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Norepinephrine Induced Pulmonary Congestion in Patients with Aortic Valve Regurgitation

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Norepinephrine Induced Pulmonary Congestion in Patients with Aortic Valve Regurgitation NOREPINEPHRINE INDUCED PULMONARY CONGESTION IN PATIENTS WITH AORTIC VALVE REGURGITATION Timothy J. Regan, … , Kenan Binak, Harper K. Hellems J Clin Invest. 1959;38(9):1564-1571. https://doi.org/10.1172/JCI103935. Research Article Find the latest version: https://jci.me/103935/pdf NOREPINEPHRINE INDUCED PULMONARY CONGESTION IN PATIENTS WITH AORTIC VALVE REGURGITATION * By TIMOTHY J. REGAN, VALENTINO DEFAZIO, KENAN BINAKt AND HARPER K. HELLEMS (From the Cardiovascular Research Laboratories, Departments of Medicine, Wayne State Uni- versity College of Medicine, and City of Detroit Receiving Hospital, Detroit, Mich.) (Submitted for publication March 3, 1959; accepted May 14, 1959) The regulation of venous blood flow into the METHODS heart and the effects of blood volume redistribution All subjects were studied in the fasting state approxi- upon cardiac function have not been amply defined. mately two hours after receiving 0.1 Gm. of pentobarbital While enhanced venomotor tone induced by nor- sodium. A double lumen catheter was used to measure epinephrine has been found to increase the volume pressures simultaneously from the pulmonary "capillary" and pulmonary artery. The "capillary" position was as- of a central reservoir in the dog (1), such a vol- sumed to be present when the catheter could not be ad- ume shift has not been demonstrated in man, ex- vanced farther in the lung bed, the tip did not move with cept inferentially by the finding of a decrease in the cardiac cycle and a compatible pressure pattern was the limb venous volume (2). obtained. A specimen of blood saturated with oxygen This type of alteration might be expected to af- was secured from the wedged catheter tip whenever this particularly was possible. fect cardiopulmonary hemodynamics, After serial oxygen consumptions showed constancy, in a situation where the volume of this central 15 mg. of Evans blue dye was injected into the pulmo- system has already been expanded. Such a state, nary artery and collected at two second intervals in a exclusive of congestive failure, occurs to a notable rotating fraction collector from a Cournand needle in the degree in aortic regurgitation where deficient valve brachial artery. Total collection time was about 50 sec- function fails to limit diastolic volume. Thus, a onds to accommodate the expected prolongation of the dye curve downslope, and was followed by a simultaneous study of the response to norepinephrine in eight recording of the systemic arterial, pulmonary arterial and patients with this clinical state has been contrasted "capillary" pressures with electrically integrated means. with the findings in seven normals. An infusion of norepinephrine, 0.2 ,ug. per Kg. of body weight per minute, was then begun through a polyethyl- ene tube lying in the subclavian vein and continued for 15 PATIENT MATERIAL minutes. The electrocardiogram and pressures from the Eight patients with isolated aortic regurgitation due to pulmonary "capillary," pulmonary artery and brachial rheumatic fever, lacking clinical and hemodynamic evi- artery were recorded continuously. At 15 minutes, Evans dence of mitral stenosis, were selected for this study. blue dye was again injected. The effect of venous occlu- All had substantial left ventricular enlargement with the sion upon the norepinephrine response was assessed by point of maximum apical impulse occurring in the sixth repeating the infusion in four patients. Sphygmomanom- interspace, at, or within a few centimeters of, the an- eter cuffs had been applied to three extremities at dias- terior axillary line, while the electrocardiogram showed tolic arterial pressure levels 15 minutes previously and a left ventricular hypertrophy pattern in each instance. maintained during the subsequent 15 minute infusion. At the time of study, there were no symptoms or signs Since the assessment of the cardiac responsiveness to of heart failure, although three patients had had previ- filling pressure and arterial pressure elevation requires ous manifestations of decompensation and were subse- information on the volume of blood which the contracting quently well controlled on digitalis. Seven subjects were muscle ejects, the quantity partitioned into the forward chosen for control studies. All had normal hearts by and regurgitant flow must be ascertained. While the physical examination, X-ray and the electrocardiogram. former is obtained with reasonable accuracy by the Hamilton method, the reliability of current methods for * This investigation was supported by Grant H-1492, estimating regurgitation in man is not established. The National Heart Institute, National Institutes of