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CARDIOVASCULAR ANESTHESIA

Inhaled Nitric Oxide Versus Intravenous Vasodilators in Severe Pulmonary Hypertension After Cardiac Surgery

Edith R. Schmid, MD^*, Christoph Bürki, MD^*, Markus H. C. Engel, MD^*, Daniel Schmidlin, MD^*, Mico Tornic, MD^*, and Burkhardt Seifert, PhD

*Division of Cardiovascular Anesthesia, Institute of Anesthesiology, University Hospital of Zurich; and Department of Biostatistics, University of Zurich, Zurich, Switzerland

Address correspondence and reprint requests to Edith R. Schmid, MD, Division of Cardiovascular Anesthesia, Institute of Anesthesiology, University Hospital, CH-8091 Zürich, Switzerland. Address e-mail to edith.schmid{at}ifa.usz.ch

Inhaled nitric oxide (iNO) is superior to i.v. vasodilators for treatment of pulmonary hypertension (PH) after cardiac surgery, but iNO is a potentially toxic gas, and patient subsets who benefit from iNO are not yet clearly defined. We administered iNO 40 ppm, prostaglandin E₁ (PGE₁) 0.1 µg · kg^-1 · min^-1, and nitroglycerin (NTG) 3 to 5 µg · kg^-1 · min^-1, in a randomized crossover study to 14 adult patients with severe PH after cardiac surgery. iNO, PGE₁, and NTG were of similar efficacy in reducing pulmonary vascular resistance (P = 0.003). iNO induced selective pulmonary vasodilation, while PGE₁ and NTG had significant concomitant systemic vasodilatory effects. iNO led to an increase in cardiac index (CI) (P = 0.012), and PGE₁ increased CI (P = 0.006) and right ventricular (RV) ejection fraction (P = 0.015), while NTG had no effect on CI and RV performance. After study completion, patients continued with PGE₁ administration with favorable in-hospital outcome. We conclude that PH per se, even if severe, does not necessarily imply postoperative RV dysfunction, and selective pulmonary vasodilation with iNO may not be superior to PGE₁ with regard to CI and RV performance.

Implications: In a prospective, randomized crossover study of inhaled nitric oxide (iNO) versus IV vasodilators, performed in adult patients with severe pulmonary hypertension but preserved right ventricular function after cardiac surgery, iNO was not superior to IV prostaglandin E₁ with regard to cardiac index and right ventricular performance. Considering the potential toxicity of iNO, better definition of patient subsets with a positive benefit/risk ratio is warranted.

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