POSTO

PERAT

IVE

POSTO

PERAT

IVE

PULM

ONARY

PULM

ONARY

HYPERT

ENSION

HYPERT

ENSION

IN C

ARDIAC S

URGERY

IN C

ARDIAC S

URGERY

PATI

ENTS

PATI

ENTS

BY- D

R. ARMAAN S

INGH

BY- D

R. ARMAAN S

INGH

GUIDELINES FOR MANAGEMENT OF PULMONARY HYPERTENSION IN CARDIAC SURGERY PATIENTS

Increased PVR during postop period:

• SIRS 20 to CPBP (pulmonary vasoconstriction)

• Protamine (pulmonary vasoconstriction)

• Hypoxia (pulmonary vasoconstriction)

• ↑ pCO2, acidemia (pulmonary vasoconstriction)

• PEEP, ventilator dysynchrony (pulmonary vasoconstriction)

GUIDELINES FOR MANAGEMENT OF PULMONARY HYPERTENSION IN CARDIAC SURGERY PATIENTS

Pulmonary vasoconstriction:

• Hyperventilation counteracts hypoxic pulmonary vasoconstriction in man

• PAP increased (p < 0.001) with elevations in PaCO2

• Marked decrease in SVR with increasing PaCO2

• Blood pressure decreased (p < 0.001) with ↑ in PaCO2 up to 50 mmHg

GUIDELINES FOR MANAGEMENT OF PULMONARY HYPERTENSIONIN CARDIAC SURGERY PATIENTS

Pulmonary vasoconstriction:

• Can precipitate acute right heart failure

• More frequent conditions: MVR, CHD with L → R shunt

• Heart Tx, Lung Tx

• Pneumonectomy

Dr. Armaan Singh

GUIDELINES FOR MANAGEMENT OF PULMONARY HYPERTENSIONIN CARDIAC SURGERY PATIENTS

Treatment of the underlying cause:

• Pulmonary vasoconstriction (pre-capillary PH) Avoidance of hypoxemia, hypercarbia & acidosis Sedation, analgesia & muscle relaxants Selective pulmonary vasodilatation

• Passive pulmonary hypertension with ↑ LAP (post-capillary PH) Improve LV contractility Decrease degree of MR Nesiritide

Dr. Armaan Singh

MANAGEMENT OF LEFT HEART FAILURE WITH SECONDARY PULMONARY HYPERTENSION

IN CARDIAC SURGERY PATIENTS

Nesiritide :

Perioperative management of patients with severe MR, severe LV dysfunction and secondary pulmonary hypertension

Expected mortality by EuroSCORE 26% Preoperative treatment with Nesiritide for 13-55 hr (mean=24 hr) Postoperative treatment with Nesiritide for 2-80 hr (mean=22 hr) Improves postop renal function and survival

MANAGEMENT OF LEFT HEART FAILURE WITH SECONDARY PULMONARY HYPERTENSION

IN CARDIAC SURGERY PATIENTS

Nesiritide :

MANAGEMENT OF LEFT HEART FAILURE WITH SECONDARY PULMONARY HYPERTENSION

IN CARDIAC SURGERY PATIENTS

Nesiritide:

Hemodynamic benefits: ↓ PAP, ↓ CVP, ↑ CO Improves postop renal function Decreases respiratory failure and AF Decreases LOS Decreases mortality

MANAGEMENT OF LEFT HEART FAILURE WITH SECONDARY PULMONARY HYPERTENSION

IN CARDIAC SURGERY PATIENTS

Nesiritide (Natrecor):

• Standard Dilution:

[1.5 mg] [250 ml D5W, D5½S or NS]

• Loading dose:

2 mcg/kg over 20 min

• Followed by 0.01 mcg/kg/min

• Continuous infusion x 48 hours

GUIDELINES FOR MANAGEMENT OF PULMONARY HYPERTENSION IN CARDIAC SURGERY PATIENTS

Selective pulmonary vasodilatation:

• Right heart failure resistant to therapy

• Pre-existing pulmonary hypertension

* Inhaled Nitric Oxide (iNO)

