iloprost and Postoperative-Complications

Pulmonary hypertension is a major risk factor in cardiac surgery and has significant impact on morbidity and mortality in the perioperative period. Nitric oxide (NO) is considered to be the gold standard for treatment of pulmonary hypertension in the perioperative setting. The aerosolized administration of the prostacyclin analogue iloprost is a new alternative with similar pulmonary-selective vasodilation and virtually no systemic side-effects. Relevant complications including increased postoperative bleeding have not been observed.

Topics: Administration, Inhalation; Cardiac Surgical Procedures; Endarterectomy; Heart Transplantation; Humans; Hypertension, Pulmonary; Iloprost; Intraoperative Complications; Mitral Valve; Postoperative Complications; Vasodilator Agents

Prostacyclins (PGl2) inhibit platelet-platelet interactions at concentrations that do not affect platelet adhesion to collagen and other arterial subendothelial structures exposed during injury. Such compounds can be encapsulated within platelets by reversible electroporation and, using the platelet's natural haemostatic propensity, they can be targeted to injured vessels in vivo. In rat (aorta), rabbit (ileofemoral) and pig (carotid) angioplasty models, autologous platelets, electro-loaded with the stable prostacyclin iloprost and given intravenously after balloon overstretch injury, substantially reduced platelet deposition at the lesion site as compared with control platelets. In the pig model, when the drug-loaded platelets were delivered directly to the injury site during angioplasty via a double balloon delivery catheter, platelet deposition was restricted to monolayer coverage (> 80% reduction compared with controls). Candidate antiproliferative drugs (for co-encapsulating with iloprost) are being investigated in order to develop a combined antithrombotic/antirestenosis strategy for use during angioplasty and thrombolysis procedures. Autologous platelets as drug-targeting vehicles should obviate many of the immunological, toxicological and biodegradability concerns inherent in the use of other drug transport vectors such as antibodies, viruses, liposomes and synthetic polymer microcapsules.

Topics: Angioplasty, Balloon; Animals; Arterial Occlusive Diseases; Arteries; Blood Platelets; Drug Carriers; Drug Delivery Systems; Humans; Iloprost; Infusions, Intravenous; Platelet Aggregation Inhibitors; Postoperative Complications; Rabbits; Rats; Swine; Thrombosis

Obviously, no single modality will prove to be universally applicable or completely effective at preventing postoperative adhesion formation. Increasing understanding of the pathophysiology of peritoneal healing provides the intellectual basis for the development of specific interventions at critical points along the adhesion formation cascade. We believe that multimodality therapy, including the use of pharmacologic adjuvants such as immunomodulatory drugs and fibrinolytic/anticoagulant agents in conjunction with a barrier material tailored to the specific operative procedure may provide optimal results. Hopefully, developments in the 1990's will provide reproductive surgeons with the means to help patients derive maximal benefit from their reconstructive procedures.

Topics: Adjuvants, Immunologic; Animals; Calcium Channel Blockers; Female; Humans; Iloprost; Infertility, Female; Pentoxifylline; Peritoneal Diseases; Poloxalene; Postoperative Complications; Tissue Adhesions; Wound Healing

Topics: Animals; Arachidonic Acid; Cyclooxygenase Inhibitors; Drug Synergism; Epoprostenol; Fibrinolytic Agents; Graft Survival; Humans; Iloprost; Ischemia; Lipoxygenase; Lipoxygenase Inhibitors; Nitric Oxide; Postoperative Complications; Prostaglandin-Endoperoxide Synthases; Prostaglandins; Skin; Skin Transplantation; Surgical Flaps; Thrombosis; Vasodilator Agents

