Nitroglycerine improves cardiac functions during gynaecological laparoscopic surgery in patients with valvular heart disease, transesophageal echocardiographic study

ABSTRACT

Gynaecological laparoscopic surgery is being increasingly applied to a variety of operations. In patients with valvular heart disease, there may be a dangerous haemodynamic effects of both Trendelenburg position and abdominal gas insufflation in the form of increased regurgant flow with subsequent decrease in the ejection fraction. With the use of vasodilators [Nitroglycerine] this effect was improved to a great extent with the possibility that we can use the laparoscopic technique in valvular cardiac patients provided that the heart is compensated. We used transesophageal echocardiography [TEE] to monitor cardiac performance, gas embolism, and hemodynamic effects of positioning and pneumoperitoneum in 20 females complaining of regurgant valvular heart disease [mild to moderate mitral, tricusped, or aortic valve regurge], undergoing laparoscopic gynaecological surgical procedures.A four-chamber view was used continuously, except at predetermined intervals, when a complete TEE examination for cardiac function was performed. Other clinical variables recorded include systolic, diastolic, and mean arterial blood pressure; heart rate [HR], pulse oximetric saturations; and end-tidal CO2. Baseline valvular incompetence was seen in 13 of the 16 patients when supine and asleep. After positioning for surgery and induction of pneumoperitoneum, TEE revealed valvular incompetence with regurgitation more pronounced from baseline in 15 of 16 patients. In one patient, gas entered the right atrium from the inferior vena cava, worsening tricuspid regurgitation. Nitroglycerine infusion 1-2 micro g/kg/min was started after abdominal insufflation to evaluate its effects on valvular dysfunction during pneumoperitoneum and Trendelenburg position. Hemodynamic variables and ejection fraction were tested by using repeated-measures analysis of variance for significance [P<0.05]. Trendelenburg position resulted in insignificant increase in heart rate and decrease in mean arterial pressure. Pneumoperitoneum with Trendelenburg position resulted in significant increase in systolic and mean arterial pressure, with significant reduction in ejection fraction. The regurgant flow was significantly increased in all patients as detected by TEE. With the use of nitroglycerine infusion, significant improvement EF, with significant increase in heart rate. Using TEE, the regurgant flow was significantly decreased in all patients after nitroglycerine infusion. Laparoscopic gynaecologic surgical procedures can be performed in patients with mild to moderate valvular regurgitations. Nitroglycerine infusion can be of great help to decrease the regurgant flow which is increased due to both the Trendelenburg position and pneumoperitoneum