Preliminary Results of Supra-Hepatic Intraaortic Perfusion with Nitroglycerin for Patients with Significant Hepatic Dysfunction
Background: Preoperative hepatic dysfunction is a risk factor for postoperative fulminant hepatic failure and death. We noted persistent hepatic artery vasospasm in patients dying of postoperative hepatic failure. We hypothesized that an intra-aortic vasodilator such as nitroglycerin could attenuate vasospasm and prevent hepatic failure.
Methods: Nineteen consecutive patients with significant preoperative hepatic dysfunction underwent cardiac surgery using cardiopulmonary bypass with continuous infusion of intra-aortic nitroglycerin via a catheter placed above the celiac axis. Serial hepatic artery Doppler studies were done perioperatively with and without the nitroglycerin infusion on. Hepatic artery Doppler, hepatic artery size, alterations in liver function and serum creatinine, and outcomes were noted. Survival was compared to the Euroscore and a hepatic risk score that was based on a historical cohort and reported literature.
Results: One patient could not be weaned off cardiopulmonary bypass. In the remaining 18 patients, reversible hepatic arterial vasospasm was noted, and this persisted at 24 hours in 12 patients and 48 hours in 7 patients. All patients had resolution of vasospasm at 72 hours. Serial paired hepatic artery diameter measurements showed a significant difference (P < .001). There was a significant reduction in mortality (5.2 %) compared to historical control and predicted mortality (logistic Euroscore 37.4%, P = .023). None of the survivors had a significant alteration in hepato-renal function.
Conclusion: Intra-aortic nitroglycerin can attenuate hepatic arterial vasospasm induced by cardiopulmonary bypass and preserve hepatic function. This may reduce the risk associated with cardiopulmonary bypass and surgery in patients with liver dysfunction.
Adluri RK, Singh AV, Skoyles J, et al. 2010, Effect of increased pump flow on hepatic blood flow and systemic inflammatory response following on-pump coronary artery bypass grafting. Perfusion 25:293-303.nAndrews JC. 2004. Vascular complications following liver transplantation. Semin Intervent Radiol 21:221-33.nChauhan S, Wasir HS, Bhan A, Rao BH, Saxena N, Venugopal P. 2000. Adenosine for cardioplegic induction: a comparison with St Thomas solution. J Cardiothorac Vasc Anesth 14:21-4.nDurand F, Valla D. 2005. Assessment of the prognosis of cirrhosis: Child-Pugh versus MELD. J Hepatol 42:S100-7.nFaul F, Erdfelder E, Buchner A, Lang AG. 2009. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods 41:1149-60.nFetough FA, Salah M, Mostafa M, Fawzy A, Sewielem M, Sedeek K. 2008. The effects of normothermic versus hypothermic cardiopulmonary bypass on hepatic blood flow. Can J Anaesth 55(Suppl 1). Abstract 4719651.nFilsoufi F, Salzberg SP, Rahmanian PB, et al. 2007. Early and late outcome of cardiac surgery in patients with liver cirrhosis. Liver Transpl 13:990-5.nHoteit MA, Ghazale AH, Bain AJ, et al. 2008. Model for end-stage liver disease score versus Child score in predicting the outcome of surgical procedures in patients with cirrhosis. World J Gastroenterol 14:1774-80.nKuhn-Régnier F, Natour E, Dhein S, et al. 1999. Beta-blockade versus Buckberg blood-cardioplegia in coronary bypass operation. Eur J Cardiothorac Surg 15:67-74.nLeier CV, Bambach D, Thompson MJ, Cattaneo SM, Goldberg RJ, Unverferth DV. 1981. Central and regional hemodynamic effects of intravenous isosorbide dinitrate, nitroglycerin and nitroprusside in patients with congestive heart failure. Am J Cardiol 48:1115-23.nMalik M, Chauhan S, Malik V, Gharde P, Kiran U, Pandey RM. 2010. Is EuroSCORE applicable to Indian patients undergoing cardiac surgery? Ann Card Anaesth 13:241-5.nModi A, Vohra HA, Barlow CW. 2010. Do patients with liver cirrhosis undergoing cardiac surgery have acceptable outcomes? Interact Cardiovasc Thorac Surg 11:630-4.nOrlino EN, Liu H. 2005. Child-Pugh and MELD classifications and the mortality following cardiac surgery. Available at http://www.scahq.org/sca3/newsletters/2005oct/drug1.shtml'>http://www.scahq.org/sca3/newsletters/2005oct/drug1.shtmlnRichter S, Mücke I, Menger MD, Vollmar B. 2000. Impact of intrinsic blood flow regulation in cirrhosis: maintenance of hepatic arterial buffer response. Am J Physiol Gastrointest Liver Physiol 279:G454-62.nRinne T, Harmoinen A, Kaukinen S. 2000. Esmolol cardioplegia in unstable coronary revascularisation patients. A randomised clinical trial. Acta Anaesthesiol Scand 44:727-32.nSuman A, Barnes DS, Zein NN, Levinthal GN, Connor JT, Carey WD. 2004. Predicting outcome after cardiac surgery in patients with cirrhosis: a comparison of Child-Pugh and MELD scores. Clin Gastroenterol Hepatol 2:719-23.nVinten-Johansen J, Zhao ZQ, Corvera JS, et al. 2003. Adenosine in myocardial protection in on-pump and off-pump cardiac surgery. Ann Thorac Surg 75:S691-9.nVollmar B, Menger MD. 2009. The hepatic microcirculation: mechanistic contributions and therapeutic targets in liver injury and repair. Physiol Rev 89:1269-339.nZipprich A, Steudel N, Behrmann C, et al. 2003. Functional significance of hepatic arterial flow in patients with cirrhosis. Hepatology 37:385-92.n
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