Inhaled nitric oxide in the preoperative evaluation of pulmonary hypertension in heart transplant candidates.

OBJECTIVE: The goal of this study was to evaluate the efficacy of 100% oxygen and inhaled nitric oxide (iNO) in decreasing pulmonary vascular resistance (PVR) and transpulmonary gradient (TPG) in dilated cardiomyopathy patients being evaluated for orthotopic heart transplantation (OHT); who, despite maximal intravenous (IV) dilator therapy, had persistent moderate-to-severe pulmonary hypertension. DESIGN: A prospective nonrandomized clinical study. SETTING: University hospital, major transplant center. PARTICIPANTS: Twenty-one adult patients undergoing OHT evaluation. INTERVENTIONS: One hundred percent oxygen and iNO at 20 and 40 ppm were sequentially administered to the patients once they were optimized with IV vasodilators and inotropes. MEASUREMENTS AND MAIN RESULTS: Although no significant change was noted with oxygen, iNO 20 ppm reduced the mean pulmonary artery pressure (44.1 +/- 1.7 to 38.6 +/- 1.8 mmHg, p < 0.05), PVR index (823 +/- 47 to 621 +/- 55 dyne/s/m(2)/cm(5), p < 0.05), TPG (22.4 +/- 1.4 to 17.0 +/- 1.5 mmHg, p < 0.05), and right ventricular stroke work index (14.7 +/- 1.2 to 11.1 +/- 1.2 g . m/m(2)/beat, p < 0.05). In 13 of 21 patients, PVR decreased by greater than 25% after iNO therapy. Nine of these patients had PVR and TPG decrease to levels considered acceptable for OHT listing. CONCLUSIONS: iNO can further improve right ventricular hemodynamics even after presumed optimization with IV vasodilators and serves as a test of PVR reversibility during the preoperative assessment of OHT candidates.

Conscious sedation for interventional procedures: a practical guide.

Sedation is often used in interventional procedures to minimize discomfort, improve the patient's experience, and reduce the risk of procedural complications by assuring nonmobility and compliance of the patient. Sedation, however, adds a new dimension to the procedure by compromising the patients' normal protective mechanisms and carries the potential of cardiac, respiratory, and cognitive complications. Interventional procedures could be performed under local anesthesia with or without sedation, or under general anesthesia. Sedation itself could be categorized into minimal, moderate, or deep sedation. The choice generally depends on patient factors such as age, cardiovascular stability, pain tolerance, and procedural factors such as complexity, extent, and degree of induced pain. In longer and more extensive procedures on more fragile patients, the assistance of an anesthesiologist will be required. The purpose of this article is to provide a basic understanding and a practical guideline for minimal and moderate sedation for the interventionalist contemplating to administer sedation for less involved procedures.

Pulse contour analysis for cardiac output monitoring in cardiac surgery for congenital heart disease.

UNLABELLED: Conventional methods of cardiac output monitoring using pulmonary artery catheters may not be feasible in patients with congenital heart disease because of patients' small size or aberrant anatomy. We studied the accuracy of a new device, which uses pulse contour analysis to measure continuous cardiac output, in children and adults undergoing congenital heart surgery. Sixteen patients, median ages 7 yr old, were included in this prospective study. One-hundred-ninety-one data points were obtained in the pre- and postcardiopulmonary bypass periods and in the first 12 h after intensive care unit admission. We evaluated the relationship between cardiac index (CI) derived from transpulmonary thermodilution (TDCI) and CI derived from pulse contour analysis (PCCI). Bias and limits of agreement between TDCI and PCCI over all time periods were 0.1 +/- 1.94, indicating a wide dispersion of the data. Coefficient of correlation (r) between the TDCI and PCCI was 0.7. Although in previous studies, PCCI has been suggested to be accurate in adult cardiac surgery, we found it to be less reliable in our study patients, even after shunt correction. The relationships of the volume and pressure based measures of preload, intrathoracic blood volume index (ITBI), and central venous pressure with CI were also investigated. After repair, correlation (r) between PCCI or TDCI and ITBI (0.56 and 0.71, respectively) was better than that between PCCI or TDCI and CVP (0.16 and 0.11, respectively), indicating greater validity of ITBI as a measure of preload. IMPLICATIONS: Our results suggest that the pulse contour analysis cardiac output (CO) monitoring in patients undergoing congenital heart surgery may not provide as accurate or reliable measures of CO as previously suggested. The volume-based variable of preload intrathoracic blood volume index (ITBI) has better correlation with cardiac index (CI) than the central venous pressure, suggesting that ITBI may be a better indicator of preload.