Using Inhaled Iloprost to Wean from Cardiopulmonary Bypass After Implanting a Left Ventricular Assist Device

Winterhalter, Michael; Fischer, Stefan; Tessmann, R; Goerler, A.; Piepenbrock, S.; Haverich, Axel; Strueber, M.

doi:10.1213/01.ane.0000227219.60581.f2

Cited by 8 publications

(6 citation statements)

References 7 publications

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“…The first described use of inhaled iloprost for treatment of acute RVF was in two HeartMate II recipients . In these patients, a single 20‐μg dose of inhaled iloprost was used intraoperatively as rescue therapy in the setting of PAH and RVF.…”

Section: Summary Of the Evidencementioning

confidence: 99%

“…The first described use of inhaled iloprost for treatment of acute RVF was in two HeartMate II recipients. 58 In these patients, a single 20-lg dose of inhaled iloprost was used intraoperatively as rescue therapy in the setting of PAH and RVF. In both cases, mPAP and measures of RV function improved immediately, and both patients were successfully weaned from CPB without mechanical RV support.…”

Section: Iloprostmentioning

confidence: 99%

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Inhaled Pulmonary Vasodilator Therapy for Management of Right Ventricular Dysfunction after Left Ventricular Assist Device Placement and Cardiac Transplantation

et al. 2017

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Right ventricular failure (RVF) after cardiac transplant (CTX) or implantation of a continuous-flow left ventricular assist device (CF-LVAD) is associated with significant postoperative morbidity and mortality. A variety of modalities have been used to treat postoperative RVF, including management of volume status, intravenous inotropes and vasodilators, and right-sided mechanical support. Inhaled vasodilator agents are a unique treatment option aimed at minimizing systemic absorption by delivering therapy directly to the pulmonary vasculature. Current LVAD and CTX guidelines endorse inhaled vasodilators for managing postoperative RVF; however, no guidance is offered regarding agent selection, dosing, or administration. A review of the current literature confirms that inhaled pulmonary vasodilator agents have been shown to decrease pulmonary artery pressure when used in the perioperative period of CF-LVAD implant or CTX. However, the literature regarding the potential impact on clinical outcomes (e.g., survival or risk of developing RVF) is lacking with these medications. Based on our assessment of the literature, we suggest that when RVF occurs in the setting of a normal pulmonary vascular resistance (PVR), traditional inotropic therapy (e.g., dobutamine) should be used. Conversely, if the PVR is elevated (> 250 dynes/sec/cm 5 or 3 Wood units), or the patient has other evidence of a high right ventricular afterload (i.e., a transpulmonary gradient > 12 mm Hg), then an inhaled pulmonary vasodilator would be the preferred initial pharmacologic agent. Drug selection depends largely on the institution's capacity to safely prepare and administer the medication, along with formulary considerations, such as the high costs associated with inhaled iloprost and inhaled nitric oxide. KEY WORDS heart transplantation, left ventricular assist device, right heart failure, pulmonary arterial hypertension, inhaled pulmonary vasodilators. (Pharmacotherapy 2017;37(8):944-955)

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Section: Summary Of the Evidencementioning

confidence: 99%

Section: Iloprostmentioning

confidence: 99%

Inhaled Pulmonary Vasodilator Therapy for Management of Right Ventricular Dysfunction after Left Ventricular Assist Device Placement and Cardiac Transplantation

et al. 2017

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“…In patients with intraoperative severe acute right heart failure after implantation of a LVAD, successful weaning from the CPB was possible after inhaled iloprost was added [24]. …”

Section: Advantage Of Inhaled Vasodilatorsmentioning

confidence: 99%

Management of Adult Patients with Perioperative Pulmonary Hypertension: Technical Aspects and Therapeutic Options

2010

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Pulmonary hypertension (PH) is an independent risk factor for increased mortality in patients undergoing heart surgery. Existing chronic PH may be exacerbated by acute post-bypass PH, and this can lead to acute right ventricular failure. The prevention and treatment of right ventricular failure in cardiac surgery is based on three principles: optimize right ventricular preload, improve right ventricular contractility, minimize right ventricular afterload. The last of these may involve specific measures such as the inhalation of nitric oxide (NO) or of the stable prostacyclin analogue iloprost. The advantage of these inhalable substances is their pulmonary selectivity, and the subsequent reduction in systemic side effects. In order to avoid disastrous results in high-risk cardiac surgical patients, intra- and post-operative monitoring with pressure lines, a qualified team that pays attention to details, and an aggressive and early treatment in the operating room with inhaled iloprost and/or NO is necessary. The philosophy of ‘wait and see’ should be abandoned in favour of ‘be suspicious and act early’. In a prospective randomized trial, the efficacies of inhaled iloprost and of inhaled NO in the therapy of PH immediately following weaning from cardiopulmonary bypass in cardiac surgical patients were compared. Iloprost proved to be significantly more effective with respect to mean pulmonary arterial pressure, pulmonary vascular resistance, and cardiac output than inhaled NO.

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“…In the case of persistent pulmonary hypertension after weaning from a cardiopulmonary bypass, iloprost has also been found to be highly effective [5][6][7][8][9][10][11][12].…”

Section: Iloprost In Cardiac Surgerymentioning

confidence: 99%

Iloprost—different indications and different national experiences in treating pulmonary hypertension

Bonderman

Schulz

Winterhalter

et al. 2010

Clin Res Cardiol Suppl

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This paper describes experiences and clinical pilot studies with inhaled iloprost, the stable prostacyclin analog, for different (mostly not approved) indications, such as right heart failure, bridging to transplant, cardiac surgery, and prevention of contrast-induced nephropathy. Furthermore, clinical experiences with the use of inhaled iloprost in children with pulmonary arterial hypertension (PAH) are described, as well as the administration of inhaled iloprost after pediatric congenital heart defect corrective surgery. Latest data and experience in using inhaled iloprost and other specific pulmonary hypertension (PH) treatments in different European and Asian countries are presented.

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Using Inhaled Iloprost to Wean from Cardiopulmonary Bypass After Implanting a Left Ventricular Assist Device

Cited by 8 publications

References 7 publications

Inhaled Pulmonary Vasodilator Therapy for Management of Right Ventricular Dysfunction after Left Ventricular Assist Device Placement and Cardiac Transplantation

Inhaled Pulmonary Vasodilator Therapy for Management of Right Ventricular Dysfunction after Left Ventricular Assist Device Placement and Cardiac Transplantation

Management of Adult Patients with Perioperative Pulmonary Hypertension: Technical Aspects and Therapeutic Options

Iloprost—different indications and different national experiences in treating pulmonary hypertension

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