Cardiology Deparment, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos, Carnaxide, 2790-134, Portugal.
Cardiac Surgery Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.
ESC Heart Fail. 2020 Apr;7(2):673-681. doi: 10.1002/ehf2.12639. Epub 2020 Feb 11.
Right heart catheterization (RHC) is indicated in all candidates for heart transplantation (HT). An acute vasodilator challenge is recommended for those with pulmonary hypertension (PH) to assess its reversibility. The effects of inhaled nitric oxide (iNO) on pulmonary and systemic haemodynamics have been reported only in small series. Our purpose was to describe the response to iNO in a larger population and its potential clinical implications.
From 210 RHC procedures performed between 2010 and 2019, vasodilator challenge with iNO was used in 108 patients, of which 66 had advanced heart failure undergoing assessment for HT (55±11 years old; 74.2% male gender; 43.9% ischaemic cardiomyopathy; left ventricular ejection fraction 28.4 ± 11,4%; and peak VO2 12.1 ± 3.0 mL/kg/min). iNO was administered through a tight-fitting facial mask regardless of baseline pulmonary pressures. Clinical endpoints (all-cause mortality and acute right heart failure) were assessed according to baseline haemodynamic findings over the available follow-up period. There were no side effects from iNO administration. Typical response consisted of a reduction in pulmonary vascular resistance, consequent to an increase in left ventricular filling pressures, no significant change in mean pulmonary artery pressure (resulting in a lower mean transpulmonary gradient) and a mild increase in cardiac ouput. Pulmonary arterial compliance increased significantly, whereas systemic vascular resistance was only mildly affected. In five cases (7.6%), pulmonary vascular resistance increased paradoxically. All-cause mortality and post-HT right heart failure events were overall low and similar in patients without PH or reversible PH.
Vasodilator challenge with iNO is safe in advanced heart failure patients undergoing RHC prior to HT listing. It produces a reasonably predictable haemodynamic response, which occurs predominantly at the pulmonary circulation level. Clinical implications of iNO-induced reversibility may be relevant, but further systematic validation is warranted in larger cohorts.
右心导管检查（RHC）适用于所有接受心脏移植（HT）的候选者。对于肺动脉高压（PH）患者，建议进行急性血管扩张剂挑战以评估其可逆性。仅在小系列中报道了吸入一氧化氮（iNO）对肺和全身血液动力学的影响。我们的目的是描述在更大人群中 iNO 的反应及其潜在的临床意义。
在 2010 年至 2019 年期间进行的 210 次 RHC 操作中，108 例患者使用 iNO 进行了血管扩张剂挑战，其中 66 例患有晚期心力衰竭，正在接受 HT 评估（55±11 岁；74.2%男性；43.9%缺血性心肌病；左心室射血分数 28.4 ± 11.4%；峰值 VO2 12.1 ± 3.0 mL/kg/min）。无论基础肺压如何，iNO 均通过紧贴面部的面罩给药。根据可用随访期间的基础血液动力学发现评估临床终点（全因死亡率和急性右心衰竭）。iNO 给药无副作用。典型反应包括肺血管阻力降低，继而左心室充盈压升高，平均肺动脉压无显著变化（导致较低的平均跨肺梯度），心输出量轻度增加。肺动脉顺应性显著增加，而全身血管阻力仅轻度受影响。在 5 例（7.6%）中，肺血管阻力反常性增加。全因死亡率和 HT 后右心衰竭事件总体较低，在无 PH 或可逆转 PH 的患者中相似。
在接受 HT 列入名单之前接受 RHC 的晚期心力衰竭患者中，iNO 血管扩张剂挑战是安全的。它产生了相当可预测的血液动力学反应，主要发生在肺循环水平。iNO 诱导的可逆性的临床意义可能是相关的，但需要在更大的队列中进一步进行系统验证。
