Inhaled nitric oxide following high-risk corrective congenital heart surgery in infants reduced the risk of pulmonary hypertension

Brian W. McCrindle MD MPH     发表于2001年

Endothelial dysfunction in the pulmonary vascular bed caused by excessive pressure and blood flow can lead to fixed pulmonary vascular obstructive disease and possible inoperability in patients with certain congenital cardiac lesions. Early repair is often undertaken to prevent fixed changes, but the post-operative course may, nonetheless, be complicated by reactive pulmonary hypertensive crises. These are related to ongoing endothelial dysfunction, which may be exacerbated by the effects of cardiopulmonary bypass. Many studies have documented the utility of using inhaled nitric oxide to treat episodes of pulmonary hypertensive crises. This study is a well-designed, randomized, controlled trial that builds on related previous work by the investigators. Good evidence is provided to assert that nitric oxide given prophylactically has a significant clinical impact on post-operative reactive pulmonary hypertension. While not the primary focus, it might have been optimal if the authors had performed analysis to identify a particular high-risk group that may be specifically targeted. Also, before wide-scale adoption, an economic analysis would be necessary. The authors report some concerns about rebound pulmonary hypertension upon weaning from inhaled nitric oxide, but that this did not translate into longer duration of therapy. There is some preliminary evidence to suggest that the use of sildenafil may help prevent rebound pulmonary hypertension with nitric oxide withdrawal.[1] An additional randomized, controlled study of prophylactic inhaled nitric oxide by Day et al did not show a significant beneficial effect, although the definition of a pulmonary hypertensive crisis was more strict and the sample size was much smaller. [2] Pulmonary hypertensive crises were noted in 4/20 control patients vs 3/20 patients treated with 20 ppm of inhaled nitric oxide. This magnitude of effect is not inconsistent with that observed in the current study. It remains to be seen whether this effect justifies the added resources and costs of prophylactic therapy....查看全文