素时血浆一氧化氮水平未升高。
