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Treatment of pulmonary hypertension during surgery with nitric oxide and vasodilators

Zu Yi Jiang, MD^*, Tudor Costachescu, MD^*, Marc Derouin, MD and Gilbert Blaise, MD^*

^* From the Département d'Anesthésie-Réanimation, Faculté de Médecine, Centre hospitalier de l'Université de Montréal, Hôpital Notre-Dame,
Montréal and Centre hospitalier Régional, Rimouski, Québec, Canada.

Address correspondence to: Gilbert Blaise MD, Département d'Anesthésie-Réanimation, CHUM-Hôpital Notre- Dame, 1560, rue Sherbrooke est, Montréal, Qc H2L 4M1, Canada. Phone: 514-281-6000, Ext 5397; Fax: 514-896-4615; E-mail: blaisegil{at}videotron.ca

Purpose: To describe the effects of the combination of several therapies on the pulmonary circulation and cardiac function in a patient with severe pulmonary hypertension.

Clinical features: We report the case of a female patient with chronic secondary pulmonary hypertension and cardiac failure who underwent right hemicolectomy under general anesthesia. Insertion of a pulmonary artery catheter before the operation revealed pulmonary artery pressure (PAP) of 55/24 mmHg which was lowered moderately by 40 parts per million (ppm) inhNO. During surgery, the patient presented an episode of atrial fibrillation with a slow, irregular heart rate of 45-50 min^–1 and variable systemic pressure. A dipyridamole DPD (0.2 mg•kg^–1) bolus stabilized systemic pressure and increased heart rate and cardiac output. However, PAP did not change. Nitroglycerine infusion was started at 10 mg•hr^–1 shortly after the initiation of DPD. The patient responded favourably to combined inhNO, intravenous DPD and NTG therapy with a marked and sustained reduction of PAP and a systemic hemodynamic stability.

Conclusion: We conclude that: 1) in combination with inhNO, DPD does not augment the inhNO-induced decrease in PAP; 2) DPD improves the hemodynamic profile and elevates cardiac output; 3) therapeutic combination (inhaled NO, NTG, DPD) has a potent effect on pulmonary pressure in cardiac failure patients.

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