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J Thorac Cardiovasc Surg 1998;115:517-527
© 1998 Mosby, Inc.

SURGERY FOR CONGENITAL HEART DISEASE

Dilutional And Modified Ultrafiltration Reduces Pulmonary Hypertension After Operations For Congenital Heart Disease: A Prospective Randomized Study

From the Section of Cardiothoracic Surgery,^a Divisions of Pediatric Anesthesiology^b and Pediatric Cardiology,^c James W. Riley Hospital for Children and Indiana University Medical Center, Indianapolis, Ind.

Read at the Seventy-seventh Annual Meeting of The American Association for Thoracic Surgery, Washington, D.C., May 4-7, 1997.

Received for publication May 7, 1997; revisions requested June 10, 1997; revisions received Nov. 4, 1997; accepted for publication Nov. 4, 1997. Address for reprints: Ko Bando, MD, Section of Cardiothoracic Surgery, Indiana University Medical Center, 545 Barnhill Dr., EM 215, Indianapolis, IN 46202-5123.

Objective: A prospective randomized study was performed to test whether removal of endothelin-1, by ultrafiltration techniques, will reduce pulmonary hypertension after operations for congenital heart disease.
Methods: Twenty-four patients with pulmonary hypertension (systolic pulmonary/systemic arterial pressure ratio > 60%) undergoing cardiac operations were randomized into a control group (n = 12) having conventional ultrafiltration and an experimental group (n = 12) undergoing dilutional ultrafiltration during and modified ultrafiltration after cardiopulmonary bypass. Plasma endothelin-1, nitric oxide metabolites, and cyclic guanosine monophosphate were assayed before bypass, 10 minutes into bypass, after bypass, and 0, 3, 6, and 12 hours after the operation in both groups, as well as in the ultrafiltrates and after modified ultrafiltration in the experimental group. Both groups received -blockers (chlorpromazine and/or prazosin) postoperatively using the same guidelines.
Results: The ultrafiltrates contained significant amounts of endothelin-1 (1.81 ± 0.86 pg/ml, dilutional, and 6.44 ± 1.82 pg/ml, modified ultrafiltrate). Endothelin-1 and the pulmonary/systemic pressure ratio were significantly lower in experimental compared with control patients. Nitric oxide metabolites and cyclic guanosine monophosphate increased similarly in both groups for 12 hours after the operation (p = not significant). Three of 12 control patients (25%) but no experimental patients had pulmonary hypertensive crises (p = 0.07). The experimental patients required significantly less ventilatory support (67 ± 47 hours vs 178  ± 139 hours for control patients, p = 0.048).
Conclusions: Dilutional and modified ultrafiltration reduce endothelin-1 and the pulmonary/systemic pressure ratio postoperatively and may become an important adjunct for preventing pulmonary hypertension after operations for congenital heart disease in high-risk patients.

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