CORRESPONDENCE: LETTERS TO THE EDITOR
Does inhaled nitric oxide support the hemodynamic of spontaneous breathing patients with cardiogenic shock related to right ventricular myocardial infarction?
Karim Bendjelid, MD, MS*
* Chef de Clinique Scientifique, Surgical Intensive Care Division, University Hospital of Geneva, CH-1211 Geneva 14, Switzerland (Email: karim.bendjelid{at}hcuge.ch).
We read with great interest the echocardiographic study published by Inglessis et al. (1) concerning hemodynamic effects of inhaled nitric oxide (NO) in right ventricular myocardial infarction (RVMI) and cardiogenic shock (CS). They found that inhaled NO results in acute hemodynamic improvement when administered to patients with RVMI and CS.
We have a major concern with these results. Indeed, although 10 of 13 patients were under positive pressure ventilation, the investigators leave the reader with the feeling that inhaled NO results in significant hemodynamic improvement and a reduction of right to left shunting when administered to all types of patients.
In our opinion, we may expect that the observed NO effect could not be shown in spontaneous breathing patients. Indeed, as stated by the researchers, breathing NO is thought to increase pulmonary venous return and left ventricular filling pressure when cardiac output is decreased (2). Because positive pressure ventilation acts as a circulatory pump (3) and decreases left ventricular transmural pressure, acute left ventricular failure may occur when the lungs are not mechanically assisted.
In this setting, we suggest to Inglessis et al. (1) not to extend their conclusions regarding the hemodynamic inhaled NO effects to spontaneous ventilated patients with acute RVMI and CS.
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References
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1. Inglessis I, Shin JT, Lepore JJ, et al. Hemodynamic effects of inhaled nitric oxide in right ventricular myocardial infarction and cardiogenic shock J Am Coll Cardiol 2004;44:793-798.[Abstract/Free Full Text]
2. Hare JM, Shernan SK, Body SC, Graydon E, Colucci WS, Couper GS. Influence of inhaled nitric oxide on systemic flow and ventricular filling pressure in patients receiving mechanical circulatory assistance Circulation 1997;95:2250-2253.[Abstract/Free Full Text]
3. Beattie C, Guerci AD, Hall T, et al. Mechanisms of blood flow during pneumatic vest cardiopulmonary resuscitation J Appl Physiol 1991;70:454-465.[Abstract/Free Full Text]
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