Effects of Dobutamine on Right Ventricular Function and Pulmonary Circulation in Pulmonary Hypertension During Liver Transplantation

doi:10.1016/j.transproceed.2005.10.045

Transplantation Proceedings

Volume 37, Issue 9, November 2005, Pages 3869-3870

https://doi.org/10.1016/j.transproceed.2005.10.045 Get rights and content

Abstract

Introduction

In the setting of orthotopic liver transplantation (OLT), pulmonary hypertension (PH) affects right ventricular (RV) function. When RV failure occurs, reducing RV afterload, optimizing RV preload, and preserving coronary perfusion through maintenance of systemic blood pressure are the primary goals of intraoperative treatment.

Patients and methods

To verify the effect of dobutamine on RV function and RV-arterial coupling, we compared a group of 9 cirrhotic patients with mild PH treated with OLT to a group of 20 patients with normal mean pulmonary artery pressure (MPAP). All patients received dobutamine (5–10 μg/kg/min) to maintain a cardiac index (CI) >3 L/min/m², during the anhepatic phase. Hemodynamic profile, using a pulmonary artery catheter, was performed before and during dobutamine infusion, studying MPAP, CI, and RV end-diastolic volume index (RVEDVI). RV stroke work index (RVSWI), RV end-systolic elastance (Ees), pulmonary effective elastance (Ea), and RV-arterial coupling efficiency as the Ees/Ea ratio were also calculated.

Results

RV contractility (Ees and RVSWI) and afterload (Ea) were significantly higher among the PH group. In both groups, all the studied variables improved with dobutamine: RV contractility increased, afterload decreased, and thus Ees/Ea coupling markedly increased.

Conclusion

Cirrhotic patients with mild PH who were undergoing OLT still have a reserve of RV contractile performance and pulmonary vasodilation.

Section snippets

Patients and methods

According to the current classification, mild PH is defined as a mean pulmonary artery pressure (MPAP) of 25 to 34 mm Hg.³ We studied nine cirrhotic patients with diagnosed mild PH, treated with OLT, using a piggyback technique (group PH). These patients were compared with 20 cirrhotic patients with normal MPAP (group NPH). All patients received dobutamine (DB) infusions (5–10 μg/kg/min) titrated to maintain cardiac index (CI) >3 L/min/m², during the anhepatic phase. We performed a hemodynamic

Results

RV contractility (Ees and RVSWI) and afterload (Ea) were significantly higher among the PH group. In both groups, all studied variables improved with dobutamine (Table 1).

Discussion

In the early stages of PH, RV contractility is increased; however, in more severe forms, decreased CI indicates RV dysfunction.2, 3 Careful attention to avoid RV failure from acutely elevated RV preload or afterload is a key physiologic tenet to managing PH patients.4, 5 Our study demonstrated that with abnormally increased afterload, preload loses its determinant effects on preload recruitable RVSWI relation, while afterload becomes more important; this occurs in PH patients. At the usual

References (5)

M.M. Hoeper et al.
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Lancet
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P. Kuo
Pulmonary hypertensionconsiderations in the liver transplant candidate
Transpl Int
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There are more references available in the full text version of this article.

Cited by (28)