Perioperative right ventricular (RV) failure due to pressure overload from pulmonary hypertension (PH) worsens postoperative outcomes after cardiac surgery. Inhaled iloprost is a potent pulmonary vasodilator improving RV performance, ameliorating myocardial and pulmonary ischemia-reperfusion injury and attenuating inflammation. We hypothesized that the prophylactic inhalation of iloprost would reduce postoperative ventilation times after cardiac surgery.. In this phase III, multicentre, randomized, double-blind, placebo-controlled trial, we randomly assigned 253 cardiac surgical patients at high risk of perioperative RV failure to the prophylactic inhalation of 20 µg iloprost or placebo before and during weaning from extracorporeal circulation. The primary endpoint was the duration of postoperative ventilation. Secondary endpoints included perioperative hemodynamics, intensive care unit and hospital length of stay, and 90-day mortality. Safety was assessed by the incidence of adverse events.. Iloprost had no significant effect on the median [interquartile range] duration of postoperative ventilation compared with placebo (720 [470-1170] min vs 778 [541-1219] min, respectively; median decrease, 65 min; 95% confidence interval [CI], - 77 to 210; P = 0.37). While the nebulization of iloprost decreased RV afterload and improved cardiac index, major secondary endpoints were not significantly affected. Ninety-day mortality occurred in 14% of the iloprost patients compared with 14% of the placebo patients (hazard ratio, 0.97; 95% CI, 0.50 to 1.89; P = 0.93). The incidence of adverse events was comparable in both groups.. The prophylactic inhalation of iloprost did not meaningfully improve the outcome in high-risk cardiac surgical patients.. www.clinicaltrials.gov (NCT00927654); registered 25 June, 2009.. RéSUMé: OBJECTIF: L’insuffisance cardiaque droite périopératoire due à une surcharge de pression provoquée par l’hypertension pulmonaire (HP) a un impact négatif sur le pronostic postopératoire après une chirurgie cardiaque. L’iloprost administré par inhalation est un vasodilatateur pulmonaire puissant qui améliore la performance du ventricule droit (VD), réduisant ainsi la lésion d’ischémie-reperfusion myocardique et pulmonaire et atténuant l’inflammation. Nous avons émis l’hypothèse qu’une inhalation prophylactique d’iloprost réduirait les temps de ventilation postopératoire après une chirurgie cardiaque. MéTHODE: Dans cette étude multicentrique de phase III, contrôlée par placebo, à double insu et randomisée, nous avons distribué aléatoirement 253 patients chirurgicaux courant un risque élevé d’insuffisance cardiaque droite périopératoire à une prophylaxie de 20 µg d’iloprost ou d’un placebo par inhalation avant et pendant le sevrage de la circulation extracorporelle. Le critère d’évaluation principal était la durée de ventilation postopératoire. Les critères d’évaluation secondaires étaient les données hémodynamiques périopératoires, la durée de séjour à l’unité de soins intensifs et à l’hôpital, et la mortalité à 90 jours. L’innocuité a été évaluée en fonction de l’incidence d’événements indésirables. RéSULTATS: L’iloprost n’a pas eu d’effet significatif sur la durée médiane [écart interquartile] de ventilation postopératoire par rapport au placebo (720 [470–1170] min vs 778 [541–1219] min, respectivement; réduction médiane, 65 min; intervalle de confiance [IC] 95 %, − 77 à 210; P = 0,37). Bien que la nébulisation d’iloprost ait réduit la post-charge du VD et amélioré l’index cardiaque, cette manœuvre n’a pas eu d’impact significatif sur les critères d’évaluation secondaires majeurs. Une mortalité à 90 jours a été observée chez 14 % des patients ayant reçu de l’iloprost, comparativement à 14 % des patients ayant reçu un placebo (rapport de risque, 0,97; IC 95 %, 0,50 à 1,89; P = 0,93). L’incidence d’événements indésirables était comparable dans les deux groupes. CONCLUSION: L’inhalation prophylactique d’iloprost n’a pas amélioré le pronostic des patients de chirurgie cardiaque à haut risque. ENREGISTREMENT DE L’éTUDE: www.clinicaltrials.gov (NCT00927654); enregistrée le 25 juin 2009.

Topics: Administration, Inhalation; Aged; Cardiac Surgical Procedures; Double-Blind Method; Female; Humans; Hypertension, Pulmonary; Iloprost; Length of Stay; Male; Postoperative Complications; Prospective Studies; Respiration, Artificial; Vasodilator Agents; Ventricular Dysfunction, Right

Pilot study to compare the effect of inhaled nitric oxide (iNO) and aerosolized iloprost in preventing perioperative pulmonary hypertensive crises (PHTCs).. Guidelines recommend the use of iNO to treat PHTCs, but treatment with iNO is not an ideal vasodilator. Aerosolized iloprost may be a possible alternative to iNO in this setting.. Investigator-initiated, open-label, randomized clinical trial in 15 infants (age range 77-257 days) with left-to-right shunt (11 out of 15 with additional trisomy 21), and pulmonary hypertension (i.e. mean pulmonary artery pressure [PAP] >25 mmHg) after weaning from cardiopulmonary bypass. Patients were randomized to treatment with iNO at 10 ppm or aerosolized iloprost at 0.5 µg/kg (every 2 h). The observation period was 72 h after weaning from cardiopulmonary bypass. The primary endpoint was the occurrence of PHTCs; the secondary endpoints were mean PAP, duration of mechanical ventilation, safety of administration, and in-hospital mortality.. Seven patients received iNO and eight patients received iloprost. During the observation period, 13 of the 15 patients had at least one major or minor PHTC. There was no difference between the groups with regard to the frequency of PHTCs, mean PAP and duration of mechanical ventilation (p > 0.05).. In this pilot study, aerosolized iloprost had a favorable safety profile. Larger trials are needed to compare its efficacy to iNO for the treatment of perioperative pulmonary hypertension. However, neither treatment alone abolished the occurrence of PHTCs.

