Perioperative Use of Pituitrin after Cardiac Defect Repair in Adult Patients with Severe Pulmonary Hypertension
DOI:
https://doi.org/10.1532/hsf.4569Keywords:
Pulmonary artery hypertension, congenital heart diseases, vasopressin, pituitrin, hemodynamicAbstract
Background: Vasopressin can constrict peripheral arteries without constricting the pulmonary artery. Theoretically, vasopressin is suitable for the perioperative treatment of pulmonary hypertension. Few studies have investigated the use of pituitrin (a substitute for vasopressin) after cardiac defect repair surgery. This study aimed to analyze the effect of pituitrin on hemodynamics and to determine whether pituitrin can be used after surgical repair in adult patients with pulmonary arterial hypertension-congenital heart disease (PAH-CHD).
Methods: A pulmonary artery catheter was used in all the patients for hemodynamic monitoring. Hemodynamic parameters were recorded before and at 0.5 h, 1 h, 6 h, 12 h and 24 h after pituitrin administration. The changes in the hemodynamic parameters before and after pituitrin use were analyzed through repeated measures analysis of variance.
Results: A total of 110 patients with PAH-CHD underwent repair surgery; 23 patients were included in further analysis, including 11 with atrial septal defect, 9 with ventricular septal defect, and 3 with patent ductus arteriosus. Ten (43.5%) were men, with a mean age of 29.4 ± 6.8 years. Hemodynamic parameters before and after the oxygen test were as follows: radial artery oxygen saturation, 91.5% ± 4.4 vs. 97.9 ± 2.4%; pulmonary vascular resistance, 10.5 ± 1.8 Wood units (wu) vs. 5 ± 1.2 wu; systemic-pulmonary blood flow ratio (QP/QS), 1.1 ± 0.2 vs. 2.1 ± 0.9. With prolonged use, the systolic blood pressure of the radial artery increased significantly (P = 0.001), that of the pulmonary artery decreased significantly (P = 0.009), and RP/s decreased significantly (P < 0.001).
Conclusion: Pituitrin as an alternative to vasopressin can increase arterial pressure, decrease pulmonary artery pressure, and reduce the pulmonary artery pressure/arterial pressure ratio after repair surgery in adult patients with PAH-CHD.
References
Adatia I, Beghetti M. 2009. Early postoperative care of patients with pulmonary hypertension associated with congenital cardiac disease. Cardiol Young. 19(4):315-319.
Bouchez S, Fedele F, Giannakoulas G, Gustafsson F, Harjola VP, Karason K, Kivikko M, von Lewinski D, Oliva F, Papp Z, et al. 2018. Levosimendan in Acute and Advanced Heart Failure: an Expert Perspective on Posology and Therapeutic Application. Cardiovasc Drugs Ther. 32(6):617-624.
Bradley EA, Ammash N, Martinez SC, Chin K, Hebson C, Singh HS, Aboulhosn J, Grewal J, Billadello J, Chakinala MM, et al. 2019. "Treat-to-close": Non-repairable ASD-PAH in the adult: Results from the North American ASD-PAH (NAAP) Multicenter Registry. Int J Cardiol. 291:127-133.
Bradley EA, Chakinala M, Billadello JJ. 2013. Usefulness of medical therapy for pulmonary hypertension and delayed atrial septal defect closure. Am J Cardiol. 112(9):1471-1476.
Buijk SE, Bruining HA. 1998. Vasopressin deficiency contributes to the vasodilation of septic shock. Circulation. 98(2):187.
Colucci WS, Wright RF, Jaski BE, Fifer MA, Braunwald E. 1986. Milrinone and dobutamine in severe heart failure: differing hemodynamic effects and individual patient responsiveness. Circulation. 73(3 Pt 2):III175-183.
Comin-Colet J, Manito N, Segovia-Cubero J, Delgado J, Garcia Pinilla JM, Almenar L, Crespo-Leiro MG, Sionis A, Blasco T, Pascual-Figal D, et al. 2018. Efficacy and safety of intermittent intravenous outpatient administration of levosimendan in patients with advanced heart failure: the LION-HEART multicentre randomised trial. Eur J Heart Fail. 20(7):1128-1136.
Crystal GJ, Pagel PS. 2018. Right Ventricular Perfusion: Physiology and Clinical Implications. Anesthesiology. 128(1):202-218.
Currigan DA, Hughes RJ, Wright CE, Angus JA, Soeding PF. 2014. Vasoconstrictor responses to vasopressor agents in human pulmonary and radial arteries: an in vitro study. Anesthesiology. 121(5):930-936.
Dunser MW, Hasibeder WR, Wenzel V, Mayr AJ. 2004. Lessons learned from high-dosage vasopressin infusion in septic shock. Crit Care Med. 32(6):1433-1434; author reply 1434.
Evora PR, Pearson PJ, Schaff HV. 1993. Arginine vasopressin induces endothelium-dependent vasodilatation of the pulmonary artery. V1-receptor-mediated production of nitric oxide. Chest. 103(4):1241-1245.
