Jeon Yunseok, Ryu Jung Hee, Lim Young Jin, Kim Chong Sung, Bahk Jae-Hyon, Yoon Seung Zhoo, Choi Ju Youn
Department of Anesthesiology, Seoul National University Hospital, Seoul, Republic of Korea.
Eur J Cardiothorac Surg. 2006 Jun;29(6):952-6. doi: 10.1016/j.ejcts.2006.02.032. Epub 2006 May 3.
Phosphodiesterase inhibitor is essential to the pharmacologic management of decompensated heart failure because it increases contractility and decreases afterload of right ventricle. It also improves hemodynamics and increases blood flow of the grafted internal mammary arteries and middle cerebral arteries during coronary artery bypass surgery. However, it induces vasodilation and necessitates the use of vasoconstrictors, such as norepinephrine. We hypothesized that vasopressin could recover hypotension induced by milrinone with less effect on pulmonary vascular resistance (PVR) compared to norepinephrine.
Fifty patients, undergoing coronary artery bypass graft (CABG) surgery, were assigned randomly in a double-blind manner to receive either vasopressin or norepinephrine. After baseline hemodynamic measurements, a loading dose of milrinone 50 microg/kg was infused slowly for 20 min followed by continuous infusion of 0.5 microg/(kg min). Immediately after the loading dose of milrinone, hemodynamic variables were measured, and vasopressin (VP group) or norepinephrine (NE groups) was infused. After being titrated until the mean arterial pressure was increased by 20%, hemodynamic variables were measured again.
Milrinone infusion reduced both systemic vascular resistance (SVR, 1218+/-299 dynes/cm5 vs 838+/-209 dynes/cm5, 1345+/-299 dynes/cm5 vs 1011+/-195 dynes/cm5) and PVR (95+/-34 dynes/cm5 vs 72+/-30 dynes/cm5, 119+/-85 dynes/cm5 vs 87+/-33 dynes/cm5) in the VP and NE groups, respectively. Vasopressin and norepinephrine infusion increased both SVR (838+/-209 dynes/cm5 vs 1100+/-244 dynes/cm5, 1011+/-195 dynes/cm5 vs 1446+/-681 dynes/cm5, respectively) and PVR (72+/-30 dynes/cm5 vs 84+/-18 dynes/cm5, 87+/-33 dynes/cm5 vs 139+/-97 dynes/cm5, respectively). The PRV/SVR ratio was decreased after vasopressin infusion (0.10+/-0.03 vs 0.08+/-0.03), while no changes were found after norepinephrine infusion (0.09+/-0.02 vs 0.09+/-0.02).
In the patients undergoing CABG surgery, both norepinephrine and low dose vasopressin were effective in restoring milrinone-induced decrease of SVR. However, only low-dose vasopressin decreased the PVR/SVR ratio that was increased by milrinone. Considering the importance of maintaining systemic perfusion pressure as well as reducing right heart afterload, milrinone-vasopressin may provide better hemodynamics than milrinone-norephinephrine during the management of right heart failure.
磷酸二酯酶抑制剂对失代偿性心力衰竭的药物治疗至关重要，因为它可增强心肌收缩力并降低右心室后负荷。在冠状动脉搭桥手术期间，它还可改善血流动力学，并增加移植的乳内动脉和大脑中动脉的血流量。然而，它会引起血管舒张，因此需要使用血管收缩剂，如去甲肾上腺素。我们假设与去甲肾上腺素相比，血管加压素能够纠正米力农引起的低血压，且对肺血管阻力（PVR）影响较小。
50例行冠状动脉搭桥术（CABG）的患者被随机双盲分为两组，分别接受血管加压素或去甲肾上腺素治疗。在进行基础血流动力学测量后，缓慢静脉输注负荷剂量的米力农50μg/kg，持续20分钟，随后以0.5μg/（kg·min）的速度持续输注。在米力农负荷剂量输注后立即测量血流动力学变量，并输注血管加压素（VP组）或去甲肾上腺素（NE组）。滴定至平均动脉压升高20%后，再次测量血流动力学变量。
米力农输注使VP组和NE组的全身血管阻力（SVR，分别为1218±299达因/cm⁵ 比838±209达因/cm⁵，1345±299达因/cm⁵ 比1011±195达因/cm⁵）和PVR（分别为95±34达因/cm⁵ 比72±30达因/cm⁵，119±85达因/cm⁵ 比87±33达因/cm⁵）均降低。血管加压素和去甲肾上腺素输注均使SVR（分别为838±209达因/cm⁵ 比1100±244达因/cm⁵，1011±195达因/cm⁵ 比1446±681达因/cm⁵）和PVR（分别为72±30达因/cm⁵ 比84±18达因/cm⁵，87±33达因/cm⁵ 比139±97达因/cm⁵）升高。血管加压素输注后PRV/SVR比值降低（0.10±0.03比0.08±0.03），而去甲肾上腺素输注后未发现变化（0.09±0.02比0.09±0.02）。
在接受CABG手术的患者中，去甲肾上腺素和低剂量血管加压素均能有效纠正米力农引起的SVR降低。然而，只有低剂量血管加压素降低了米力农升高的PVR/SVR比值。考虑到维持全身灌注压力以及降低右心后负荷的重要性，在右心衰竭的治疗中，米力农 - 血管加压素可能比米力农 - 去甲肾上腺素提供更好的血流动力学。