Topics: Administration, Inhalation; Bronchodilator Agents; Cardiopulmonary Bypass; Heart Diseases; Humans; Hypertension, Pulmonary; Iloprost; Infant; Nitric Oxide; Pilot Projects; Postoperative Complications; Treatment Outcome; Vasodilator Agents

Pulmonary hypertension (PHT) is common in patients undergoing mitral valve surgery and is an independent risk factor for the development of acute right ventricular (RV) failure. Inhaled iloprost was shown to improve RV function and decrease RV afterload in patients with primary PHT. However, no randomized-controlled trials on the intraoperative use of iloprost in cardiac surgical patients are available. We therefore compared the effects of inhaled iloprost vs. intravenous standard therapy in cardiac surgical patients with chronic PHT.. Twenty patients with chronic PHT undergoing mitral valve repair were randomized to receive inhaled iloprost (25 microg) or intravenous nitroglycerine. Iloprost was administered during weaning from cardiopulmonary bypass (CPB). Systemic and pulmonary haemodynamics were assessed with pulmonary artery catheterization and transoesophageal echocardiography. Milrinone and/or inhaled nitric oxide were available as rescue medication in case of failure to wean from CPB.. Inhaled iloprost selectively decreased the pulmonary vascular resistance index after weaning from CPB (208 +/- 108 vs. 422 +/- 62 dyn.s/cm(5)/m(2), P<0.05), increased the RV-ejection fraction (29 +/- 3% vs. 22 +/- 5%, P<0.05), improved the stroke volume index (27 +/- 7 vs. 18 +/- 6 ml/m(2), P<0.05) and reduced the transpulmonary gradient (10 +/- 4 vs. 16 +/- 3 mmHg, P<0.05). In all patients receiving inhaled iloprost, weaning from CPB was successful during the first attempt. In contrast, three patients in the control group required re-institution of CPB and had to be weaned from CPB using rescue medication.. In patients with pre-existing PHT undergoing mitral valve surgery, inhaled iloprost is superior to intravenous nitrogylycerine by acting as a selective pulmonary vasodilator, reducing RV afterload and moderately improving RV-pump performance.

Topics: Administration, Inhalation; Aged; Cardiac Output, Low; Cardiopulmonary Bypass; Catheterization, Swan-Ganz; Echocardiography, Transesophageal; Female; Humans; Hypertension, Pulmonary; Iloprost; Infusions, Intravenous; Male; Middle Aged; Milrinone; Mitral Valve Insufficiency; Monitoring, Intraoperative; Nitroglycerin; Postoperative Complications; Prospective Studies; Stroke Volume; Vascular Resistance; Vasodilator Agents; Ventricular Dysfunction, Right

The objective of this study was to evaluate our protocol for the identification and management of patients with immune heparin-induced thrombocytopenia undergoing cardiac surgery.. Among 1518 patients who underwent cardiac surgery between June 1998 and May 2001, 32 (2.1%) presented with platelet counts less than 150,000/mm3 preoperatively or a history of prolonged (>3 days) intravenous exposure to heparin or both. These 32 patients were evaluated with an enzyme-linked immunosorbent assay for antibodies against heparin-platelet factor 4 complex. Platelets of patients with detected antibodies were tested with the prostacyclin analog iloprost for inhibition of heparin aggregation and determination of the inhibiting concentration and corresponding intravenous infusion rate of iloprost. Patients with antibodies received heparin after complete platelet inhibition with iloprost infusion. Hypotension was prevented or treated with intravenous noradrenaline. Ten randomly selected patients with similar preoperative characteristics, no previous extended exposure to heparin, and normal platelet counts served as controls.. Ten of the 32 patients (group A, 31.3%) and none of the controls had antibodies against heparin-platelet factor 4 complex. Patients in group A underwent surgery with iloprost (6-24 ng.kg(-1).min(-1)) and had their blood pressure maintained at greater than 95 mm Hg with norepinephrine infusion (1-4 microg.kg(-1).min(-1)). Operative mortality was zero. There were no thrombotic complications or bleeding requiring exploration. One patient in group A bled 1310 mL/6 hours but did not need exploration. There was no difference in postoperative blood loss and morbidity between groups. Platelet counts were reduced by 12.5% +/- 8.7% (group A) and 38.1% +/- 15.2% (control) (P <.001) 1 hour postoperatively and reached preoperative values by the fifth postoperative day.. Immune heparin-induced thrombocytopenia can be detected preoperatively among patients with a low platelet count or a history of prolonged heparin exposure or both. Cardiac surgery can be safely undertaken using iloprost-induced platelet inhibition during heparinization.

