Original article: cardiovascular
Inhaled iloprost in patients with chronic thromboembolic pulmonary hypertension: effects before and after pulmonary thromboendarterectomy

https://doi.org/10.1016/S0003-4975(03)00728-8Get rights and content

Abstract

Background

In primary pulmonary hypertension, aerosolized prostanoids selectively reduce pulmonary vascular resistance and improve right ventricular function. In this study, hemodynamic effects of inhaled iloprost, a stable prostacyclin analogue, were evaluated in patients with chronic thromboembolic pulmonary hypertension (CTEPH) before and early after pulmonary thromboendarterctomy (PTE).

Methods

Ten patients (mean age 49 years old [32 to 70 years old], New York Heart Association functional class III and IV) received a dose of 33 μg aerosolized iloprost immediately before surgery (T1), after intensive care unit admission (T2), and 12-hours postoperatively (T3). Effects on pulmonary and systemic hemodynamics and gas exchange were recorded and compared with preinhalation baseline values.

Results

Preoperatively, inhaled iloprost did not significantly change mean pulmonary artery pressure (mPAP), cardiac index (CI), or pulmonary vascular resistance (PVR). Postoperatively, inhaled iloprost induced a significant reduction of mPAP and PVR and a significant increase of CI at T2 and T3. Preinhalation versus postinhalation PVR was as follows: at T1, 847 versus 729 dynes · s · cm−5, p = 0.45; at T2, 502 versus 316 dynes · s · cm−5, p = 0.008; and at T3, 299 versus 227 dynes · s · cm−5, p = 0.004.

Conclusions

In patients with CTEPH, inhalation of iloprost elicits no significant pulmonary vasodilation before surgery, and may have detrimental effects on systemic hemodynamics. Postoperatively, it significantly reduces mPAP and PVR, and enhances CI. Following PTE, inhalation of iloprost is useful to improve early postoperative hemodynamics.

Section snippets

Patients and methods

With approval from the state’s ethics committee and written informed patient consent [20], we designed the study as an open-label, observational trial in 10 patients with CTEPH (4 women, 6 men; mean age 49 years old [range 32 to 70 years old], New York Heart Association (NYHA) functional class III [n = 6] and class IV [n = 4]) undergoing PTE. Each patient served as his or her own control. Emergency or redo procedures were excluded.

Results

Biometric and hemodynamic data are summarized in Table 1. There were no significant changes in hemodynamics and gas exchange observed during saline inhalation at T1, T2, or T3, respectively (Table 2). A steady state was achieved before iloprost inhalation.

Comment

PTE is considered the treatment of choice for symptomatic patients with CTEPH. Reasons for early postoperative death after PTE include persistent pulmonary hypertension with right heart failure, respiratory failure due to pulmonary reperfusion edema, or both. Treatment of these conditions is primarily supportive. In the setting of respiratory failure, pulmonary hypertension, compromised right ventricular and sustained left ventricular function, the inhalational administration of nitric oxide

Acknowledgements

We thank Dr John D. Puskas, Emory University Clinic (Atlanta, GA), for his helpful suggestions regarding the manuscript.

References (46)

  • G.E. D’Alonzo et al.

    Survival in patients with primary pulmonary hypertension. Results from a national prospective registry

    Ann Intern Med

    (1991)
  • K.E. Purdy et al.

    Iloprost inhibits inositol-1,4,5-trisphosphate-mediated calcium mobilization stimulated by angiotensin II in cultured preglomerular vascular smooth muscle cells

    J Am Soc Nephrol

    (2001)
  • A. Lockinger et al.

    Protection against gas exchange abnormalities by pre-aerosolized PGE1, iloprost and nitroprusside in lung ischemia-reperfusion

    Transplantation

    (2001)
  • K. Trager et al.

    Hepatic O2 exchange, and liver energy metabolism in hyperdynamic porcine endotoxemia. effects of iloprost

    Intensive Care Med

    (2000)
  • J. Geiger et al.

    Inhibition of cADP-ribose formation produces vasodilation in bovine coronary arteries

    Hypertension

    (2000)
  • S.W. Jamieson

    Treatment of pulmonary hypertension due to chronic pulmonary thromboembolism

    Jpn J Phlebol

    (1995)
  • P.F. Fedullo et al.

    Chronic thromboembolic pulmonary hypertension

    N Engl J Med

    (2001)
  • M. Welte et al.

    PGI2 aerosol versus nitric oxide for selective pulmonary vasodilation in hypoxic pulmonary vasoconstriction

    Eur Surg Res

    (1993)
  • K. Moser et al.

    Chronic major-vessel thromboembolic pulmonary hypertension

    Circulation

    (1990)
  • M.B. Pitton et al.

    Hemodynamic effects of nonionic contrast bolus injection and oxygen inhalation during pulmonary angiography in patients with chronic major-vessel thromboembolic pulmonary hypertension

    Circulation

    (1996)
  • W.M. Zapol et al.

    Pulmonary hypertension in severe acute respiratory failure

    N Engl J Med

    (1977)
  • S. Estanove et al.

    Inhaled nitric oxide. therapeutic applications in cardiac surgery

    Bull Acad Natl Med

    (2000)
  • F. Parquin et al.

    The use of NO in prevention of reperfusion edema following pulmonary thromboendarterectomy

    Am J Respir Crit Care Med

    (2002)

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    Copyright © 2003 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.