PINOT NOIR: pulmonic insufficiency improvement with nitric oxide inhalational response

Stephen A Hart, Ganesh P Devendra, Yuli Y Kim, Scott D Flamm, Vidyasagar Kalahasti, Janine Arruda, Esteban Walker, Thananya Boonyasirinant, Michael Bolen, Randolph Setser, Richard A Krasuski, Stephen A Hart, Ganesh P Devendra, Yuli Y Kim, Scott D Flamm, Vidyasagar Kalahasti, Janine Arruda, Esteban Walker, Thananya Boonyasirinant, Michael Bolen, Randolph Setser, Richard A Krasuski

Abstract

Background: Tetralogy of Fallot (TOF) repair and pulmonary valvotomy for pulmonary stenosis (PS) lead to progressive pulmonary insufficiency (PI), right ventricular enlargement and dysfunction. This study assessed whether pulmonary regurgitant fraction measured by cardiovascular magnetic resonance (CMR) could be reduced with inhaled nitric oxide (iNO).

Methods: Patients with at least moderate PI by echocardiography undergoing clinically indicated CMR were prospectively enrolled. Patients with residual hemodynamic lesions were excluded. Ventricular volume and blood flow sequences were obtained at baseline and during administration of 40 ppm iNO.

Results: Sixteen patients (11 with repaired TOF and 5 with repaired PS) completed the protocol with adequate data for analysis. The median age [range] was 35 [19-46] years, BMI was 26 ± 5 kg/m(2) (mean ± SD), 50% were women and 75% were in NYHA class I. Right ventricular end diastolic volume index for the cohort was 157 ± 33 mL/m(2), end systolic volume index was 93 ± 20 mL/m(2) and right ventricular ejection fraction was 40 ± 6%. Baseline pulmonary regurgitant volume was 45 ± 25 mL/beat and regurgitant fraction was 35 ± 16%. During administration of iNO, regurgitant volume was reduced by an average of 6 ± 9% (p=0.01) and regurgitant fraction was reduced by an average of 5 ± 8% (p=0.02). No significant changes were observed in ventricular indices for either the left or right ventricle.

Conclusion: iNO was successfully administered during CMR acquisition and appears to reduce regurgitant fraction in patients with at least moderate PI suggesting a potential role for selective pulmonary vasodilator therapy in these patients.

Trials registration: ClinicalTrials.gov, NCT00543933.

Figures

Figure 1
Figure 1
Patient flow diagram. Twenty four potential subjects were contacted and 18 completed the imaging protocol. One of these patients had motion artifact and another had significantly distorted anatomy preventing adequate measurements.
Figure 2
Figure 2
Effect of iNO in matched paired analysis (n=16). (A) Pulmonary regurgitant fraction and (B) pulmonary artery reverse volume at baseline and during administration of 40 ppm iNO.
Figure 3
Figure 3
Right ventricular end diastolic volume index (RV EDVi) as a function of pulmonary insufficiency (PI) (n=16). RV EDVi has been shown to correlate with PI in large scale studies. We observed a similar relationship but with a low r2 value.
Figure 4
Figure 4
Pulmonary Insufficiency (PI) as a function of time from complete repair (n=16). PI is known to be a progressive disease and our observation of the contrary could reflect referral bias as most patients enrolled were referred for evaluation for symptoms.

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Source: PubMed

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