米力农复合一氧化氮对先天性心脏病患者体外循环后肺动脉高压的影响

Effects of milrinone and nitric oxide on pulmonary hypertension after cardiopulmonary bypass in patients with congenital heart disease

目的评价米力农复合一氧化氮（NO）对先天性心脏病（CHD）患者体外循环（CPB）后肺动脉高压（PH）的影响。方法先天性左向右分流型心脏病经肺动脉导管确诊为PH患者24例,随机分为3组（n=8）：NO组（N组）、米力农组（M组）和米力农复合NO组（NM组）。CPB主动脉开放后,N组于CPB结束血液动力学平稳后,吸入20 ppm NO 45 min;M组静脉注射米力农负荷量50μg/kg,然后持续静脉输注0.5μg·kg^-1·min^-1至术毕;NM组静脉注射米力农负荷量50μg/kg,然后持续静脉输注0.5μg·kg^-1·min^-1至术毕,脱离CPB后,吸入20 ppm NO 30 min。分别于切皮前（T0）、CPB结束血液动力学平稳后、吸入NO 15 min、30 min和停止NO吸入后15 min记录血液动力学指标。结果N组吸入NO时平均肺动脉压（mPAP）和肺血管阻力指数（PVRI）降低（P〈0.05）,停止吸入后,均出现不同程度的回升（P〈0.05）,平均动脉压（MAP）、体循环阻力指数（SVRI）以及心脏指数（CI）差异无统计学意义（P〉0.05）;M组静脉输注米力农期间PVRI下降,CI增加（P〈0.05）,mPAP、MAP以及SVRI差异无统计学意义（P〉0.05）。NM组给药期间mPAP和PVRI降低,CI增加（P〈0.05）,停吸NO前后mPAP、PVRI差异无统计学意义（P〉0.05）。结论CHD合并PH患者CPB后,静脉输注米力农复合吸入NO可降低mPAP和肺循环阻力,增加CI;米力农可预防NO停用后PH反跳。

Objective To investigate the effects of milrinone combined with nitric oxide（NO）on pulmonary artery pressure（PAP）after cardiopulmonary bypass（CPB）in patients with congenital heart disease （CHD）complicated by pulmonary hypertension（PH）.Methods Twenty-four ASAⅡorⅢpatients with CHD and PH（ NYHA gradeⅡorⅢ）undergoing open heart surgery under CPB were randomly divided into 3 groups（n =8 each）：groupⅠNO;groupⅡmilrinone（M）and groupⅢM＋NO.In group M the patients received after removal of aortic clamp a loading dose of milrinone 50μg/kg followed by continuous infusion at 0.5μg·kg^-1·min^-1till the end of operation.In NO group the patients inhaled 20 ppm NO for 45 min after being successfully weaned from CPB.In groupⅢpatients received a bolus of milrinone 50μg/kg followed by continuous infusion at 0.5μg·kg^-1·min^-1 till the end of operation and inhaled 20 ppm NO for 30 min after being successfully weaned from CPB.Mean pulmonary artery pressure（mPAP）,MAP,cardiac index（CI）,pulmonary vascular resistance index（PVRI）and systemic vascular resistance index（SVRI）were measured and recorded before operation（T0, baseline）,after weaning from CPB（T1）,at 15 and 30 min of NO inhalation（T2,T3）and 15 min after termination of NO inhalation（T4）.Results The 3 groups were comparable with respect to age,body weight, body surface area and CPB time.In NO group NO inhalation significantly decreased mPAP by 22%±16% and PVRI by 32%±24% as compared with baseline values at T0 but they slightly rebounded after termination of NO inhalation at T4.In group M milrinone significantly decreased PVRI by 30%±12% as compared with the baseline at T0 but did not significantly change mPAP.In groupⅢ（M＋NO）milrinone and NO significantly decreased mPAP by 26%±4% and PVRI by 31%±13% and they did not rebound after termination of NO inhalation. Conclusion Milrinone infusion combined with NO inhalation can significantly decrease mPAP and PVR after CPB in patients with CHD and PH.Milrinone can prevent rebound PH after termination of NO inhalation.