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(Circulation. 2002;106:I-76.)
© 2002 American Heart Association, Inc.

Surgery for Congenital Heart Disease

Inhaled Nitric Oxide as a Preoperative Test (INOP Test I)

The INOP Test Study Group

David T. Balzer, MD; Henry W. Kort, MD; Ronald W. Day, MD; Howard M. Corneli, MD; John P. Kovalchin, MD; Bryan C. Cannon, MD; Stephen F. Kaine, MD; D. Dunbar Ivy, MD; Steven A. Webber, MD; Abraham Rothman, MD; Robert D. Ross, MD; Sanjeev Aggarwal, MD; Masato Takahashi, MD; J. Deane Waldman, MD, MBA

From the St. Louis Children’s Hospital, St. Louis, Mo. (D.T.B., H.W.K.); Primary Children’s Medical Center, Salt Lake City, Utah (R.W.D., H.M.C.); Texas Children’s Hospital, Houston, Tex. (J.P.K., B.C.C.); Children’s Mercy Hospital, Kansas City, Mo. (S.F.K.); Children’s Hospital of Denver, Denver, Colo. (D.D.I.); Children’s Hospital of Pittsburgh, Pittsburgh, Pa. (S.A.W.); University of California, San Diego, San Diego, Calif. (A.R.); Children’s Hospital of Michigan, Detroit, Mich. (R.D.R., S.A.); Children’s Hospital of Los Angeles, Los Angeles, Calif. (M.T.); University of New Mexico, Albuquerque, NM (J.D.W.). Authors are listed according to the number of patients enrolled from their respective institutions.

Correspondence to Ronald W. Day, MD, Pediatric Cardiology, Primary Children’s Medical Center, 100 North Medical Drive, Salt Lake City, Utah 84113. E-mail ron.day{at}hsc.utah.edu

Abstract

Background This study was performed to determine whether a preoperative hemodynamic evaluation with oxygen and inhaled nitric oxide identifies patients with pulmonary hypertension who are appropriate candidates for corrective cardiac surgery or transplantation more accurately than an evaluation with oxygen alone.

Methods and Results At 10 institutions, 124 patients with heart disease and severe pulmonary hypertension underwent cardiac catheterization to determine operability. The ratio of pulmonary and systemic vascular resistance (Rp:Rs) was determined at baseline while breathing 21% to 30% oxygen, and in 100% oxygen and 100% oxygen with 10 to 80 parts per million nitric oxide to evaluate pulmonary vascular reactivity. Surgery was performed in 74 patients. Twelve patients died or developed right heart failure secondary to pulmonary hypertension following surgery. Rp:Rs<0.33 and a 20% decrease in Rp:Rs from baseline were chosen as 2 criteria for operability to determine, in retrospect, the efficacy of preoperative testing in patient selection. In comparison to an evaluation with oxygen alone, sensitivity (64% versus 97%) and accuracy (68% versus 90%) were increased by an evaluation with oxygen and nitric oxide when Rp:Rs<0.33 was used as the criterion for operability. Specificity was only 8% when a 20% decrease in Rp:Rs from baseline was used as the criterion for operability.

Conclusion By using a combination of oxygen and inhaled nitric oxide, a greater number of appropriate candidates for corrective cardiac surgery or transplantation can be identified during preoperative testing when a specific value of Rp:Rs is used as a criterion for operability.

Key Words: heart defects, congenital • hypertension, pulmonary • nitric oxide • oxygen • surgery