Preliminary results of supra-hepatic intraaortic perfusion with nitroglycerin for patients with significant hepatic dysfunction.
BACKGROUND
Preoperative hepatic dysfunction is a risk factor for postoperative fulminant hepatic failure and death. We noted persistent hepatic artery vasospasm in patients dying of postoperative hepatic failure. We hypothesized that an intra-aortic vasodilator such as nitroglycerin could attenuate vasospasm and prevent hepatic failure.


METHODS
Nineteen consecutive patients with significant preoperative hepatic dysfunction underwent cardiac surgery using cardiopulmonary bypass with continuous infusion of intra-aortic nitroglycerin via a catheter placed above the celiac axis. Serial hepatic artery Doppler studies were done perioperatively with and without the nitroglycerin infusion on. Hepatic artery Doppler, hepatic artery size, alterations in liver function and serum creatinine, and outcomes were noted. Survival was compared to the Euroscore and a hepatic risk score that was based on a historical cohort and reported literature.


RESULTS
One patient could not be weaned off cardiopulmonary bypass. In the remaining 18 patients, reversible hepatic arterial vasospasm was noted, and this persisted at 24 hours in 12 patients and 48 hours in 7 patients. All patients had resolution of vasospasm at 72 hours. Serial paired hepatic artery diameter measurements showed a significant difference (P < .001). There was a significant reduction in mortality (5.2 %) compared to historical control and predicted mortality (logistic Euroscore 37.4%, P = .023). None of the survivors had a significant alteration in hepato-renal function.


CONCLUSIONS
Intra-aortic nitroglycerin can attenuate hepatic arterial vasospasm induced by cardiopulmonary bypass and preserve hepatic function. This may reduce the risk associated with cardiopulmonary bypass and surgery in patients with liver dysfunction.
Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India. prasannasimha@gmail.com
Prasanna Simha Mohan
PS
Rao
Parimala Prasanna
PP
Simha
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D013504:Cardiovascular Surgical Procedures / Q000009:adverse effects*; D005260:Female; D006499:Hepatic Artery / Q000187:drug effects*; D006801:Humans; D017093:Liver Failure / Q000175:diagnosis / Q000209:etiology* / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D005996:Nitroglycerin / Q000008:administration & dosage*; D010865:Pilot Projects; D011292:Premedication / Q000379:methods*; D016896:Treatment Outcome; D014665:Vasodilator Agents / Q000008:administration & dosage; D055815:Young Adult
D014665:Vasodilator Agents; D005996:Nitroglycerin