Inhaled prostacyclin and platelet function after cardiac surgery and cardiopulmonary bypass

Haraldsson, Åsa; Kieler-Jensen, Niels; Wadenvik, Hans; Ricksten, Sven‐Erik

doi:10.1007/s001340050044

Cited by 42 publications

(19 citation statements)

References 33 publications

(31 reference statements)

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“…Inhaled PGI 2 also acutely improves pulmonary hemodynamics after acute massive PE [299]. Although PGI 2 impairs platelet aggregation, clinical bleeding was not increased in one study [300]. The potential anticoagulant effect should be remembered, however, especially in patients after surgery and receiving concomitant heparin.…”

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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“…No pharmacokinetic studies have evaluated plasma drug levels of epoprostenol after administration via inhalation; however, the risk of systemic side effects with inhalation therapy as compared to intravenous administration are likely reduced, given that generally only 10% of aerosolized drug reaches the alveolar epithelium during mechanical ventilation . Inhaled epoprostenol has been associated with impaired in vitro measures of platelet aggregation, providing evidence that the drug has at least some systemic absorption . However, in one study, inhaled epoprostenol was not associated with longer bleeding times or differences in chest tube drainage output after cardiac surgery .…”

Section: Pharmacology and Adverse Effects Of Inhaled Pulmonary Vasodimentioning

confidence: 99%

“…Inhaled epoprostenol has been associated with impaired in vitro measures of platelet aggregation, providing evidence that the drug has at least some systemic absorption . However, in one study, inhaled epoprostenol was not associated with longer bleeding times or differences in chest tube drainage output after cardiac surgery . Conversely, another study in CF‐LVAD patients found earlier administration of inhaled epoprostenol was associated with higher postoperative blood loss during LVAD placement …”

Section: Pharmacology and Adverse Effects Of Inhaled Pulmonary Vasodimentioning

confidence: 99%

Inhaled Pulmonary Vasodilator Therapy for Management of Right Ventricular Dysfunction after Left Ventricular Assist Device Placement and Cardiac Transplantation

et al. 2017

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Right ventricular failure (RVF) after cardiac transplant (CTX) or implantation of a continuous-flow left ventricular assist device (CF-LVAD) is associated with significant postoperative morbidity and mortality. A variety of modalities have been used to treat postoperative RVF, including management of volume status, intravenous inotropes and vasodilators, and right-sided mechanical support. Inhaled vasodilator agents are a unique treatment option aimed at minimizing systemic absorption by delivering therapy directly to the pulmonary vasculature. Current LVAD and CTX guidelines endorse inhaled vasodilators for managing postoperative RVF; however, no guidance is offered regarding agent selection, dosing, or administration. A review of the current literature confirms that inhaled pulmonary vasodilator agents have been shown to decrease pulmonary artery pressure when used in the perioperative period of CF-LVAD implant or CTX. However, the literature regarding the potential impact on clinical outcomes (e.g., survival or risk of developing RVF) is lacking with these medications. Based on our assessment of the literature, we suggest that when RVF occurs in the setting of a normal pulmonary vascular resistance (PVR), traditional inotropic therapy (e.g., dobutamine) should be used. Conversely, if the PVR is elevated (> 250 dynes/sec/cm 5 or 3 Wood units), or the patient has other evidence of a high right ventricular afterload (i.e., a transpulmonary gradient > 12 mm Hg), then an inhaled pulmonary vasodilator would be the preferred initial pharmacologic agent. Drug selection depends largely on the institution's capacity to safely prepare and administer the medication, along with formulary considerations, such as the high costs associated with inhaled iloprost and inhaled nitric oxide. KEY WORDS heart transplantation, left ventricular assist device, right heart failure, pulmonary arterial hypertension, inhaled pulmonary vasodilators. (Pharmacotherapy 2017;37(8):944-955)

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“…Furthermore, prostacyclin does not produce the toxic metabolites or exhibit the same rate of potential complications as NO. Although prostacyclin inhibits platelet aggregation in vitro, this has not to date demonstrated a prolongation in bleeding time or increase in chest tube drainage when utilized in cardiac surgery [53,58]. Rebound PH after prostacyclin use has, however, been reported in a high-risk patient that experienced increased RV afterload and developed cardiogenic shock following its withdrawal [59].…”

Section: Pulmonary Vasodilatorsmentioning

confidence: 99%

Pharmacologic Management of Perioperative Pulmonary Hypertension

Cheng

Tonelli

Pettersson

et al. 2014

Journal of Cardiovascular Pharmacology

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Perioperative pulmonary hypertension can originate from an established disease or acutely develop within the surgical setting. Patients with increased pulmonary vascular resistance are consequently at greater risk for complications. In spite of the various specific therapies available, the ideal therapeutic approach in this patient population is not currently clear. This article describes the basic principles of perioperative pulmonary hypertension and reviews the different classes of agents used to promote pulmonary vasodilation in the surgical setting.

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Inhaled prostacyclin and platelet function after cardiac surgery and cardiopulmonary bypass

Abstract: Inhalation of PGI2 for 6 h in patients after cardiac surgery is associated with impaired platelet aggregation detected by in vitro techniques, with no in vivo signs of platelet dysfunction.

Cited by 42 publications

References 33 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

Inhaled Pulmonary Vasodilator Therapy for Management of Right Ventricular Dysfunction after Left Ventricular Assist Device Placement and Cardiac Transplantation

Pharmacologic Management of Perioperative Pulmonary Hypertension

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