Topics: Aged; Anticoagulants; Blood Coagulation; Blood Pressure; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Dose-Response Relationship, Drug; Female; Greece; Hematocrit; Heparin; Humans; Iloprost; Infusions, Intravenous; Length of Stay; Male; Middle Aged; Norepinephrine; Phenylephrine; Platelet Aggregation; Platelet Aggregation Inhibitors; Platelet Count; Postoperative Complications; Preoperative Care; Purpura, Thrombocytopenic, Idiopathic; Reoperation; Severity of Illness Index; Treatment Outcome; Vasoconstrictor Agents; Vasodilator Agents

Severe pulmonary hypertension (PH) is a major cause of right ventricular (RV) dysfunction. Various iv vasodilator modalities have been used with limited results because of lack of pulmonary selectivity. The aim of the present controlled study was to evaluate the efficacy of inhaled iloprost, a synthetic prostacyclin analogue, in patients with elevated pulmonary vascular resistance (PVR) immediately after separation from cardiopulmonary bypass (CPB).. Twelve patients with persistent PH after discontinuation of CPB were included in the study. In all patients standard hemodynamic monitoring was used. Inhaled iloprost was administered via nebulized aerosol at a cumulative dose of 0.2 micro g*kg(-1) for a total duration of 20 min. Complete sets of hemodynamic measurements were performed before inhalation (baseline), during and after cessation of the inhalation period. Echocardiographic monitoring of RV function was also used.. Inhaled iloprost induced a reduction in the transpulmonary gradient at the end of the inhalation period in comparison to baseline (9.33 +/- 3.83 mmHg vs 17.09 +/- 6.41 mmHg, P < 0.05). The mean pulmonary artery pressure to systemic artery pressure ratio decreased over this period (0.28 +/- 0.08 vs 0.45 +/- 0.17, P < 0.05). A statistically significant decrease of the PVR to systemic vascular resistance ratio was also observed (0.15 +/- 0.05 vs 0.21 +/- 0.05, P < 0.05). Improved indices of RV function were observed in echocardiographic monitoring.. Inhaled iloprost appears to be a selective pulmonary vasodilator and may be effective in the initial treatment of PH and the improvement of RV performance in the perioperative setting.

Topics: Administration, Inhalation; Aged; Cardiopulmonary Bypass; Electrocardiography; Female; Hemodynamics; Humans; Hypertension, Pulmonary; Iloprost; Male; Middle Aged; Monitoring, Intraoperative; Postoperative Complications; Pulmonary Circulation; Vascular Resistance; Vasodilator Agents; Ventricular Function, Right

To evaluate the ventricle-unloading properties of dopexamine and iloprost and to compare their effects on right ventricular (RV) function and oxygen transport in patients with low RV ejection fraction (RVEF) after cardiac surgery.. A prospective, randomized, double-blind, cross-over, clinical study.. University hospital.. Twenty patients with proximal total stenosis of the right coronary artery studied immediately after coronary artery surgery.. Treatment drugs were administered in a random order in doses equipotent with respect to cardiac output response. Infusion rates were increased stepwise to induce a 25% increase in cardiac index. A washout period of 60 minutes was allowed between treatments.. Central hemodynamics, RV function assessed by the EF (fast-response thermodilution), end-systolic and end-diastolic volumes, and systemic oxygenation were measured before and after the first drug, after the washout period, and after the second drug. Central filling pressures remained constant during treatments. Both drugs decreased pulmonary vascular resistance index, but iloprost was more effective (p < 0.05). Iloprost decreased mean arterial and pulmonary artery pressure, which were unaffected by dopexamine. Dopexamine increased EF significantly more than iloprost (p < 0.001). End-systolic volume index decreased subsequent to dopexamine only (p < 0.001). Iloprost increased intrapulmonary shunt more than dopexamine (p < 0.001). Changes in oxygen delivery, consumption, and extraction were similar.. The findings suggest that dopexamine is more effective than iloprost for support and unloading of the postoperatively disturbed RV in terms of RVEF and end-systolic volume. The reduction of pulmonary vascular resistance after administration of iloprost without a decrease in end-systolic volume might not be considered a reduction of RV afterload. Iloprost increases the pulmonary shunt fraction, however, more than dopexamine, indicating a more prominent vasodilator effect.

Topics: Cardiac Output; Coronary Artery Bypass; Cross-Over Studies; Dopamine; Double-Blind Method; Female; Hemodynamics; Humans; Iloprost; Male; Middle Aged; Oxygen; Postoperative Care; Postoperative Complications; Prospective Studies; Stroke Volume; Vasodilator Agents; Ventricular Function, Right

The inhibition of platelet aggregation during cardiopulmonary bypass and effects on post-operative placebo-controlled study of 145 patients. Significant preservation of platelet numbers and function were shown without significant haemodynamic problems, but no effect on cerebral deficits could be found. The use of iloprost in patients with severe thrombocytopenia seems justified, but the clinical benefits from its use in routine cardiopulmonary bypass remain to be shown.