Galie N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, 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(1):67-119.
Hoeper MM, Granton J. 2011. Intensive care unit management of patients with severe pulmonary hypertension and right heart failure. Am J Respir Crit Care Med. 184(10):1114-1124.
Klinzing S, Simon M, Reinhart K, Bredle DL, Meier-Hellmann A. 2003. High-dose vasopressin is not superior to norepinephrine in septic shock. Crit Care Med. 31(11):2646-2650.
Konstam MA, Kiernan MS, Bernstein D, Bozkurt B, Jacob M, Kapur NK, Kociol RD, Lewis EF, Mehra MR, Pagani FD, et al. 2018. Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association. Circulation. 137(20):e578-e622.
Lindberg L, Olsson AK, Jogi P, Jonmarker C. 2002. How common is severe pulmonary hypertension after pediatric cardiac surgery? J Thorac Cardiovasc Surg. 123(6):1155-1163.
Lowe BS, Therrien J, Ionescu-Ittu R, Pilote L, Martucci G, Marelli AJ. 2011. Diagnosis of pulmonary hypertension in the congenital heart disease adult population impact on outcomes. J Am Coll Cardiol. 58(5):538-546.
Medel J, Boccara G, Van de Steen E, Bertrand M, Godet G, Coriat P. 2001. Terlipressin for treating intraoperative hypotension: can it unmask myocardial ischemia? Anesth Analg. 93(1):53-55, TOC.
Miller OI, Tang SF, Keech A, Pigott NB, Beller E, Celermajer DS. 2000. Inhaled nitric oxide and prevention of pulmonary hypertension after congenital heart surgery: a randomised double-blind study. Lancet. 356(9240):1464-1469.
Mohamed A, Nasef N, Shah V, McNamara PJ. 2014. Vasopressin as a rescue therapy for refractory pulmonary hypertension in neonates: case series. Pediatr Crit Care Med. 15(2):148-154.
Mullens W, Abrahams Z, Francis GS, Skouri HN, Starling RC, Young JB, Taylor DO, Tang WH. 2008. Sodium nitroprusside for advanced low-output heart failure. J Am Coll Cardiol. 52(3):200-207.
Olsson KM, Halank M, Egenlauf B, Fistera D, Gall H, Kaehler C, Kortmann K, Kramm T, Lichtblau M, Marra AM, et al. 2018. Decompensated right heart failure, intensive care and perioperative management in patients with pulmonary hypertension: Updated recommendations from the Cologne Consensus Conference 2018. Int J Cardiol. 272S:46-52.
Ortoleva J, Shapeton A, Vanneman M, Dalia AA. 2020. Vasoplegia During Cardiopulmonary Bypass: Current Literature and Rescue Therapy Options. J Cardiothorac Vasc Anesth. 34(10):2766-2775.
Panchal AR, Berg KM, Hirsch KG, Kudenchuk PJ, Del Rios M, Cabanas JG, Link MS, Kurz MC, Chan PS, Morley PT, et al. 2019. 2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal Cardiopulmonary Resuscitation During Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 140(24):e881-e894.
Price LC, Wort SJ, Finney SJ, Marino PS, Brett SJ. 2010. Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review. Crit Care. 14(5):R169.
Scheurer MA, Bradley SM, Atz AM. 2005. Vasopressin to attenuate pulmonary hypertension and improve systemic blood pressure after correction of obstructed total anomalous pulmonary venous return. J Thorac Cardiovasc Surg. 129(2):464-466.
Siehr SL, Feinstein JA, Yang W, Peng LF, Ogawa MT, Ramamoorthy C. 2016. Hemodynamic Effects of Phenylephrine, Vasopressin, and Epinephrine in Children With Pulmonary Hypertension: A Pilot Study. Pediatr Crit Care Med. 17(5):428-437.
Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, Bernard GR, Chiche JD, Coopersmith CM, et al. 2016. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 315(8):801-810.
Smilowitz NR, Armanious A, Bangalore S, Ramakrishna H, Berger JS. 2019. Cardiovascular Outcomes of Patients With Pulmonary Hypertension Undergoing Noncardiac Surgery. Am J Cardiol. 123(9):1532-1537.
Sommer RJ, Hijazi ZM, Rhodes JF, Jr. 2008. Pathophysiology of congenital heart disease in the adult: part I: Shunt lesions. Circulation. 117(8):1090-1099.
Treschan TA, Peters J. 2006. The vasopressin system: physiology and clinical strategies. Anesthesiology. 105(3):599-612; quiz 639-540.
van Riel AC, Schuuring MJ, van Hessen ID, Zwinderman AH, Cozijnsen L, Reichert CL, Hoorntje JC, Wagenaar LJ, Post MC, van Dijk AP, et al. 2014. Contemporary prevalence of pulmonary arterial hypertension in adult congenital heart disease following the updated clinical classification. Int J Cardiol. 174(2):299-305.