* Inhaled Prostacyclin (iPGI2)

* Inhaled Iloprost

* Sildenafil

Dr. Armaan Singh

GUIDELINES FOR MANAGEMENT OF PULMONARY HYPERTENSION IN CARDIAC SURGERY PATIENTS

Inhaled Nitric Oxide (iNO):

• Usual dose: 5 - 40 ppm • Selective pulmonary vasodilator • Does not cause systemic hypotension • Distributed only to ventilated portions of the lungs • Requires accurate gas delivery system to monitor NO and NO2 • May cause methemoglobinemia • May cause rebound pulmonary hypertension • Expensive

Dr. Armaan Singh

GUIDELINES FOR MANAGEMENT OF PULMONARY HYPERTENSION IN CARDIAC SURGERY PATIENTS

Inhaled prostacyclin (iPGI2):

• Usual dose: 5 - 50 ng/kg/min • Short-acting selective pulmonary vasodilator • Equally effective as iNO • Does not cause systemic hypotension • Distributed only to ventilated portions of the lungs • May cause thrombocytopenia • Does not cause rebound pulmonary hypertension • Inexpensive

Dr. Armaan Singh

GUIDELINES FOR MANAGEMENT OF PULMONARY HYPERTENSION IN CARDIAC SURGERY PATIENTS

Inhaled prostacyclin (iPGI2):

• Usual starting dose: 50 ng/kg/min • Weaning (3-4 days): 25-10-5-3 ng/kg/min • Selective pulmonary vasodilator • Does not cause systemic hypotension • Equally effective as iNO • Prolonged use is not associated with systemic effects • Readily available in most hospitals • Inexpensive

GUIDELINES FOR MANAGEMENT OF PULMONARY HYPERTENSION IN CARDIAC SURGERY PATIENTS

Selective pulmonary vasodilatation:

n= dobut norepi reop intub mort

IV dilators 18 4.1 0.03 2 31 2

iNO group 21 2.9 0 0 20 1

iPGI2 group 19 3.1 0 1 18 0

GUIDELINES FOR MANAGEMENT OF PULMONARY HYPERTENSION IN CARDIAC SURGERY PATIENTS

Inhaled prostacyclin (iPGI2):

• Equally effective as iNO

• Neither iPGI2 nor its metabolites have toxic effects

• Possible thrombocytopenia but does not increase risk of bleeding

• Easy administration

• Inexpensive

GUIDELINES FOR MANAGEMENT OF PULMONARY HYPERTENSION IN CARDIAC SURGERY PATIENTS

Inhaled iloprost:

• Usual dose: 12 - 20 mcg q 4-6 hr

• Intermittent nebulization

• Longer half-life selective pulmonary vasodilator

• Equally effective as iNO

• Does not cause systemic hypotension

• May cause thrombocytopenia

• Does not cause rebound pulmonary hypertension

• Intermittent nebulization requires periodic interruption of PEEP

Dr. Armaan Singh

GUIDELINES FOR MANAGEMENT OF PULMONARY HYPERTENSION IN CARDIAC SURGERY PATIENTS

Inhaled iloprost:

GUIDELINES FOR MANAGEMENT OF PULMONARY HYPERTENSION IN CARDIAC SURGERY PATIENTS

Sildenafil:

• Equally effective as iNO

• Increases cardiac output

• Does not increase wedge pressure

• Oral or IV administration

• Inexpensive

GUIDELINES FOR MANAGEMENT OF PULMONARY HYPERTENSION IN CARDIAC SURGERY PATIENTS

Sildenafil:

GUIDELINES FOR MANAGEMENT OF PULMONARY HYPERTENSION IN CARDIAC SURGERY PATIENTS

Sildenafil:

GUIDELINES FOR MANAGEMENT OF PULMONARY HYPERTENSION IN CARDIAC SURGERY PATIENTS

Sildenafil:

• Initial dose: 50-75 mg PO 10-30 min before induction of anesthesia

• Maintenance dose: 25 mg BID - 50 mg TID

• Pediatric dose: 0.4 mg/kg before discontinuing iNO