Health, method most thoroughly scrutinized is that devised by United States Public Health Service; Michigan Heart Korner and Shillingford (3). Association; and by the Receiving Hospital Research The validity of this method of estimating regurgitant Corporation. flow depends upon the thesis that the downslope of the t Research Fellow. Rockefeller Foundation (1958- descending limb of the indicator dilution curve is fixed 1959). for a given cardiac output and central volume. The pres- 1564 NOREPINEPHRINE INDUCED PULMONARY CONGESTION 1565 ence of valvular incompetence produces a decrease in the tion in the interpretation of dilution curves. The cham- gradient of this downslope which is used as a measure of ber size and elasticity factors during the infusion of regurgitant flow. norepinephrine are, in all probability, opposite in direction Minor variations of this gradient have been observed to those associated with the large error alluded to above between normal subjects with the same forward flow and for the following reasons. Epinephrine in the dog has central volume and place a limit on the accuracy of back- been shown with a cinefluorographic technique to increase flow quantification in a given patient (3). However, when the left ventricular diastolic area (10), and a similar sequential testing is performed, this inaccuracy is dimin- change may be inferred for norepinephrine from the rise ished (4, 5). While it is generally agreed that small val- in left ventricular diastolic pressures associated with its vular leaks are not reliably detected by this method (6), use (11). Similar pressure changes occur in man, judged gross leakage, sufficient to be clinically certain, is usu- by left atrial mean pressures (12). Since the distensi- ally detectable (5) and thus, the patients chosen were bility of the ventricle is increased by epinephrine (11), those who appeared to have a substantial, isolated, re- such pressure changes would imply a greater diastolic vol- gurgitant lesion of the aortic valve. Moreover, the modi- ume in the left ventricle. fication of this flow in the same model or patient may be The calculation of resistances to forward flow was fairly accurately detected, if sufficiently large, once one done by accepted methods, as was the total left ventricular already has an indicator dilution curve for comparative stroke work, with a correction for the contribution of fill- purposes describing the particular system to be modified ing pressure to the calculated ventricular work (13). (4, 5). Since the slopes of the dye curve may allegedly be Statistical significance was appraised by the Fischer "t' altered by inadequate flow rates to the fraction collector test method (14). (7), it is pertinent to note that the volumes collected in Since none of the patients selected had mitral stenosis, the control state were above this minimal rate. As the use of the pulmonary "capillary" mean pressure as a the collection volumes increased after norepinephrine, measure of the filling pressure of the left ventricle ap- with and without tourniquets, any change in the dye pears justified: first of all by its close correspondence to curve slope would also not be ascribed to this factor. the left atrial mean pressures in man (15); and sec- In addition, the qualitative contour of the curve has been ondly, by a sufficiently close correlation of this latter found not significantly altered despite varied sampling parameter with the end-diastolic pressure of the left ven- volumes obtained through simultaneous determinations tricle to minimize inaccuracy in the interpretation of the from the ear, radial and femoral arteries (8). relation of filling pressure to stroke work (16). Direct The calculation of the reciprocal of the slope predicted measurement of the force of ventricular contraction, show- for a given cardiac output and central volume (Hamilton ing a linear relationship with calculated stroke work dur- method) was derived from the Korner-Shillingford re- ing the changes induced by norepinephrine, justifies the gression equation based on 91 indicator dilution curves: use of this parameter as a measure of contractility (17). log 1/s = 0.8766 - 0.0614 (cardiac output) + 1.129 log vol- Calculation of the transaortic valvular pressure differ- ume. In the absence of valvular insufficiency or shunts, ence throughout diastole was not feasible in the absence, these authors, based on studies in models and patients, in nearly all instances, of a suitable dicrotic notch in the claimed that 1/s is quite predictable. In a modification of brachial arterial curve to indicate the onset of diastole. the original method (6), the observed slope is calcu- Left ventricular pressure curves, not warranted in these lated from the semilogarithmically plotted curve: patients, would constitute the only means of timing the diastolic phase precisely. Thus, we have employed
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