Critical Care Management of the Patient with Pulmonary Hypertension
2021, Clinics in Chest Medicine
Citation Excerpt :
At higher doses, β2 receptor activation can cause systemic vasodilation and hypotension, which often limits its use at these doses. Dobutamine improves hemodynamics in severe RV infarction and in PH after liver transplantation.37,56 Milrinone, a selective PDE-3 inhibitor, often is used in pulmonary vascular dysfunction due to LV dysfunction or post–cardiac transplant, because it reduces PA pressures and improves RV function.57,58
Three-Dimensional Echocardiography for the Assessment of Right Ventriculo-Arterial Coupling
2018, Journal of the American Society of Echocardiography
Citation Excerpt :
In addition, analysis of the coupling of RV systolic function to afterload was shown to be an independent predictor of survival in patients with PH of variable severities and origin.16,19 Our results show that echocardiography-derived RVAC, PA Ea, and RV Emax measurements, although not strictly interchangeable with the RHC-CMR-derived ones, are in accordance with previously reported invasive and noninvasive results obtained in humans and animals.7,34-36 Although further studies are required to assess their variations during follow-up and their predictive value, these echocardiographic estimates of elastance and RVAC seem promising and may be useful in clinical practice to better apprehend the RV-PA unit.
The analysis of right ventriculo-arterial coupling (RVAC) from pressure-volume loops is not routinely performed. RVAC may be approached by the combination of right heart catheterization (RHC) pressure data and cardiac magnetic resonance (CMR)–derived right ventricular (RV) volumetric data. RV pressure and volume measurements by Doppler and three-dimensional echocardiography (3DE) allows another way to approach RVAC.
Ninety patients suspected of having pulmonary hypertension underwent RHC, 3DE, and CMR (RHC mean pulmonary artery pressure [mPAP] 37.9 ± 11.3 mm Hg; range, 15–66 mm Hg). Three-dimensional (3D) echocardiography was performed in 30 normal patients (echocardiographic mPAP 18.4 ± 3.1 mm Hg). Pulmonary artery (PA) effective elastance (Ea), RV maximal end-systolic elastance (Emax), and RVAC (PA Ea/RV Emax) were calculated from RHC combined with CMR and from 3DE using simplified formulas including mPAP, stroke volume, and end-systolic volume.
Three-dimensional echocardiographic and RHC-CMR measures for PA Ea (3DE, 1.27 ± 0.94; RHC-CMR, 0.71 ± 0.52; r = 0.806, P < .001), RV Emax (3DE, 0.72 ± 0.37; RHC-CMR, 0.38 ± 0.19; r = 0.798, P < .001), and RVAC (3DE, 2.01 ± 1.28; RHC-CMR, 2.32 ± 1.77; r = 0.826, P < .001) were well correlated despite a systematic overestimation of 3DE elastance parameters. Among the whole population, 3D echocardiographic PA Ea and 3D echocardiographic RVAC but not 3D echocardiographic RV Emax were significantly lower in patients with mPAP < 25 mm Hg (n = 41) than in others (n = 79). Among the 90 patients who underwent RHC, 3D echocardiographic PA Ea and 3D echocardiographic RVAC but not 3D echocardiographic RV Emax increased significantly with increasing levels of pulmonary vascular resistance.
Three-dimensional echocardiography–derived PA Ea, RV Emax, and RVAC correlated well with the reference RHC-CMR measurements. Ea and RVAC but not Emax were significantly different between patients with different levels of afterload, suggesting failure of the right ventricle to maintain coupling in severe pulmonary hypertension.
Pulmonary Hypertension in the Intensive Care Unit
2012, Progress in Cardiovascular Diseases
Citation Excerpt :
Doses up to 10 μg kg− 1 min− 1 in patients with left heart failure result in improved myocardial contractility, reduced PVR and SVR, and less tachycardia when compared with dopamine.81 Dobutamine improves hemodynamics in patients with PH at liver transplantation and after severe RV infarction.64,82 Given dobutamine's β2-mediated systemic vasodilatory properties, it is important to anticipate possible systemic hypotension with its use by avoiding high doses and treating concomitantly with vasopressors if systemic hypotension occurs.56
Pulmonary hypertension, a condition that can lead to right ventricular failure and hemodynamic collapse, can be very challenging to manage in critically ill patients who require the intensive care unit. Because of the underlying structure of the right ventricle, significant increases in right ventricular afterload initiate a vicious cycle of degenerating right ventricular function, giving rise to right ventricular failure and cardiogenic shock. In patients with pulmonary hypertension, inciting factors such as sepsis and arrhythmias can exacerbate this process. Important management principles include close monitoring of hemodynamics with both noninvasive and invasive modalities, optimization of right ventricular preload, maintenance of systemic blood pressure, enhancement of right ventricular contractility, reduction of right ventricular afterload, and reversal of identifiable inciting factors. The goal of this review is to discuss these key concepts in managing this difficult patient population.
Anesthesia and Pulmonary Hypertension
2012, Progress in Cardiovascular Diseases
Citation Excerpt :
Epinephrine is typically reserved for patients in severe shock. In normotensive patients who need inotropic support for RV failure, dobutamine is the preferred agent to improve RV contractility and CO, and it is sometimes used in combination with vasopressin to maintain adequate systemic blood pressure.107 Dopamine has less potential for causing hypotension than dobutamine, however it may cause more tachycardia and is not generally considered a first-line agent for managing patients with PH and RV failure.
