J Extra Corpor Technol 2024 , 56 , 120 – 124 Ó The Author ( s ), published by EDP Sciences , 2024 https :// doi . org / 10.1051 / ject / 2024018
Available online at : ject . edpsciences . org
CASE REPORT
A case of the effective inhalation of nitric oxide therapy for caused severe pulmonary hypertension with protamine neutralization of systemic heparinization during totally endoscopic minimally invasive cardiac surgery
Tomohisa Takeichi ( CCP ) 1 ,* , Yoshihisa Morimoto ( MD ) 2 , Akitoshi Yamada ( MD ) 2 , and Takanori Tanaka ( CCP ) 1
1 Department of Clinical Engineering , Kitaharima Medical Center , 926-250 , Ichiba-cho , Ono-shi , Hyogo 675-1392 , Japan 2 Department of Cardiovascular Surgery , Kitaharima Medical Center , 926-250 , Ichiba-cho , Ono-shi , Hyogo 675-1392 , Japan
Received 2 April 2024 , Accepted 8 July 2024
Abstract – Severe pulmonary vasoconstriction induced by protamine is a rare complication . We report a case of a 77-year-old male patient with a history of mitral valve plasty ( MVP ). He underwent redo MVP via right thoracotomy under the totally endoscopic procedure ( MICS redo-MVP ). Immediately after weaning cardiopulmonary bypass ( CPB ), protamine was administrated . 10 min later peak systolic pulmonary arterial pressure ( sys PAP ) rose to 62 mmHg , and 30 min later to 80 mmHg . Due to the negative impact of protamine administration , nitric oxide inhalation ( iNO ) therapy was started with a concentration of 20 ppm . 10 min after iNO therapy started , sys PAP decreased to 63 mmHg . After entering the intensive care unit ( ICU ), sys PAP decreased to 35 mmHg . Here , we present an effective iNO therapy case for pulmonary hypertension due to protamine and the patient had a good postoperative recovery . This study was approved by the Institutional Review Board at Kitaharima Medical Center ( IRB-0602 ) with the waiver of informed consent .
Key words : Cardiopulmonary bypass ( CPB ), Nitric oxide , Respiratory therapy , Pulmonary hypertension , Protamine .
Introduction
Protamine covalently binds to anionic heparin forming a stable precipitate and neutralizing the anticoagulant effect of heparin [ 1 , 2 ]. On the other hand , there are some adverse effects such as Type I , characterized by hypotension due to rapid infusion ; Type II , presenting as an anaphylactic-like reaction ; and Type III , associated with severe pulmonary hypertension caused by significant pulmonary vasoconstriction [ 1 , 3 – 7 ]. Notably , Type III ( catastrophic pulmonary hypertension ) is rare , and often results in right heart failure . There are not many reports using iNO therapy for pulmonary hypertension of protamine adverse effects [ 2 , 8 , 9 ]. In this case report , we report a patient who developed a marked elevation of sys PAP ( 80 mmHg ) following protamine administration , but without evidence of RV ( right ventricular ) failure or systemic hypotension , for which iNO therapy was started at a concentration of 20 ppm . PAP gradually decreased , and after entering the ICU , sys PAP decreased to 35 mmHg . iNO therapy was started
* Corresponding author : tommo . tommo @ outlook . jp with a concentration of 20 ppm , PAP gradually decreased , and after entering the ICU , sys PAP decreased to 35 mmHg .
Case report
The patient ( height 155 cm ; weight 64.1 kg ) had a history of MVP twenty-three years ago . The patient was diagnosed with moderate mitral valve regurgitation ( MR ) recurring by transthoracic echocardiography ( TTE ). Additional echo findings were left ventricular ejection fraction ( LVEF ) of 56 %, left ventricular internal dimension in diastole ( LVDd ) of 56.4 mm , left ventricular internal in systole ( LVDs ) was measured at 39.5 mm , tricuspid regurgitation peak gradient ( TRPG ) of 42.5 mmHg , and tricuspid valve regurgitation ( TR ). A right heart catheterization revealed features indicative of moderate pulmonary hypertension ( PH ) with the following parametric values : PAP , 52 / 23 mmHg ( mean , 30 mmHg ), pulmonary capillary wedge pressure ( PCWP ), 24 mmHg , RVP 38 / 12 ( mean , 15 mmHg ), central venous pressure ( CVP ), 17 mmHg , cardiac index ( CI ), 2.8 L / min / m 2 , calculated total pulmonary resistance ( TPR ), 1733 dyne / s / cm 5 , and pulmonary vascular
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