Tratamiento con óxido nítrico, levosimendán y sildenafilo en paciente con disfunción ventricular derecha e hipertensión pulmonar severa tras cirugía cardíaca / Nitrid oxide, levosimendan and sildenafile in a patient with right ventricle dysfunction and severe pulmonary hypertension after cardiac surgery

La hipertensión pulmonar (HTP), y como consecuencia la disfunción del ventrículo derecho, son importantes factores de riesgo de morbimortalidad en pacientes sometidos a cirugía cardíaca. El tratamiento de la HTP y la disfunción del ventrículo derecho debe ir enfocado a proteger la función cardíaca. Como objetivos principales del manejo hemodinámico se incluye mantener una adecuada precarga del ventrículo derecho, mejorar su función, reducir la poscarga del ventrículo derecho y las resistencias vasculares pulmonares con vasodilatadores. La terapia combinada con fármacos vasodilatadores que presentan diferentes mecanismos de acción es una opción terapéutica emergente en el tratamiento de la HTP. Presentamos el caso de una mujer de 65 años diagnosticada de insuficiencia mitral, aórtica, tricuspídea y con una dilatación de aorta ascendente con HTP sistólica de 115 mmHg estimada mediante ecografía. Se le practicó una plastia mitral, aórtica, tricuspídea y una aortoplastia. En el perioperatorio presentó disfunción del ventrículo derecho e HTP, siendo tratada con óxido nítrico, sildenafilo intravenoso y levosimendán. La evolución fue satisfactoria, manteniéndose el control de la funcionalidad cardíaca y de la HTP sin presentar fenómenos de hipotensión arterial sistémica ni alteraciones respiratorias relevantes (AU)

Pulmonary hypertension (PHT) and the resulting right ventricle dysfunction are important risk factors in patients who undergo cardiac surgery. The treatment of PHT and right ventricle dysfunction should be focused on maintaining the correct right ventricle after load, improving right ventricle function and reducing the right ventricle pre-load and therefore reducing pulmonary vascular resistance by means of vasodilators. A combined therapy of vasodilators and medicines which have different mechanisms of action, is becoming an option for the treatment of PHT. We present a 65 year old woman that suffered from mitral regurgitation, aortic valve disease, tricuspid and ascending aortic dilation with 115 mmHg of pulmonary artery pressure (by ultrasound evaluation). The patient was operated on of mitral, aortic valve and tricuspid plastia and proximal aortic artery plastia as well. Previosly to surgery the patient suffered right ventricle dysfunction and PHT and was treated with nitric oxide, intravenous sildenafil and levosimendan. Subsequent evolution was satisfactory, PHT being controlled, without arterial hypotension nor respiratory alterations (AU)

[Nitrid oxide, levosimendan and sildenafile in a patient with right ventricle dysfunction and severe pulmonary hypertension after cardiac surgery]. / Tratamiento con óxido nítrico, levosimendán y sildenafilo en paciente con disfunción ventricular derecha e hipertensión pulmonar severa tras cirugía cardíaca.

Pulmonary hypertension (PHT) and the resulting right ventricle dysfunction are important risk factors in patients who undergo cardiac surgery. The treatment of PHT and right ventricle dysfunction should be focused on maintaining the correct right ventricle after load, improving right ventricle function and reducing the right ventricle pre-load and therefore reducing pulmonary vascular resistance by means of vasodilators. A combined therapy of vasodilators and medicines which have different mechanisms of action, is becoming an option for the treatment of PHT. We present a 65 year old woman that suffered from mitral regurgitation, aortic valve disease, tricuspid and ascending aortic dilation with 115mmHg of pulmonary artery pressure (by ultrasound evaluation). The patient was operated on of mitral, aortic valve and tricuspid plastia and proximal aortic artery plastia as well. Previosly to surgery the patient suffered right ventricle dysfunction and PHT and was treated with nitric oxide, intravenous sildenafil and levosimendan. Subsequent evolution was satisfactory, PHT being controlled, without arterial hypotension nor respiratory alterations.

[Mortality following cardiac surgery in the National Health Service Hospitals of the Community of Valencia in 2007: a descriptive analysis]. / Análisis descriptivo de mortalidad en cirugía cardiaca en los hospitales públicos de la Comunidad Valenciana en el año 2007.

OBJECTIVE: To analyze clinical records of cardiac surgery patients in an attempt to identify factors associated with mortality in the postoperative critical care units of the public health service hospitals in the Community of Valencia, Spain, in 2007. METHODS: Retrospective study of cases from January 1, 2007 to December 31, 2007. The charts of all patients who underwent cardiac surgery with or without extracorporeal circulation were reviewed. A data collection protocol was followed to obtain information on age, sex, body mass index (BMI), presurgical risk factors, type of surgery, duration of extracorporeal circulation, duration of ischemia, cause of death, and length of stay in the postoperative critical care unit. RESULTS: The study population consisted of 2113 patients at 5 public hospitals; 124 patients (70 men, 54 women) died. The mean (SD) age was 70 (9.43) years (range, 36-91 years). The mean BMI was 28.19 kg/m2 (maximum, 42 kg/m2). The mean Euroscore was 21.92 (maximum, 94.29). Hypertension was present as a preoperative risk factor in most patients (74.2%); dyslipidemia was present in 51.6%, diabetes mellitus in 38.7%, stroke in 73%, and renal failure in 2.4%. It was noteworthy was that the group who underwent coronary revascularization had the highest mortality rate (nearly 35% of the 124 patients). The next highest mortality rate (19.4%) was in patients who had combined procedures (valve repair or substitution plus coronary revascularization). Mortality was 18.5% in the group undergoing aortic valve surgery and 11.3% in those undergoing mitral valve surgery. The mean duration of extracorporeal circulation was 148.63 minutes. The mean duration of myocardial ischemia was 94.91 minutes. The most frequent cause of death was cardiogenic shock (54.8%). This was followed by distributive shock (29.8%) and hemorrhagic shock (8.9%). The mean length of stay in the postoperative critical care unit was 13.6 days. Overall mortality was 5.87%. CONCLUSIONS: The highest mortality rate among cardiac surgery patients in postoperative critical care units in hospitals in the Community of Valencia in 2007 was in patients who underwent coronary revascularization. The most prevalent preoperative risk factor was hypertension. Cardiogenic shock and distributive shock were the most frequent causes of death in these patients. A system for classifying risk is needed in order to predict mortality in critical care units and improve perioperative care.