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CLINICAL RESEARCH

Hemodynamic effects of inhaled nitric oxide in right ventricular myocardial infarction and cardiogenic shock

Ignacio Inglessis, MD^*, Jordan T. Shin, MD^*,, John J. Lepore, MD^*, Igor F. Palacios, MD, FACC^*, Warren M. Zapol, MD, Kenneth D. Bloch, MD^*, and Marc J. Semigran, MD^*,*

^* Cardiology Division
Cardiovascular Research Center
Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA

Manuscript received February 4, 2004; revised manuscript received April 30, 2004, accepted May 4, 2004.

^* Reprint requests and correspondence: Dr. Marc J. Semigran, Massachusetts General Hospital, Bigelow 842, 32 Fruit Street, Boston, Massachusetts 02114 (Email: msemigran{at}partners.org).

OBJECTIVES: We sought to determine whether or not inhaled nitric oxide (NO) could improve hemodynamic function in patients with right ventricular myocardial infarction (RVMI) and cardiogenic shock (CS).

BACKGROUND: Inhaled NO is a selective pulmonary vasodilator that can decrease right ventricular afterload.

METHODS: Thirteen patients (7 males and 6 females, age 65 ± 3 years) presenting with electrocardiographic, echocardiographic, and hemodynamic evidence of acute inferior myocardial infarction associated with RVMI and CS were studied. After administration of supplemental oxygen (inspired oxygen fraction [F_iO₂] = 1.0), hemodynamic measurements were recorded before, during inhalation of NO (80 ppm at F_iO₂ = 0.90) for 10 min, and 10 min after NO inhalation was discontinued (F_iO₂ = 1.0).

RESULTS: Breathing NO decreased the mean right atrial pressure by 12 ± 3%, mean pulmonary arterial pressure by 13 ± 2%, and pulmonary vascular resistance by 36 ± 8% (all p < 0.05). Nitric oxide inhalation increased the cardiac index by 24 ± 11% and the stroke volume index by 23 ± 12% (p < 0.05). The NO administration did not change systemic arterial or pulmonary capillary wedge pressures. Contrast echocardiography identified three patients with a patent foramen ovale and right-to-left shunt flow while breathing at F_iO₂ = 1.0. Breathing NO decreased shunt flow by 56 ± 5% (p < 0.05) and was associated with markedly improved systemic oxygen saturation.

CONCLUSIONS: Nitric oxide inhalation results in acutehemodynamic improvement when administered to patients with RVMI and CS.

Abbreviations and Acronyms   CI = cardiac index   CS = cardiogenic shock   FiO2 = inspired oxygen fraction   HR = heart rate   LV = left ventricle/ventricular   MI = myocardial infarction   NO = nitric oxide   PA = pulmonary artery/arterial   PCI = percutaneous coronary intervention   PCWP = pulmonary capillary wedge pressure   PVR = pulmonary vascular resistance   RA = right atrium/atrial   RV = right ventricle/ventricular   RVMI = right ventricular myocardial infarction   SAP = systemic arterial pressure   TIMI = Thrombolysis In Myocardial Infarction

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