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Ann Thorac Surg 2008;86:882-888. doi:10.1016/j.athoracsur.2008.05.014
© 2008 The Society of Thoracic Surgeons
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Jiming Cai
Zhiwei Xu
Yanmin Yang
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Original Articles: Pediatric Cardiac

Nitric Oxide and Milrinone: Combined Effect on Pulmonary Circulation After Fontan-Type Procedure: A Prospective, Randomized Study

Jiming Cai, MD, Zhaokang Su, MD, Zhenying Shi, MD, Yanping Zhou, MD, Zhuoming Xu, MD, Zhiwei Xu, MD, Yanmin Yang, MD*

Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine (Formerly Shanghai Second Medical University), Shanghai, China

Accepted for publication May 5, 2008.

* Address correspondence to Dr Yang, Cardiac Studies, Institute for Biodiagnostics, National Research Council of Canada, 435 Ellice Ave, Winnipeg, Manitoba, R3B 1Y6, Canada (Email: victor.yang{at}nrc-cnrc.gc.ca).

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.

Background: Early morbidity and mortality after Fontan operations are related to the elevation of postoperative pulmonary vascular resistance. Inhalation of nitric oxide (iNO) and intravenous milrinone are two options capable of reducing pulmonary vascular resistance. We hypothesized that their combined use could maximally stabilize the pulmonary circulation after Fontan operation.

Methods: Forty-six patients with high pulmonary vascular resistance (transpulmonary pressure gradient >10 mm Hg or central venous pressure >15 mm Hg) and impaired oxygenation after Fontan operation were prospectively randomized into three groups: group Mil (n = 15, milrinone at 0.5 µg · kg–1 · min–1), group iNO (n = 15, iNO at <20 ppm), and group iNO + Mil (n = 16, iNO plus Mil). Pulmonary hemodynamic and oxygenation changes were compared among the three groups.

Results: Inhalation of nitric oxide with milrinone led to (1) the most significant reduction of pulmonary vascular resistance (transpulmonary pressure gradient from 11.26 ± 1.40 mm Hg [baseline] to 7.93 ± 0.90 mm Hg [24-hour use] in group iNO + Mil versus from 11.10 ± 1.38 to 8.69 ± 0.86 mm Hg; p = 0.048 in group iNO and from 11.17 ± 1.41 mm Hg to 9.72 ± 1.32 mm Hg; p < 0.001 in group Mil); (2) the most significant improvement of arterial blood oxygenation (ratio of arterial oxygen partial pressure to inspired fraction of oxygen from 68.88 ± 14.09 to 131.25 ± 15.92 in group iNO + Mil versus from 70.07 ±14.24 to 120.20 ± 15.92; p = 0.047 in group iNO and from 72.60 ± 12.92 to 95.20 ± 13.49; p < 0.001 in group Mil). Time on mechanical ventilation was shortest in group iNO + Mil (p = 0.043).

Conclusions: Combined use of iNO and milrinone optimally stabilized pulmonary hemodynamics after Fontan operation.






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