Hemodynamic effects of inhaled nitric oxide in right ventricular myocardial infarction and cardiogenic shock

Inglessis, Ignacio; Shin, Jordan T.; Lepore, John J.; Palacios, Igor F.; Zapol, Warren M.; Bloch, Kenneth D.; Semigran, Marc J.

doi:10.1016/j.jacc.2004.05.047

Cited by 87 publications

(24 citation statements)

References 34 publications

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“…This minimizes systemic vasodilatation, although it necessitates continuous delivery into the ventilator circuit [206]. NO selectively reduces PVR and improves CO in PAH [212], secondary PH [205,213,214], acute PE [215,216], ischemic RV dysfunction [217,218], and postsurgical PH [202,219-234]. NO also improves oxygenation [235], RVEF, and reduces vasopressor requirements in PH after cardiac surgery [236], especially in patients with higher baseline PVR [237], with no augmented effect seen at doses above 10 ppm in these patients [238].…”

Section: Resultsmentioning

confidence: 99%

Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review

et al. 2010

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IntroductionPulmonary vascular dysfunction, pulmonary hypertension (PH), and resulting right ventricular (RV) failure occur in many critical illnesses and may be associated with a worse prognosis. PH and RV failure may be difficult to manage: principles include maintenance of appropriate RV preload, augmentation of RV function, and reduction of RV afterload by lowering pulmonary vascular resistance (PVR). We therefore provide a detailed update on the management of PH and RV failure in adult critical care.MethodsA systematic review was performed, based on a search of the literature from 1980 to 2010, by using prespecified search terms. Relevant studies were subjected to analysis based on the GRADE method.ResultsClinical studies of intensive care management of pulmonary vascular dysfunction were identified, describing volume therapy, vasopressors, sympathetic inotropes, inodilators, levosimendan, pulmonary vasodilators, and mechanical devices. The following GRADE recommendations (evidence level) are made in patients with pulmonary vascular dysfunction: 1) A weak recommendation (very-low-quality evidence) is made that close monitoring of the RV is advised as volume loading may worsen RV performance; 2) A weak recommendation (low-quality evidence) is made that low-dose norepinephrine is an effective pressor in these patients; and that 3) low-dose vasopressin may be useful to manage patients with resistant vasodilatory shock. 4) A weak recommendation (low-moderate quality evidence) is made that low-dose dobutamine improves RV function in pulmonary vascular dysfunction. 5) A strong recommendation (moderate-quality evidence) is made that phosphodiesterase type III inhibitors reduce PVR and improve RV function, although hypotension is frequent. 6) A weak recommendation (low-quality evidence) is made that levosimendan may be useful for short-term improvements in RV performance. 7) A strong recommendation (moderate-quality evidence) is made that pulmonary vasodilators reduce PVR and improve RV function, notably in pulmonary vascular dysfunction after cardiac surgery, and that the side-effect profile is reduced by using inhaled rather than systemic agents. 8) A weak recommendation (very-low-quality evidence) is made that mechanical therapies may be useful rescue therapies in some settings of pulmonary vascular dysfunction awaiting definitive therapy.ConclusionsThis systematic review highlights that although some recommendations can be made to guide the critical care management of pulmonary vascular and right ventricular dysfunction, within the limitations of this review and the GRADE methodology, the quality of the evidence base is generally low, and further high-quality research is needed.

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Section: Resultsmentioning

confidence: 99%

Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review

et al. 2010

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“…The objective of medical treatment is based on volume optimization, pulmonary vasodilators, and inotropic support. Selective pulmonary vasodilators such as inhaled and parenteral epoprostenol and nitric oxide allow for a decrease in pulmonary vascular resistances in an effort to improve RV stroke volume …”

Section: Discussionmentioning

confidence: 99%

Initial experience with Impella RP in a quaternary transplant center

2020

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Right ventricular failure is one of the most common complications encountered after left ventricular assist device implantation and heart transplantation. It has been reported to have an incidence up to 30%. It increases morbidity and short‐term mortality. Impella RP is a small pump that can provide up to 4L/min of flow. We analyzed all the patients with right ventricular failure that were treated with Impella RP in our institution. The Impella RP was implanted percutaneously in the catheterization laboratory guided by fluoroscopy. Overall, 7 patients required the implantation of an Impella RP due to right ventricular failure: 2 after long‐term LVAD, 3 presented with acute right ventricular failure immediately after LVAD implantation, and 2 needed it after heart transplantation. Regarding complications, we report 2 patients with hemolysis. Hemodynamic parameters as well as end‐organ perfusion and inotropic requirements improved after the insertion of the Impella. Overall, 30‐day survival is 58%. Median time of support was 9 (5–19) days. RV failure is one of the most challenging complications after LVAD implantation and heart transplantation. The major challenge is the timing of implantation. The minimally invasive nature of the Impella RP facilitates de‐escalation of treatment and paves the road to recovery. Impella RP proved useful in facilitating ECMO wean. Used in a prompt manner alongside the ease of implantation and the minimal rate of complications, Impella RP seems to be an appropriate device to tackle RV failure providing enough flow to allow for recovery or escalation decision‐making.

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“…The short half-life does necessitate the need for a continuous delivery system [36]. Inhaled NO improves hemodynamics and RV performance in a variety of clinical settings including postsurgical pulmonary hypertension, acute pulmonary embolism, RV myocardial infarction, acute RV failure following left ventricular assist device implantation, and cardiac transplantation [37][38][39][40][41]. Prolonged use of NO can lead to accumulation of toxic metabolites, reactive nitrogen species, and methemoglobinemia [42].…”

Section: Afterload Reductionmentioning

confidence: 99%

Management of Pulmonary Hypertension and Right Heart Failure in the Intensive Care Unit

Grinstein

Gomberg‐Maitland

2015

Curr Hypertens Rep

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Management of acute right ventricular failure, both with and without coexisting pulmonary hypertension, is a common challenge encountered in the intensive care setting. Both right ventricular dysfunction and pulmonary hypertension portend a poor prognosis, regardless of the underlying cause and are associated with significant morbidity and mortality. The right ventricle is embryologically distinct from the left ventricle and has unique morphologic and functional properties. Management of right ventricular failure and pulmonary hypertension in the intensive care setting requires tailored hemodynamic management, pharmacotherapy, and often mechanical circulatory support. Unfortunately, our understanding of the management of right ventricular failure lags behind that of the left ventricle. In this review, we will explore the underlying pathophysiology of the failing right ventricle and pulmonary vasculature in patients with and without pulmonary hypertension and discuss management strategies based on evidence-based studies as well as our current understanding of the underlying physiology.

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Hemodynamic effects of inhaled nitric oxide in right ventricular myocardial infarction and cardiogenic shock

Abstract: Nitric oxide inhalation results in acute hemodynamic improvement when administered to patients with RVMI and CS.

Cited by 87 publications

References 34 publications

Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review

Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review

Initial experience with Impella RP in a quaternary transplant center

Management of Pulmonary Hypertension and Right Heart Failure in the Intensive Care Unit

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