Topics: Blood Transfusion; Cardiopulmonary Bypass; Hemodynamics; Humans; Iloprost; Platelet Aggregation; Platelet Count; Postoperative Complications; Psychomotor Performance

Acute right ventricular dysfunction is a challenging problem in the immediate postoperative period following orthotopic heart transplantation. There are no prior reports of the use of inhaled iloprost in the setting of acute right ventricular dysfunction and acute pulmonary hypertension. Our hypothesis was that the use of inhaled iloprost in heart transplant recipients would be associated with a reduction in the duration of mechanical ventilation compared to patients being treated with continuous inhaled epoprostenol. Additionally, we hypothesized that the change in inhaled vasodilatory therapy would not be associated with a significant change in postoperative bleeding or use of vasoactive medications.. We reviewed charts of 80 consecutive patients undergoing heart transplantation at our institution between July 1, 2003, and August 8, 2008. From July 1, 2003 to March 13, 2006, epoprostenol was our primary vasodilator; subsequently epoprostenol was replaced with iloprost. We included 39 subjects who received epoprostenol and 40 subjects who received iloprost. Data were collected on the use of inhaled vasodilators, comparing periods before and after our institutional protocol change. Demographic data, hemodynamic values, drain output, and any requirement for vasoactive medication infusions were collected. Our primary end point was the natural logarithm of duration of mechanical ventilation. Secondary end points were hemodynamic values and length of ICU and hospital stay.. Subjects treated with iloprost were mechanically ventilated for 0.36 ± 0.20 (adjusted mean ± SE) log days, which was shorter (. Use of inhaled iloprost was associated with shorter duration of mechanical ventilation compared to inhaled epoprostenol, without safety concerns.

Topics: Administration, Inhalation; Adult; Epoprostenol; Female; Heart Transplantation; Hemodynamics; Humans; Hypertension, Pulmonary; Iloprost; Male; Outcome and Process Assessment, Health Care; Postoperative Complications; Respiration, Artificial; Retrospective Studies; Vasodilator Agents; Ventricular Dysfunction, Right

During cardiac operations, weaning from cardiopulmonary bypass (CPB) may prove challenging as a result of superimposed acute right ventricular dysfunction in the setting of elevated pulmonary vascular resistance (PVR). The aim of this study was to retrospectively evaluate the effect of inhaled milrinone versus inhaled iloprost in patients with persistent pulmonary hypertension following discontinuation of CPB. Eighteen patients with elevated PVR post-bypass were administered inhaled milrinone at a cumulative dose of 50 μg kg

Topics: Administration, Inhalation; Aged; Aged, 80 and over; Arterial Pressure; Cardiopulmonary Bypass; Dose-Response Relationship, Drug; Echocardiography, Transesophageal; Female; Follow-Up Studies; Heart Diseases; Humans; Hypertension, Pulmonary; Iloprost; Male; Middle Aged; Milrinone; Postoperative Complications; Retrospective Studies; Treatment Outcome; Vascular Resistance; Vasodilator Agents

Inhaled nitric oxide (iNO) is considered standard therapy for pediatric postcardiac surgical pulmonary hypertension (PH). Limited data suggest that inhaled iloprost (inIlo), an aerosolized prostacyclin, may be a feasible and more affordable therapeutic alternative. The goal of this study was to determine if significant hemodynamic change or adverse events would occur in postoperative congenital heart surgery (CHS) patients with PH after their transition from iNO to inIlo. This retrospective review investigated CHS patients with postoperative PH (mean pulmonary artery pressure [mPAP] >25 mmHg) between January 1, 2010 and December 31, 2011 who transitioned from iNO to inIlo. By protocol, CHS patients receiving stable doses of iNO were gradually transitioned to inIlo. After full transition, the patients received inIlo every 2 h, with a final dosing range of 1.25-5 μg/dose. Both PAP and systemic arterial pressure (SAP) were invasively measured during the transition period. Seven patients ages 10 days to 1.5 years completed the protocol. Measurements of mPAP (p = 0.27) and systolic PAP (p = 0.25) did not differ between iNO and inIlo therapy alone. No serious adverse events or complications (bleeding or thrombocytopenia) occurred. The ratio of systolic PAP to SAP decreased in all patients receiving inIlo alone (p = 0.03). Pulmonary hypertension in postoperative CHS patients can be managed successfully with inIlo, and the measured hemodynamics with this agent are similar to those observed with iNO. For the management of postoperative PH, inIlo may be a reasonable alternative, thus reducing the need for costly iNO. Larger confirmatory studies would more robustly facilitate its integration into standard care.

Topics: Administration, Inhalation; Cardiac Surgical Procedures; Female; Heart Defects, Congenital; Hemodynamics; Humans; Hypertension, Pulmonary; Iloprost; Infant; Infant, Newborn; Male; Nitric Oxide; Postoperative Complications; Retrospective Studies; Treatment Outcome; Vasodilator Agents

Pulmonary hypertension (PH) is an independent risk factor for increased mortality in patients undergoing heart surgery. Existing chronic PH may be exacerbated by acute post-bypass PH, and this can lead to acute right ventricular failure. The prevention and treatment of right ventricular failure in cardiac surgery is based on three principles: optimize right ventricular preload, improve right ventricular contractility, minimize right ventricular afterload. The last of these may involve specific measures such as the inhalation of nitric oxide (NO) or of the stable prostacyclin analogue iloprost. The advantage of these inhalable substances is their pulmonary selectivity, and the subsequent reduction in systemic side effects. In order to avoid disastrous results in high-risk cardiac surgical patients, intra- and post-operative monitoring with pressure lines, a qualified team that pays attention to details, and an aggressive and early treatment in the operating room with inhaled iloprost and/or NO is necessary. The philosophy of 'wait and see' should be abandoned in favour of 'be suspicious and act early'. In a prospective randomized trial, the efficacies of inhaled iloprost and of inhaled NO in the therapy of PH immediately following weaning from cardiopulmonary bypass in cardiac surgical patients were compared. Iloprost proved to be significantly more effective with respect to mean pulmonary arterial pressure, pulmonary vascular resistance, and cardiac output than inhaled NO.

