Original Articles
Hemodynamic Effects of Human Atrial Natriuretic Peptide After Modified Fontan Procedure

https://doi.org/10.1016/S0003-4975(97)01352-0Get rights and content

Abstract

Background. Reduction of pulmonary vascular resistance and maintenance of urine output are important after the modified Fontan procedure. Atrial natriuretic peptide (ANP) has the effects of a vasodilator (including the pulmonary arteries) and a physiologic diuretic, and newly synthesized human ANP is available. We measured plasma ANP levels before and after the Fontan procedure and examined the effects of human ANP on hemodynamic parameters after the Fontan procedure.

Methods. Eight patients, aged 2 to 15 years, underwent the Fontan procedure (atriopulmonary connection). Blood samples were taken before and 3 hours after operation, and plasma ANP levels were measured by radioimmunoassay. The correlation between central venous pressure and ANP was examined. Human ANP was infused intravenously at a dosage of 0.1 μg · kg−1 · min−1 for 1 hour after the Fontan procedure under controlled ventilation and another blood sample was obtained. Urine volume and central venous pressure were measured, and pulmonary vascular resistance and the cardiac index were calculated by the thermodilution catheter method before and after human ANP infusion. One hour after human ANP infusion was discontinued, the evaluation was repeated. No other diuretics were given and the infusion rates of catecholamine were kept constant during these measurements.

Results. Plasma ANP levels before and after the Fontan procedure were 29.1 and 54.9 pg/mL, respectively, and a positive correlation was obtained between central venous pressure and plasma ANP levels (r = 0.661, p < 0.05). Human ANP infusion significantly decreased central venous pressure and pulmonary vascular resistance, and increased urine volume and the cardiac index, whereas the plasma ANP level was elevated to 617.5 pg/mL. Systemic blood pressure did not change significantly.

Conclusions. Atrial natriuretic peptide is secreted in response to elevated central venous pressure after the Fontan procedure, but its concentration might not be sufficient. Human ANP can be a therapeutic choice after the Fontan procedure as a physiologic diuretic and a pulmonary vasodilator.

Section snippets

Patients

Eight children underwent the Fontan procedure (connection of the right atrial appendage to the pulmonary artery), 1 for pulmonary atresia with an intact ventricular septum, 1 for pure pulmonary stenosis, 1 for a criss-crossed heart, 2 for a common atrioventricular canal, 1 for a single right ventricle, and 1 for a single left ventricle. The children ranged in age from 2 to 15 years (mean, 7.6 ± 1.1 years). Permission to conduct the study was granted by the Ethical Committee of the Tokyo Women’s

Plasma Atrial Natriuretic Peptide

The plasma ANP level was 29.1 ± 15.6 pg/mL before operation and increased significantly to 54.9 ± 16.3 pg/mL after operation (Fig. 1). The plasma BNP level increased slightly after operation, but the difference did not reach statistical significance. After the administration of HANP for 1 hour, the plasma ANP level increased to 617.5 ± 132.4 pg/mL.

Correlation Between Central Venous Pressure and Plasma Atrial Natriuretic Peptide Levels Before and After Operation

There was a statistically significant positive correlation between plasma ANP levels and CVP before and after operation (r = 0.720, p < 0.05) (Fig. 2

Comment

In the natriuretic peptide family, ANP and BNP are derived from the heart and are strongly associated with the pathophysiology of heart failure [4]. Atrial natriuretic peptide, with 28 amino acid residues, has multiple biologic actions. It is a diuretic, a natriuretic, a vasodilator of the systemic and pulmonary arteries, and an inhibitor of the secretion of aldosterone [2]. Brain natriuretic peptide, with 32 amino acid residues, plays an important role in regulating somatic fluid and blood

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