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J Thorac Cardiovasc Surg 1997;113:793-795
© 1997 Mosby, Inc.
BRIEF COMMUNICATIONS |
Kyoto, Japan
Received for publication July 26, 1996 accepted for publication Sept. 16, 1996. Address for reprints: Kazunobu Nishimura, MD, PhD, Department of Cardiovascular Surgery, Kyoto University Faculty of Medicine, Kyoto, 606, Japan.
The atrium has specific granules that contain atrial natriuretic polypeptides (ANP), which are secreted from the heart and circulate throughout the body as a hormone. The main pharmacologic properties of ANP are natriuresis, diuresis, vasorelaxation, and inhibition of aldosterone.
1 Synthetic ANP is currently available and provides beneficial effects in patients with heart failure. In this paper, the case of a patient with giant atria lacking ANP is described. The effect of synthetic ANP infusion is reported.
Case report.
A 55-year-old woman was transferred to our department because of orthopnea and hepatocardiomegaly caused by mitral stenosis and tricuspid regurgitation. She has twice previously undergone mitral operation (closed mitral commissurotomy at age 21 years and open mitral commissurotomy at age 23 years), and congestive heart failure had developed because of recurrent mitral stenosis combined with severe tricuspid regurgitation that caused marked enlargement of both the left and right atria. The left atrium measured 73 mm according to the echocardiogram. The plasma concentration of ANP was less than the detectable value (<5.0 pg/ml; normal range, 8 to 32) whereas that of aldosterone was extraordinarily high (1731 pg/ml; normal range, 57 to 161). Renal function was within normal limits with a 0.9 ml/dl creatinine level.
We first used femorofemoral cardiopulmonary bypass (CPB) and approached the heart through a right thoracotomy for fear of injuring the right atrium, the wall of which was remarkably thinned. The mitral valve was replaced with a Björk-Shiley valve and the enlarged ring of the tricuspid valve was repaired with a Carpentier ring. The CPB time was 259 minutes, and the weaning process from CPB with the assistance of inotropic drugs was uncomplicated. The postoperative course was fairly stable in terms of hemodynamic parameters with optimal cardiac indices. Fig. 1 illustrates the events of the entire postoperative time course.
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Successful extubation was accomplished 74 hours after operation. After cessation of alpha-ANP infusion, pulmonary arterial pressure increased again and urine volume decreased, suggesting that ANP was effective in this patient. Four weeks after operation, she received further alpha-ANP infusion at the same dosage for 4 days because of resistance to conventional diuretics. She recovered fully and was discharged from the hospital 3 months later. At that time, the plasma concentration of ANP was as before less than the detectable value.
Discussion.
The special features of this case were marked enlargement of both the left and right atria and an extraordinarily low plasma ANP concentration. In general, the plasma ANP concentration shows a graded rise in patients with congestive heart failure because atrial distention is a key trigger that stimulates ANP secretion. 2 This patient underwent closed and open mitral commissurotomy more than 30 years ago, at which time the appendages must have been removed or ligated. We previously reported that the secretory function of ANP was impaired after resection of atrial appendages in experimental heart failure models. 3 In addition, sustained mitral stenosis and tricuspid regurgitation induced excessive extension of the atria, which may have further diminished the granules producing ANP. Thus it is considered that the patient had a lack of ANP secretion despite congestive heart failure.
Infusion of alpha-ANP was notably effective in this patient in terms of diuresis and in reducing preload level. Saito and associates 1 first reported the beneficial effect of ANP administration in patients with congestive heart failure. We also reported the hemodynamic effects of ANP infusion after cardiac operation as cardiac output increased and pulmonary arterial pressure decreased. 4 We recently performed a trial of continuous infusion of ANP for more than 24 hours in more than 10 patients after cardiac operation irrespective of the plasma ANP concentration. In selected patients, ANP infusion markedly increased urine volume whereas in these patients the diuretic effect of furosemide was minimal (unpublished data). Continuous infusion of alpha-ANP should be tried in patients after cardiac operations when oliguria develops.
Footnotes
From the Department of Cardiovascular Surgery, Kyoto University Faculty of Medicine, Kyoto, Japan. 
References
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