Topics: Adult; Cardiac Surgical Procedures; Heart Diseases; Humans; Hypertension, Pulmonary; Iloprost; Nitric Oxide; Perioperative Care; Postoperative Complications; Risk Factors; Vasodilator Agents

Congenital heart disease (CHD) is responsible for pulmonary hypertension (PH) in children in about 50% of cases. This pre-operative dynamic pulmonary hypertension can be superimposed and aggravated by acute post-operative PH or persist as chronic PH, especially in children who are not operated on early enough. Inhaled iloprost, a stable prostacyclin analogue, is used for the post-operative management of PH in infants and children with CHD. In a prospective open-label proof-of-concept study, the efficacies of inhaled nitric oxide (iNO) and inhaled iloprost were directly compared. Primary endpoints were the occurrence of a major or minor pulmonary hypertensive crisis. No significant difference between the effects of iNO versus iloprost on peri-operative PH was observed. Neither substance on its own prevented pulmonary hypertensive crises in high-risk infants, so a combination of both substances should be tested in future trials. In China, there are more than 4 million untreated CHD patients. More than 50% of them are untreated adults. Acute pulmonary vasoreactivity tests were performed in CHD patients between 9 months and 43 years of age using inhaled iloprost, in order to find out whether a pre-operative response to inhaled iloprost is a good predictor for the post-operative performance of these patients. The results showed that patient selection criteria for surgery should include both a 20% reduction in pulmonary vascular resistance (PVR) index after iloprost inhalation and a resulting PVR index <11 Wood U/m(2). CHD children between 14 days and 11 years of age took part in a placebo-controlled pilot study that investigated the role of aerosolized iloprost in the treatment of PH after corrective surgery. They received either low- or high-dose iloprost or placebo. Inhaled iloprost significantly improved haemodynamics in a dose-dependent manner and prevented reactive PH and pulmonary hypertensive crises in most of these mechanically ventilated children after CHD repair.

Topics: Cardiac Surgical Procedures; Child; Heart Defects, Congenital; Humans; Hypertension, Pulmonary; Iloprost; Nitric Oxide; Perioperative Care; Postoperative Complications; Risk Factors; Vasodilator Agents

Pulmonary hypertensive crisis (PHC) is a significant contributor to the morbidity and mortality of surgery for congenital heart defect. Management of such a potentially fatal complication has been evolving for the past decades. Inhaled iloprost has been reported as an alternative treatment for this condition. We evaluated the use of aerosolized iloprost as a rescue therapy for PHC in children undergoing congenital heart surgery.. In this clinical study, 12 high risk children were monitored in order to identify postoperative PHC after congenital heart repair. Factors being monitored included pulmonary artery pressure, systemic blood pressure, left atrial pressure, transcutaneous oximetry and heart rate. PHC was defined as an acute rise in pulmonary pressure which causes cardiopulmonary compromise as reflected by desaturation and hypotension. Despite conventional medical treatment to prevent postoperative PHC, children with PHC were therefore administered with aerosolized iloprost (0.5 microg/kg).. Eight of the 12 children had one or more episodes of PHC, secondary to the pulmonary vasoreactivity. All responded to the aerosolized iloprost treatment, as demonstrated by a fall in their mean pulmonary pressure from 47.9 + or - 14.9 to 30.2 + or - 7.9 mmHg (p=0.012) and a rise in the arterial saturation from 82.2 + or - 16.7 to 93.4 + or - 11.5 % (p=0.012) while mean systemic blood pressure tended to increase from 59.4 + or - 12.1 to 64 + or - 10.3 mmHg (p=0.16).. In medical setting with limited access to the nitric oxide, inhaled iloprost is consider to be an effective alternative treatment for postoperative PHC in children undergoing congenital heart surgery.

