The document provides guidelines for the management of pulmonary hypertension in cardiac surgery patients. It discusses causes of increased pulmonary vascular resistance postoperatively including hypoxia, hypercarbia, acidosis, and pulmonary vasoconstriction. It recommends treating the underlying cause by avoiding factors that cause pulmonary vasoconstriction. For passive pulmonary hypertension, it suggests improving left ventricular contractility and decreasing mitral regurgitation. It also discusses selective pulmonary vasodilators like inhaled nitric oxide, prostacyclin, and iloprost as well as oral sildenafil.

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2. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Increased PVR during postop period:
• SIRS 20
to CPBP (pulmonary vasoconstriction)
• Protamine (pulmonary vasoconstriction)
• Hypoxia (pulmonary vasoconstriction)
• ↑ pCO2, acidemia (pulmonary vasoconstriction)
• PEEP, ventilator dysynchrony (pulmonary vasoconstriction)
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;24:374-382.
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:296-308.

3. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Pulmonary vasoconstriction:
• Hyperventilation counteracts hypoxic pulmonary vasoconstriction in man
• PAP increased (p < 0.001) with elevations in PaCO2
• Marked decrease in SVR with increasing PaCO2
• Blood pressure decreased (p < 0.001) with ↑ in PaCO2 up to 50 mmHg
Bindslev L, et al. Hypoxic pulmonary vasoconstriction in man: effects of hyperventilation. Acta Anesthesiol
Scand. 1985;29:547-551.
Avidan MS, et al. Mild hypercapnia after uncomplicated heart surgery is not associated with hemodynamic
compromise. J Cardiothorac Vasc Anesth 2007;21:371-374.

4. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Pulmonary vasoconstriction:
• Can precipitate acute right heart failure
• More frequent conditions: MVR, CHD with L → R shunt
• Heart Tx, Lung Tx
• Pneumonectomy
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;24:374-382.

5. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Treatment of the underlying cause:
• Pulmonary vasoconstriction (pre-capillary PH)
Avoidance of hypoxemia, hypercarbia & acidosis
Sedation, analgesia & muscle relaxants
Selective pulmonary vasodilatation
• Passive pulmonary hypertension with ↑ LAP (post-capillary PH)
Improve LV contractility
Decrease degree of MR
Nesiritide
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;24:374-382.

6. MANAGEMENT OF LEFT HEART FAILURE WITH
SECONDARY PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Nesiritide :
 Perioperative management of patients with severe MR, severe LV
dysfunction and secondary pulmonary hypertension
 Expected mortality by EuroSCORE 26%
 Preoperative treatment with Nesiritide for 13-55 hr (mean=24 hr)
 Postoperative treatment with Nesiritide for 2-80 hr (mean=22 hr)
 Improves postop renal function and survival
Salzberg SP, et al: High-Risk mitral valve surgery. Perioperative hemodynamic optimization with Nesiritide
(BNP). Ann Thorac Surg 2005;80:502-506.

7. MANAGEMENT OF LEFT HEART FAILURE WITH
SECONDARY PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Nesiritide :
Salzberg SP, et al: High-Risk mitral valve surgery. Perioperative hemodynamic optimization with Nesiritide
(BNP). Ann Thorac Surg 2005;80:502-506.

8. MANAGEMENT OF LEFT HEART FAILURE WITH
SECONDARY PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Nesiritide:
Hemodynamic benefits: ↓ PAP, ↓ CVP, ↑ CO
Improves postop renal function
Decreases respiratory failure and AF
Decreases LOS
Decreases mortality
Blais DM. Nesiritide Compared with Milrinone for Cardiac Surgery. Ann Pharmacother 2007;41:502-504.
Mentzer RM, et al: Effects of Perioperative Nesiritide in Patients With Left Ventricular Dysfunction
Undergoing Cardiac Surgery. The NAPA Trial. J Am Coll Cardiol 2007;49:716-726.

9. MANAGEMENT OF LEFT HEART FAILURE WITH
SECONDARY PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Nesiritide (Natrecor):
• Standard Dilution:
[1.5 mg] [250 ml D5W, D5½S or NS]
• Loading dose:
2 mcg/kg over 20 min
• Followed by 0.01 mcg/kg/min
• Continuous infusion x 48 hours

10. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Selective pulmonary vasodilatation:
• Right heart failure resistant to therapy
• Pre-existing pulmonary hypertension
* Inhaled Nitric Oxide (iNO)
* Inhaled Prostacyclin (iPGI2)
* Inhaled Iloprost
* Sildenafil
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;24:374-382.

11. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Inhaled Nitric Oxide (iNO):
• Usual dose: 5 - 40 ppm
• Selective pulmonary vasodilator
• Does not cause systemic hypotension
• Distributed only to ventilated portions of the lungs
• Requires accurate gas delivery system to monitor NO and NO2
• May cause methemoglobinemia
• May cause rebound pulmonary hypertension
• Expensive
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;24:374-382.

12. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Inhaled prostacyclin (iPGI2):
• Usual dose: 5 - 50 ng/kg/min
• Short-acting selective pulmonary vasodilator
• Equally effective as iNO
• Does not cause systemic hypotension
• Distributed only to ventilated portions of the lungs
• May cause thrombocytopenia
• Does not cause rebound pulmonary hypertension
• Inexpensive
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;24:374-382.

13. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Inhaled prostacyclin (iPGI2):
• Usual starting dose: 50 ng/kg/min
• Weaning (3-4 days): 25-10-5-3 ng/kg/min
• Selective pulmonary vasodilator
• Does not cause systemic hypotension
• Equally effective as iNO
• Prolonged use is not associated with systemic effects
• Readily available in most hospitals
• Inexpensive
Lowson SM, et al: Inhaled prostacyclin for the treatment of pulmonary hypertension after cardiac surgery.
Crit Care Med 2002; 30:2762-2764.

14. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Selective pulmonary vasodilatation:
n= dobut norepi reop intub mort
IV dilators 18 4.1 0.03 2 31 2
iNO group 21 2.9 0 0 20 1
iPGI2 group 19 3.1 0 1 18 0
Fattouch K, et al: Treatment of pulmonary hypertension in patients undergoing cardiac surgery with
cardiopulmonary bypass: a randomized, prospective, double-blind study. J Cardiovasc Med 2006;
7:119-123.

15. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Inhaled prostacyclin (iPGI2):
• Equally effective as iNO
• Neither iPGI2 nor its metabolites have toxic effects
• Possible thrombocytopenia but does not increase risk of bleeding
• Easy administration
• Inexpensive
Fattouch K, et al: Treatment of pulmonary hypertension in patients undergoing cardiac surgery with
cardiopulmonary bypass: a randomized, prospective, double-blind study. J Cardiovasc Med 2006;
7:119-123.

16. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Inhaled iloprost:
• Usual dose: 12 - 20 mcg q 4-6 hr
• Intermittent nebulization
• Longer half-life selective pulmonary vasodilator
• Equally effective as iNO
• Does not cause systemic hypotension
• May cause thrombocytopenia
• Does not cause rebound pulmonary hypertension
• Intermittent nebulization requires periodic interruption of PEEP
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;24:374-382.

17. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Inhaled iloprost:
Rex S, et al: Inhaled iloprost to control pulmonary artery hypertension in patients undergoing mitral valve
surgery: a prospective, randomized-controlled trial. Acta Anaesthesiol Scand 2008; 52: 65-72.

18. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Sildenafil:
• Equally effective as iNO
• Increases cardiac output
• Does not increase wedge pressure
• Oral or IV administration
• Inexpensive
Michelakis E, et al: Oral Sildenafil is an effective and specific pulmonary vasodilator in patients with
pulmonary arterial hypertension. Comparison with inhaled nitric oxide. Circulation 2002;105:2398-2403.

19. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Sildenafil:
Michelakis E, et al: Oral Sildenafil is an effective and specific pulmonary vasodilator in patients with
pulmonary arterial hypertension. Comparison with inhaled nitric oxide. Circulation 2002;105:2398-2403.

20. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Sildenafil:
Namachivayam P, et al. Sildenafil prevents rebound pulmonary hypertension after withdrawal of nitric oxide
in children. Am J Respir Crit Care 2006;174:1042-1047.

21. GUIDELINES FOR MANAGEMENT
OF PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Sildenafil:
• Initial dose: 50-75 mg PO 10-30 min before induction of anesthesia
• Maintenance dose: 25 mg BID - 50 mg TID
• Pediatric dose: 0.4 mg/kg before discontinuing iNO
Shim JK, et al. Effect of oral sildenafil citrate on intraoperative hemodynamics in patients with pulmonary
hypertension undergoing valvular heart surgery. J Thorac Cardiovasc Surg 2006;132:1420-1425.
Trachte AL, et al: Oral sildenafil reduces pulmonary hypertension after cardiac surgery. Ann
Thorac Surg 2005;79:194-197.