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CARDIOVASCULAR ANESTHESIA

Inhaled Nitric Oxide Reduces Pulmonary Vascular Resistance More Than Prostaglandin E₁ During Heart Transplantation

Angela Rajek, MD^*,§, Thomas Pernerstorfer, MD^*, Johannes Kastner, MD, Peter Mares, MD^*, Martin Grabenwöger, MD, Daniel I. Sessler, MD^*,§,¶, Georg Grubhofer, MD^*, and Michael Hiesmayr, MD^*

Departments of *Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Cardiology, and Cardiothoracic Surgery, University of Vienna, Vienna, Austria; §Department of Anesthesia and Perioperative Care, University of California–San Francisco, San Francisco, California; ||Ludwig Boltzmann Institute for Clinical Anesthesia and Intensive Care, Vienna, Austria; and ¶Outcomes Research^TM Group

Address correspondence to Dr. Angela Rajek, Department of Anesthesia and Intensive Care (C), Vienna General Hospital, University of Vienna, Wahringer Gurtel 18-20, Vienna A-1090, Austria. Address e-mail to maria.rajek{at}univie.ac.at

Heart transplantation in patients with increased pulmonary vascular resistance is often associated with postbypass right heart failure. We therefore compared the abilities of prostaglandin E₁ (PGE₁) and inhaled nitric oxide to reduce pulmonary vascular resistance during heart transplantation. Patients undergoing orthotopic heart transplantation for congestive heart failure were randomly assigned to either a PGE₁ infusion at a rate of 8 ng · kg· ^-1min^-1 starting 10 min before weaning from cardiopulmonary bypass (CPB) (n = 34) or inhalation of 4 ppm nitric oxide starting just before weaning from CPB (n = 34). Both treatments were increased stepwise, if necessary, and were stopped 6 h postoperatively. Hemodynamic values were recorded after the induction of anesthesia, 10 and 30 min after weaning from CPB, and 1 h and 6 h postoperatively. Immediately after weaning from CPB, pulmonary vascular resistance was nearly halved in the nitric oxide group but reduced by only 10% in the PGE₁ group. Pulmonary artery pressure was decreased approximately 30% during nitric oxide inhalation, but only approximately 16% during the PGE₁ infusion. Six hours after surgery, pulmonary vascular resistance and pulmonary artery pressure were similar in the two groups. The ratio between pulmonary vascular resistance and systemic vascular resistance was significantly less in the nitric oxide patients at all postbypass times. In contrast, the pulmonary-to-systemic vascular resistance ratio increased approximately 30% in the patients given PGE₁. Cardiac output, heart rate, mean arterial pressure, right atrial pressure, and pulmonary wedge pressure did not differ between the groups. Weaning from CPB was successful in all patients assigned to nitric oxide inhalation; in contrast, weaning failed in six patients assigned to PGE₁ (P = 0.03).

Implications: Nitric oxide inhalation selectively reduces pulmonary vascular resistance and pulmonary artery pressure immediately after heart transplantation which facilitates weaning from cardiopulmonary bypass.

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