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J Thorac Cardiovasc Surg 2004;128:627-629
© 2004 The American Association for Thoracic Surgery
Brief communication |
a Department of Cardiothoracic Surgery, Lankenau Hospital, Wynnewood, Pa, USA
b Department of Cardiothoracic Anesthesia, Lankenau Hospital, Wynnewood, Pa, USA
Received for publication February 9, 2004; accepted for publication February 23, 2004.
* Address for reprints: Louis E. Samuels, MD, MCP Hahnemann University, Department of Cardiothoracic Surgery 245 N 15th St, Mail Stop 111, Philadelphia, PA 19102-1192, USA
SamuelsLE{at}aol.com
The use of nesiritide has been shown to be efficacious in patients with decompensated heart failure.1 The role of nesiritide in cardiac surgery, however, remains undetermined. The purpose of this report is to document our initial experience with nesiritide as an adjunctive therapy in adult patients with heart failure undergoing high-risk cardiac surgery.
Patients and methods
Between October 2003 and January 2004, a total of 12 patients with advanced heart failure underwent cardiac surgery by a single surgeon at a single center. The use of nesiritide was determined by 4 intraoperative criteria: (1) congestive heart failure (New York Heart Association functional class III-IV), (2) pulmonary hypertension (systolic pulmonary arterial pressure [PAP] >40 mm Hg), (3) low cardiac index (CI. <2.0 L/[min · m2]), and (4) elevated central venous pressure (CVP, >15 mm Hg). Patients with and without renal insufficiency were included. Nesiritide was instituted as an infusion (0.1 µg/[kg · min]) after placement of a Swan-Ganz catheter (Edwards Lifesciences, Irvine, Calif). The infusion was continued after the operation until the desired hemodynamic state was established. Other cardiac medications were administered as needed to augment cardiac output (eg, milrinone), systemic blood pressure (eg, norepinephrine), and arrhythmia control (eg, amiodarone). Hemodynamic parameters (systemic blood pressure, PAP, CVP, and CI) were measured immediately before, during, and 24 hours after surgery. In addition, the serum creatinine level was measured before surgery and on the first postoperative day. The urinary output was measured continuously and recorded 24 hours after admission to the intensive care unit.
Results
There were 8 women and 4 men with a mean age of 67.1 years (range 45-83 years). There were 4 coronary artery bypass grafting operations, 4 valvular operations, 3 combined coronary and valvular operations, and 1 ventricular assist device procedure (Table 1). Before nesiritide infusion, the mean systolic blood pressure was 115 mm Hg, the mean systolic PAP was 63.5 mm Hg, the mean CVP was 22.5 mm Hg, and the mean CI was 1.7 L/(min · m2). The mean baseline serum creatinine level was 1.3 g/dL. After the operation, the mean systolic blood pressure was 114 mm Hg, the mean systolic PAP was 40.1 mm Hg, the mean CVP was 14 mm Hg, and the mean CI was 2.5 L/(min · m2) (Table 2). The mean urinary output for the first 24 postoperative hours was 2290 mL. The mean postoperative serum creatinine level was 1.4 g/dL. The mean ventilator time, intensive care unit stay, and postoperative length of stay were 9.5 hours, 2.3 days, and 8 days, respectively. There were no deaths and 6 morbidities: 1 surgical hemorrhage requiring re-exploration, 2 cases of prolonged mechanical ventilation (>24 hours), and 3 new-onset atrial fibrillations. No patient required discontinuation of nesiritide before the establishment of an optimal hemodynamic state. Nesiritide infusion remained at 0.01 µg/(kg · min) during the entire infusion period. The mean duration of nesiritide therapy was 35 hours (range 24-48 hours).
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Nesiritide, human recombinant B-type natriuretic peptide, is among a family of natriuretic peptides with vasodilatory effects. Its role in the treatment of decompensated congestive heart failure is well established. Hemodynamic efficacy with direct and indirect cardiovascular and renal responses has been demonstrated.1 Nesiritide has been shown to directly augment coronary artery perfusion,2 reduce pulmonary capillary wedge pressure, PAP, and CVP, and indirectly improve cardiac output with no effect on heart rate.3 Nesiritide has also been shown to increase urinary sodium excretion (natriuresis) and urinary volume while preserving creatinine clearance.4 Finally, nesiritide suppresses the release of norepinephrine, the release of endothelin 1, and the renin-angiotensin-aldosterone axis.5
The role of nesiritide in adult cardiac surgery is undefined. A limited number of studies have examined the use of nesiritide in various settings.6-8 Truong and associates,6 for example, described 24 patients requiring inotropic support (milrinone) who were evaluated for transplantation after a 24- to 48-hour nesiritide infusion. As a result of the improved hemodynamics, 14 patients were directly listed and 7 additional patients received elective—as opposed to emergency—left ventricular assist devices. Similarly, nesiritide therapy has been found to act favorably as an adjunct to the treatment of decompensated heart failure immediately after cardiac transplantation.7 Finally , Moazami and colleagues8 have described positive cardiovascular and renal effects in 2 patients given nesiritide after coronary artery bypass grafting.8
Our study adds to the experience of others in helping to define the role of nesiritide in cardiac surgery. As the complexity of cardiac surgery becomes more apparent, with sicker patients and weaker hearts, advanced pharmacologic therapies become necessary for management. The properties of nesiritide lend themselves to the heart failure population, whether medical or surgical. In an effort to define nesiritide's role and application, we sought to establish a protocol in which a nesiritide infusion was instituted in patients with heart failure undergoing cardiac surgery. Specific parameters were defined in the operating room, and a simple infusion scheme was established. The infusion was kept constant until the desired hemodynamic status was achieved, often in combination with other cardiac medications (eg, milrinone). We found little role for loop diuretic and low-dose ("renal dose") dopamine. The use of norepinephrine was not uncommon, a consequence of the combined vasodilatory characteristics of milrinone and nesiritide. The duration of norepinephrine use was less than 48 hours and the dosage range was low. We did not observe any ventricular arrhythmias.
Conclusions
In our opinion, nesiritide therapy serves as an important adjunct in the management of patients with heart failure undergoing cardiac surgery. When combined with other cardiac medications, such as milrinone, a therapeutic balance of cardiovascular and renal effects is safe and practical.
References
This article has been cited by other articles:
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  D. M Blais Nesiritide Compared with Milrinone for Cardiac Surgery Ann. Pharmacother., March 1, 2007; 41(3): 502 - 504. [Abstract] [Full Text] [PDF]
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 J. L. Kristeller, H. Papps, and R. F. Stahl Risk of worsening renal function with nesiritide following cardiac surgery Am. J. Health Syst. Pharm., December 1, 2006; 63(23): 2351 - 2353. [Abstract] [Full Text] [PDF]
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