Anesthesia and surgery are associated with significantly increased morbidity and mortality in patients with pulmonary hypertension due mainly to right ventricular failure, arrhythmias, postoperative hypoxemia, and myocardial ischemia. Preoperative risk assessment and successful management of patients with pulmonary hypertension undergoing cardiac surgery involve an understanding of the pathophysiology of the disease, screening of patients at-risk for pulmonary arterial hypertension, analysis of preoperative and operative risk factors, thorough multidisciplinary planning, careful intraoperative management, and early recognition and treatment of postoperative complications. This article will cover each of these aspects with particular focus on the anesthetic approach for non-cardiothoracic surgeries.
Pulmonary Arterial Hypertension
2008, Journal of the American College of Cardiology
Citation Excerpt :
Many patients are volume overloaded at presentation, and diuresis, even in the setting of marginal cardiac output and low blood pressure, may be required. In some cases, support with inotropes or pressors is necessary: animal data suggest a better hemodynamic response with sympathomimetic agents such as dobutamine, norepinephrine, and dopamine rather than vasopressin or phenylephrine; milrinone also has favorable effects on cardiac output but may lead to excessive hypotension (89–92). A variety of other substances may play roles as mediators through a final common pathway of pulmonary angiogenesis and may therefore be appealing therapeutic targets.
Significant advances in the treatment of pulmonary arterial hypertension (PAH) have occurred over the last 10 years, starting with the approval of epoprostenol in 1998. Subsequently, multiple additional medications have received approval, including a subcutaneous prostacyclin, an inhaled prostacyclin, and oral medications in 2 separate classes. Over this same period, the classification of pulmonary hypertension has been revised with changes including the substitution of the term idiopathic for primary PAH and an expanded list of conditions felt to be associated with the development of PAH. Long-term follow-up studies have provided better information on prognosis and expected outcomes with treatment, with particularly valuable data on reassessment of prognosis after treatment with epoprostenol. Combination therapy is more frequently being used, and limited data on novel therapies such as stem cell transplantation have been published. The purpose of this review is to describe the current state of evidence for the diagnosis, prognosis, and treatment of the patient with PAH.
Surviving 2019 novel coronavirus pneumonia: A successful critical case report
2020, Heart and Lung
Citation Excerpt :
Prone position ventilation therapy could facilitate the alveolar recruitment, improve hypoxemia and hypercapnia, as a result, reduced PAP and protected right ventricular function.17 Meanwhile, dobutamine, a β1 adrenoceptor agonist, has been demonstrated to be able to optimize ventricular artery coupling and improve right ventricular function by increasing heart rate and myocardial contractility.18 In our case, the prone position ventilation therapy, combining with dobutamine and diuretic, reduced acute pulmonary arterial hypertension caused by COVID-19 successfully.
. An outbreak of acute respiratory illness was proved to be infected by a novel coronavirus, officially named Coronavirus Disease 2019 (COVID-19) from World Health Organization (WHO), was confirmed first in Wuhan, China, and has become endemic worldwide, which was a serious threaten to public health all over the world. Herein, we reported a successful critical case of COVID-19 and shared our experience of treatment, which would do a favor for other COVID-19 patients.
. A 65-year-old man, Wuhan citizen, was infected by COVID-19, and his pulmonary lesions progressed quickly in five days. On admission to Tongji Hospital, Wuhan, China, the immediate arterial blood gas(ABG) analysis showed the PaO2/FiO2(P/F) ratio was 134.4mmHg, moderate acute respiratory distress syndrome(ARDS) was diagnosed. Emergency tracheal intubation was performed, and the initial ventilator mode and parameters were set up based on the lung-protective ventilation strategy, but the P/F ratio could not be improved, and then the prone position ventilation was carried out for four consecutive days, as long as 16 hours every day, the P/F ratio rose to 180mmHg approximately, which still did not reach to the standard of extubation. And then we found that it was complicated with acute cor pulmonale(ACP) by ultrasound examination, dobutamine and diuretic were used for the treatment of ACP caused by ARDS successfully, and the P/F ratio went up to about 250mmHg. Seven days later after admission, the endotracheal intubation was successfully removed, after extubation, High-Flow nasal cannula(HFNC) oxygen therapy was used as a sequential strategy to prevent reintubation. Ultimately, he was discharged on day 34 after admission.
. Our case presented the treatment process of a critical COVID-19. Effective therapy was crucial to heal COVID-19, and organ function support therapy, especially the cardiorespiratory function support therapy, was the core of treatment.

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Liver transplantationCandidate risk factorEffects of Dobutamine on Right Ventricular Function and Pulmonary Circulation in Pulmonary Hypertension During Liver Transplantation

Abstract

Introduction

Patients and methods

Results

Conclusion

Section snippets

Patients and methods

Results

Discussion

Lancet

Pulmonary hypertensionconsiderations in the liver transplant candidate

Transpl Int

Liver transplantation
Candidate risk factor
Effects of Dobutamine on Right Ventricular Function and Pulmonary Circulation in Pulmonary Hypertension During Liver Transplantation