Novel Goal-Directed Hemodynamic Optimization Therapy Based on Major Vasopressor during Corrective Cardiac Surgery in Patients with Severe Pulmonary Arterial Hypertension: A Pilot Study
DOI:
https://doi.org/10.1532/hsf.1576Abstract
Introduction: Pulmonary arterial hypertension (PAH) is a common and fatal complication of congenital heart disease (CHD). PAH-CHD increases the risk for postoperative complications. Recent evidence suggests that perioperative goal-directed hemodynamic optimization therapy (GDHOT) significantly improves outcomes in surgery patients. Standard GDHOT is based on major solution volume, vasodilators and inotropic therapy, while novel GDHOT is based on major vasopressor and inotropic therapy. Therefore, we tested whether standard or novel GDHOT improves surgical outcomes in PAH-CHD patients.Methods: Forty PAH-CHD patients with a ventricular septal defect (VSD) and mean pulmonary arterial pressure (mPAP) >50 mmHg, who were scheduled for corrective surgery, were randomly assigned to 2 groups: SG (study group, n = 20) and CG (control group, n = 20). SG patients received perioperative hemodynamic therapy guided by novel GDHOT, while CG patients received standard GDHOT. Outcome data were recorded up to 28 days postoperatively. Ventilator time, length of ICU stay, and mortality were the primary endpoints.
Results: There were no significant differences in preoperative data, surgical procedure, and hospital mortality rates between the 2 groups. Time of mechanical ventilation and length of ICU stay were significantly shorter in SG patients compared to CG patients (P < .05, n = 20). Patients in SG showed a significantly increased systemic vascular resistance index and decreased cardiac index, but no change in pulmonary vascular resistance index at 12 and 24 hours after surgery compared to the controls (P < .05). Patients in SG had significantly decreased PAP, pulmonary arterial pressure/systemic arterial pressure (Pp/Ps), and RVSWI (right ventricular stroke work index) at 12 and 24 hours after surgery
(P < .05, respectively). Patients in SG also showed significantly decreased central venous pressure at 4, 12, and 24 hours after surgery compared to those treated with standard protocol (P < .05).
Conclusion: Our study provides clinical evidence that perioperative goal-directed hemodynamic optimization therapy based on major vasopressor is associated with reduced duration of postoperative respiratory support, and length of ICU stay in PAH-CHD patients undergoing elective surgery. These outcomes, then, may be linked to improved hemodynamics and preservation of right ventricular dynamic function.
References
Barst RJ, Ertel SI, Beghetti M, et al. 2011. Pulmonary arterial hypertension: a comparison between children and adults. Eur Respir J 37:665-77.
Barst RJ, Ivy DD, Foreman AJ, et al. 2014. Four- and seven-year outcomes of patients with congenital heart disease-associated pulmonary arterial hypertension (from the REVEAL Registry). Am J Cardiol 113:147-55.
Beghetti M, Tissot C. 2010. Pulmonary hypertension in congenital shunts. Rev Esp Cardiol 63:1179-93.
Carrel T, Englberger L, Mohacsi P, et al. 2000. Low systemic vascular resistance after cardiopulmonary bypass: Incidence, etiology, and clinical importance. J Card Surg 15:347-53.
Currigan DA, Hughes RJ, Wright CE, et al. 2014. Vasoconstrictor responses to vasopressor agents in human pulmonary and radial arteries: an in vitro study. Anesthesiology 121:930-6.
Egi M, Bellomo R, Langenberg C, et al. 2007. Selecting a vasopressor drug for vasoplegic shock after adult cardiac surgery: a systematic literature review. Ann Thorac Surg 83:715-23.
Frank DB, Hanna BD. 2015. Pulmonary arterial hypertension associated with congenital heart disease and Eisenmenger syndrome: current practice in pediatrics. Minerva Pediatr 67:169-85.
Galiè N, Humbert M,Vachiery JL, et al. 2016. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J 37:67-119.
Haworth SG, Hislop AA. 2009. Treatment and survival in children with pulmonary arterial hypertension: The UK Pulmonary Hypertension Service for Children 2001–2006. Heart 95:312-17.
Huh JW, Oh BJ, Lim CM, et al. 2013. Comparison of clinical outcomes between intermittent and continuous monitoring of central venous oxygen saturation (ScvO2) in patients with severe sepsis and septic shock: a pilot study. Emerg Med J 30:906-9.
Krishnan U, Rosenzweig EB. 2013. Pulmonary arterial hypertension associated with congenital heart disease. Clin Chest Med 34:707-17.
Minai OA, Yared JP, Kaw R, et al. 2013. Perioperative risk and management in patients with pulmonary hypertension. Chest 144:329-40.
Mutlu GM, Factor P. 2004. Role of vasopressin in the management of septic shock. Intensive Care Med 30:1276-91.
Nomura N, Asano M, Saito T, et al. 2013. Sivelestat attenuates lung injury in surgery for congenital heart disease with pulmonary hypertension. Ann Thorac Surg S0003-4975.
Pullamsetti S, Savai R, Janssen W, et al. 2011. Inflammation, immunological reaction and role of infection in pulmonary hypertension. Clin Microbiol Infect 17:7-14.
Rivers E, Nguyen B, Havstad S, et al. 2001. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345:1368-77.
Salzwedel C, Puig J, Carstens A, et al. 2013. Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study. Crit Care 17:R191.
Strumpher J, Jacobsohn E. 2011. Pulmonary hypertension and right ventricular dysfunction: physiology and perioperative management. J Cardiothorac Vasc Anesth 25:687-704.
Thunberg CA, Gaitan BD, Grewal A, et al. 2013. Pulmonary hypertension in patients undergoing cardiac surgery: pathophysiology, perioperative management, and outcomes. J Cardiothorac Vasc Anesth 27:551-72.
Udeh CI, Diaz-Gómez JL, Anthony D, et al. 2012. Recent advances in perioperative anesthetic management update on the role of vasopressin and its effects on outcomes. Curr Pharm Des 18:6308-13.