Topics: Administration, Inhalation; Adolescent; Child; Child, Preschool; Heart Defects, Congenital; Humans; Hypertension, Pulmonary; Iloprost; Infant; Postoperative Complications; Prospective Studies

The purpose of this study was to investigate the application of intravenous iloprost as a novel therapy for the treatment of post-transplant distal limb syndrome (PTDLS). PTDLS is a benign but disabling complication in the first year after renal transplantation. It is characterized by bilateral, often incapacitating pain in the feet and or knees on motion and a significant rise in alkaline phosphatase levels on laboratory evaluation. On MRI, bone marrow edema of the affected bone regions can be demonstrated. PTDLS differs from steroid induced osteonecrosis of the hip in terms of localization, an average cumulative steroid dosage within expected limits, and a benign outcome, as PTDLS does not progress to overt cell necrosis. From August 2003 to April 2005 we treated 10 patients with MRI-proven diagnosis of PTDLS following a standardized regimen of intravenous iloprost over 5 days. Iloprost led to prompt pain relief measured on a visual analogous scale (VAS) ranging from 1 to 10 (5.6 +/- 1.5 before vs. 2.1 +/- 1.3 after treatment, p = 0.0004). PTDLS represents a benign but disabling complication following renal transplantation. Intravenous iloprost might be a promising therapeutic concept leading to a quick relief of symptoms without relevant side effects.

Topics: Adult; Aged; Bone Diseases; Female; Foot Bones; Humans; Iloprost; Infusions, Intravenous; Kidney Transplantation; Knee; Magnetic Resonance Imaging; Male; Middle Aged; Pain, Postoperative; Postoperative Complications; Syndrome; Treatment Outcome; Vasodilator Agents

This experimental study was designed to investigate whether iloprost can reverse impaired colonic healing caused by immediate postoperative intraperitoneal administration of 5-fluorouracil plus leucovorin.. Eighty Wistar rats were randomized into four groups. After resection of a 1-cm segment of transverse colon, an end-to-end sutured anastomosis was generated. Rats received saline solution (Group 1), 5-fluorouracil plus leucovorin (Group 2), iloprost (Group 3), and 5-fluorouracil plus leucovorin plus iloprost (Group 4) intraperitoneally from the day of operation and once daily until killing. Each group was further randomized into two subgroups. Subjects were killed on the fifth (Subgroup a) and eighth (Subgroup b) postoperative days. After killing, anastomoses were examined macroscopically and graded histologically. Rats were measured for anastomotic bursting pressures and tissue hydroxyproline levels.. The leakage rate of the anastomoses was significantly higher in the 5-fluorouracil plus leucovorin group compared with the other groups (P = 0.049). Bursting pressure was significantly lower in 2a subgroup (5-fluorouracil plus leucovorin, postoperative Day 5) than in 4a (5-fluorouracil plus leucovorin plus iloprost, postoperative Day 5; P < 0.001). Adhesion formation was significantly higher in all b subgroups compared with the Control b subgroup. Neoangiogenesis was significantly higher in iloprost and iloprost plus 5-fluorouracil plus leucovorin subgroups compared with the 5-fluorouracil plus leucovorin subgroups. Hydroxyproline levels, collagen deposition, fibroblasts, and white cell count were significantly higher in the iloprost plus 5-fluorouracil plus leucovorin b subgroup (postoperative Day 8) compared with the 5-fluorouracil plus leucovorin b subgroup (postoperative Day 8).. The immediate postoperative, intraperitoneal administration of iloprost counteracts and reverses the negative effects of 5-fluorouracil plus leucovorin chemotherapy and protects colonic healing in rats.

Topics: Anastomosis, Surgical; Animals; Antimetabolites, Antineoplastic; Collagen; Colon; Female; Fibroblasts; Fluorouracil; Hydroxyproline; Iloprost; Injections, Intraperitoneal; Leucovorin; Manometry; Models, Animal; Neovascularization, Physiologic; Postoperative Complications; Random Allocation; Rats; Rats, Wistar; Tissue Adhesions; Vasodilator Agents; Vitamin B Complex; Wound Healing

This case report describes the treatment of reperfusion lung oedema after pulmonary thromboendarterectomy using intravenous iloprost infusion in a 52-year-old woman diagnosed with chronic thromboembolic pulmonary hypertension.

Topics: Endarterectomy; Female; Humans; Hypertension, Pulmonary; Iloprost; Infusions, Intravenous; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Pulmonary Edema; Pulmonary Embolism; Reperfusion Injury

Perioperative acute right heart failure after orthotopic heart transplantation contributes significantly to morbidity and mortality. Vasodilators administered intravenously may decrease pulmonary vascular resistance, but also affect systemic circulation. A decrease of mean arterial pressure will result in reduced right coronary blood flow and deterioration of right ventricular performance. Vasodilators administered by inhalation, i.e. nitric oxide and prostacyclin, are attractive due to a more selective effect on the pulmonary circulation. This is the first report on the use of aerosolized iloprost, a long-acting prostacyclin analogue, applied for treatment of postoperative right heart failure in cardiac transplantation. After uneventful surgery, a heart transplant recipient was extubated on the first postoperative day and exhibited right heart failure on the following day. Standard treatment did not resolve this clinical problem sufficiently. A trial with inhalation of iloprost (16 microg per inhalation cycle, applied six times per day) was initiated. Iloprost inhalation resulted in a sufficient decrease of pulmonary vascular resistance (-23.5%), while cardiac index (+24.0%) and mixed venous saturation (+9.0%) increased. No profound effect on the systemic vascular resistance was observed (-2.8%). Iloprost inhalation may be an effective alternative to nitric oxide in the intensive care management of acute right heart failure after orthotopic heart transplantation. Due to the prolonged effect on the pulmonary vascular resistance, iloprost is especially useful for extubated patients.

