Nitroprusside in Critically Ill Patients with Left Ventricular Dysfunction and Aortic Stenosis
Umesh N. Khot, M.D., Gian M. Novaro, M.D., Zoran B. Popovi, M.D., Roger M. Mills, M.D., James D. Thomas, M.D., E. Murat Tuzcu, M.D., Donald Hammer, M.D., Steven E. Nissen, M.D., and Gary S. Francis, M.D.
Background Vasodilators are considered to be contraindicatedin patients with severe aortic stenosis because of concern thatthey may precipitate life-threatening hypotension. However,vasodilators such as nitroprusside may improve myocardial performanceif peripheral vasoconstriction is contributing to afterload.
Methods We determined the response to intravenous nitroprussidein 25 patients with severe aortic stenosis and left ventricularsystolic dysfunction. Patients were included in the study ifthey had been admitted to the intensive care unit for invasivehemodynamic monitoring of heart failure and if they had a depressedejection fraction (0.35), severe aortic stenosis (aortic-valvearea, 1 cm2), and a depressed cardiac index (2.2 liters perminute per square meter). Patients were excluded if they hadhypotension, defined as either the need for intravenous inotropicor pressor agents or a low mean systemic arterial pressure (<60mm Hg). Patients were enrolled irrespective of other, coexistingvalve disease or coronary artery disease.
Results At base line, the mean (±SD) ejection fractionwas 0.21±0.08; the aortic-valve area was 0.6±0.2cm2, with peak and mean gradients of 65±37 and 39±23mm Hg, respectively; and the cardiac index was 1.60±0.35liters per minute per square meter. After six hours of therapywith nitroprusside (at which time the dose had been increasedto a mean of 103±67 µg per minute), the cardiacindex had increased to 2.22±0.44 liters per minute persquare meter (P<0.001 for the comparison with base line).After 24 hours of nitroprusside infusion (dose, 128±96µg per minute), the cardiac index had increased further,to 2.52±0.55 liters per minute per square meter (P<0.001for the comparison with base line). Nitroprusside was well toleratedand had minimal side effects.
Conclusions Nitroprusside rapidly and markedly improves cardiacfunction in patients with decompensated heart failure due tosevere left ventricular systolic dysfunction and severe aorticstenosis. It provides a safe and effective bridge to aortic-valvereplacement or oral vasodilator therapy in these criticallyill patients.
Source Information
From Indiana Heart Physicians, Indianapolis (U.N.K.); the Department of Cardiology, Cleveland Clinic Florida, Weston, Fla. (G.M.N.); and the Department of Cardiology, Cleveland Clinic Foundation, Cleveland (Z.B.P., R.M.M., J.D.T., E.M.T., D.H., S.E.N., G.S.F.).
Address reprint requests to Dr. Khot at Indiana Heart Physicians, 112 N. 17th Ave., Suite 300, Beech Grove, IN 46107, or at khot{at}cvresearch.net.
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, M.D., Roger M. Mills, M.D., James D. Thomas, M.D., E. Murat Tuzcu, M.D., Donald Hammer, M.D., Steven E. Nissen, M.D., and Gary S. Francis, M.D.
0.35), severe aortic stenosis (aortic-valve area, 
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