title: High-risk mitral valve surgery: perioperative hemodynamic optimization with nesiritide (BNP).
abstract: BACKGROUND
  Nesiritide is a recombinant brain-type natriuretic peptide (BNP), which decreases pulmonary arterial (PA) pressures and myocardial oxygen consumption while increasing coronary flow and urine output. Mitral valve (MV) surgery in patients with severe mitral regurgitation (MR), impaired left ventricular function, and pulmonary hypertension is associated with a high operative mortality. We hypothesized that the perioperative use of Nesiritide is safe, and may improve surgical outcomes.
  
  
  METHODS
  From May 2003 to August 2004, 14 patients (11 male, 3 female; mean age, 64 years [23-87 years]; mean systolic PA, 63 mm Hg [48-94 mm Hg]; mean ejection fraction, 36% [10-50%]), undergoing MV surgery (10 repairs, 2 replacements, and 2 rereplacements) for severe MR, were treated for a median of 24 hours (13-55 hours) preoperatively with intravenous Nesiritide. Expected mortality by EuroSCORE was 26% (7.8-59%) (5 reoperations). Concomitant procedures included tricuspid valve repair (n = 7), coronary artery bypass grafting (n = 5), and left atrial maze procedure (n = 3). Eleven patients received Nesiritide postoperatively during a mean duration of 22 hours (2-80 hours).
  
  
  RESULTS
  Operative mortality was 0%. Prior to surgery after BNP treatment, mean systolic PA pressure dropped to 39 mm Hg (p = 0.0003), pulmonary capillary wedge pressure to 15 mm Hg (p = 0.001), central venous pressure to 6 mm Hg (p = 0.002), and weight by 3.7 kg (p = 0.006). Postoperative median ventilation time was 14 hours (4-48 hours). All other major hemodynamic parameters (systemic blood pressure, heart rate, and cardiac output) remained constant. The treatment was well-tolerated in all patients.
  
  
  CONCLUSIONS
  Perioperative use of Nesiritide is safe, and may contribute to improved early outcomes in high-risk patients undergoing MV surgery. This may be due to improved ventricular loading conditions (decreased PA pressures, more effective diuresis) and/or a direct myocardial effect of BNP. Further prospective evaluation of the role of BNP in cardiac surgery is warranted.
authors.affiliation: Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, New York 10029, USA.
authors.forename: Sacha P
authors.initials: SP
authors.lastname: Salzberg
authors.forename: Farzan
authors.initials: F
authors.lastname: Filsoufi
authors.forename: Anelechi
authors.initials: A
authors.lastname: Anyanwu
authors.forename: Kai
authors.initials: K
authors.lastname: von Harbou
authors.forename: Alan
authors.initials: A
authors.lastname: Gass
authors.forename: Sean P
authors.initials: SP
authors.lastname: Pinney
authors.forename: Alain
authors.initials: A
authors.lastname: Carpentier
authors.forename: David H
authors.initials: DH
authors.lastname: Adams
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006348:Cardiac Surgical Procedures; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D005260:Female; D006439:Hemodynamics; D006801:Humans; D006976:Hypertension, Pulmonary / Q000188:drug therapy / Q000209:etiology; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology / Q000601:surgery*; D020097:Natriuretic Peptide, Brain / Q000627:therapeutic use*; D011446:Prospective Studies; D018487:Ventricular Dysfunction, Left / Q000188:drug therapy / Q000209:etiology
chemical_list: D002317:Cardiovascular Agents; D020097:Natriuretic Peptide, Brain