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Diagnosis and management of postoperative pulmonary hypertensive crisis
Insights
A rare complication after ventricular septal defect repair involves pulmonary hypertensive crises. Tolazoline effectively treated two of three pediatric patients, improving right ventricular pressures and reducing hypoxia-induced vasoconstriction.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Critical Care Medicine
Background:
- Complete correction of large, unrestrictive ventricular septal defects (VSD) is a standard procedure.
- Uncommon complications can arise postoperatively, necessitating careful monitoring and management.
- Pulmonary hypertensive crises and right-heart failure are severe potential adverse events.
Observation:
- Three pediatric patients developed a previously unreported complication after VSD repair.
- Two patients experienced pulmonary hypertensive crises and severe right-heart failure.
- These crises were linked to hypoxia, pulmonary vasoconstriction, elevated right ventricular pressures, and right-to-left shunting through a patent foramen ovale.
Findings:
- Tolazoline successfully treated the pulmonary hypertensive crises in two of the three patients.
- In one patient, right ventricular pressures normalized post-tolazoline treatment and remained stable for 12 months.
- While tolazoline reduced right ventricular pressures in the third patient, they did not normalize.
Implications:
- Postoperative monitoring of pulmonary artery and right ventricular pressures is crucial for infants with large VSDs, especially when unexplained complications occur.
- Tolazoline demonstrates efficacy in managing pulmonary vasoconstriction secondary to hypoxia in this context.
- Early recognition and intervention are key to managing severe postoperative complications following VSD repair.
Abstract:
In this paper we discuss two infants and one child who experienced a previously unreported complication after complete correction of a large, unrestrictive ventricular septal defect. Two patients had documented pulmonary hypertensive crises and severe right-heart failure secondary to hypoxia and pulmonary vasoconstriction. These crises were associated with significantly increased right ventricular (RV) peak systolic and end-diastolic pressures and right-to-left shunting via a foramen ovale which, in turn, exaggerated the hypoxis. The crises were treated successfully with tolazoline in the second and third patients. RV pressure returned to normal values and have remained normal up to 12 months postoperatively in the second patient. Although the RV pressures decreased with tolazoline in the third patient, they never reached normal values. Postoperative monitoring of pulmonary artery and RV pressures in infants with large ventricular septal defects is essential when unexplained complications are encountered. Tolazoline proved to be very effective in the treatment of two patients with pulmonary vasoconstriction secondary to hypoxia.