Support of the perioperative failing heart with preexisting ventricular dysfunction: currently available options.
Perioperative support of the patient with preexisting biventricular failure requires simultaneous optimal manipulation of heart rate and rhythm, loading conditions, and contractility. Patients with preexisting ventricular dysfunction will have alterations in beta-adrenergic receptors, resulting in decreased responsiveness to catecholamines. Even patients with previously normal ventricular function can develop ventricular dysfunction caused by reperfusion injury and other potentially damaging effects of extracorporeal circulation. The mainstay of therapeutic agents used to allow separation from cardiopulmonary bypass are catecholamines, which stimulate alpha- and beta-adrenergic receptors. Submaximal responses to beta 1-adrenergic stimulation can occur in the down-regulated heart. The phosphodiesterase inhibitors provide both inotropic support and vasodilatation, which improves both systolic and diastolic function and bypasses beta-adrenergic receptors. When administered in combination, catecholamine and cyclic-AMP-specific phosphodiesterase inhibitors can have additive effects to restore beta 1-adrenergic responsiveness. Combination therapy provides an important therapeutic option to facilitate separation from cardiopulmonary bypass. Pharmacologic intervention for right ventricular dysfunction focuses on reversal of pulmonary vasoconstriction with nitrates, beta 2-adrenergic agents, phosphodiesterase inhibitors and prostaglandin E1.
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