Topics: Administration, Inhalation; Central Venous Pressure; Heart Failure; Heart Transplantation; Humans; Iloprost; Male; Middle Aged; Postoperative Complications; Pulmonary Circulation; Vascular Resistance; Vasodilator Agents

Secondary postoperative ischaemia due to venous occlusion is the most detrimental insult to free microvascular flaps. In an experimental rat free flap model the efficacy of long acting prostacyclin analogues iloprost (Ilomedin) and cicaprost in venous occlusion induced postoperative ischaemia was studied. Free, microvascular groin flaps were transplanted to the neck and the draining veins were temporarily occluded on the first postoperative day for a total of 20 min. In the untreated control group, haemorrhagic flap necrosis occurred. Intravital microscopy after secondary ischaemia revealed flap areas without reperfusion. The functional vessel density was significantly reduced. Reperfused capillaries were tortuous and significantly dilated. After reperfusion the interstitial leakage of macromolecular dextran increased, indicating loss of microvascular endothelial integrity. Intraarterial and intravenous applications of iloprost were able to diminish the ischaemic effects, giving a flap survival rate of 83%. Similar results were obtained by intravenous and enteral administration of cicaprost. Transcutaneous oxygen partial pressure measurements confirmed the viability of the surviving flaps. We conclude that both iloprost and cicaprost are effective in preventing venous occlusion induced failure of free microvascular groin flaps.

Topics: Animals; Epoprostenol; Graft Rejection; Iloprost; Ischemia; Male; Oxygen; Partial Pressure; Postoperative Complications; Prostaglandins, Synthetic; Rats; Rats, Sprague-Dawley; Surgical Flaps; Vasodilator Agents

Despite the alluring pharmacological properties of prostacyclin and its stable analogue (iloprost), these substances are little used in plastic surgery. A case is presented in which iloprost resulted in persistent patency of the vessels supplying a free flap. A patient who had had failure of a free flap because of thrombosis distal to the arterial anastomosis had a second free flap. Thrombus formed distal to the arterial anastomosis of the second flap and recurred when the anastomosis was redone. The flap was perfused with urokinase and then iloprost. After this, iloprost was given intravenously peroperatively and for 12 hours postoperatively. Postoperatively, the patient also received aspirin, ticlopidine and heparin. The flap survived without any late complications. A literature review offers confirmation of the advantages of using iloprost if microvascular anastomoses thrombose and during the reperfusion of flaps after prolonged ischaemia.

Topics: Anastomosis, Surgical; Blood Platelets; Carcinoma, Basal Cell; Female; Humans; Iloprost; Microcirculation; Microsurgery; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Skin Neoplasms; Surgical Flaps; Thrombolytic Therapy; Thrombosis

Cholesterol embolisation is a little known complication of aortic surgery and radiological procedures with a mortality of 81%. Treatment has been poorly described and inadequate. We report a case in which we have followed an aggressive policy of treatment using modern vascular techniques not previously described in this condition.

Topics: Angiography; Aorta, Abdominal; Arteriovenous Fistula; Blood Vessel Prosthesis; Cholesterol; Combined Modality Therapy; Drug Therapy, Combination; Embolism; Femoral Artery; Humans; Iloprost; Injections, Intra-Arterial; Intermittent Claudication; Ischemia; Leg; Male; Middle Aged; Postoperative Complications; Pulse; Reoperation; Streptokinase

The ability of prostacyclin analogue incorporated into a controlled-release suture to prevent postoperative venous thrombosis was investigated. Thirteen rats underwent bilateral transection and anastomosis of the common femoral vein. In each animal, polycaprolactone suture containing 0.25 micrograms/cm of the prostacyclin analogue Iloprost (Schering Ag, Berlin, West Germany) was used to perform the anastomosis on one vessel. Similar suture without prostacyclin analogue was used on the contralateral vessel, which served as a control. Functional patency and luminal surface morphology were assessed 24 hours postoperatively. All anastomoses performed using suture containing prostacyclin analogue were patent. Among controls, five anastomoses were patent and eight were occluded. This difference was highly significant (p less than 0.005). All anastomoses performed with prostacyclin analogue-containing suture exhibited a uniform absence of thrombosis. In contrast, eight control veins exhibited a dense, well-organized fibrinous clot that filled the entire lumen, effectively sealing off the vessel. These results suggest that the prostacyclin analogue released from the suture was highly effective in inhibiting thrombus formation without adversely affecting the vessel's ability to achieve hemostasis.

Topics: Animals; Epoprostenol; Graft Occlusion, Vascular; Iloprost; Male; Postoperative Complications; Rats; Rats, Inbred Strains; Sutures; Thrombophlebitis