Isaac George, MD, Steve Xydas, MD, Veli K

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Clinical Indication for Use and Outcomes After Inhaled Nitric Oxide Therapy Isaac George, MD, Steve Xydas, MD, Veli K. Topkara, MD, Corrina Ferdinando, MD, Eileen C. Barnwell, MS, RRT, Larissa Gableman, Robert N. Sladen, MD, Yoshifumi Naka, MD, PhD, Mehmet C. Oz, MD The Annals of Thoracic Surgery Volume 82, Issue 6, Pages 2161-2169 (December 2006) DOI: 10.1016/j.athoracsur.2006.06.081 Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 (A) Indication for inhaled nitric oxide (iNO) use (black bar = orthotopic heart transplantation [OHT] with pulmonary hypertension; blue bar = precapillary pulmonary hypertension; pink bar = coronary surgery with right ventricular failure; green bar = congenital cardiac disease; red bar = hypoxemia). (OLT = orthotopic lung transplantation; VAD = ventricular assist device.) All orthotopic heart transplant (OHT) and orthotopic lung transplant (OLT) patients received iNO for treatment of pulmonary hypertension, whereas right ventricular failure was the most common indication for patients undergoing cardiac surgery and ventricular assist device (VAD) implantation. (B) Average duration of iNO use per patient. Other surgical and medical patients received iNO predominantly for hypoxemia use. A trend toward a lower average duration of iNO use was seen after OHT (n = 67) and OLT (n = 45) versus cardiac surgery (n = 105), VAD (n = 66), other surgery (n = 34), and medical patients (n = 59; p = 0.09). The Annals of Thoracic Surgery 2006 82, 2161-2169DOI: (10.1016/j.athoracsur.2006.06.081) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Cumulative mortality after inhaled nitric oxide (iNO) therapy by patient group and by indication for clinical use. (A) Cumulative mortality was lower among orthotopic heart transplant (OHT) and orthotopic lung transplant (OLT) patients after iNO therapy versus cardiac surgery, ventricular assist device (VAD) implantation, other surgery, and medical patients (*p < 0.05 versus cardiac surgery, VAD, other surgery, and medical; #p < 0.05 versus medical). (Solid bar = in-hospital mortality; open bar = cumulative mortality.) (B) Mortality rate was lowest among OHT patients with pulmonary hypertension (PHTN) versus all other indications (†p < 0.05 versus precapillary PHTN, coronary surgery with right ventricular failure (RVF), hypoxemia; §p < 0.05 versus hypoxemia). The Annals of Thoracic Surgery 2006 82, 2161-2169DOI: (10.1016/j.athoracsur.2006.06.081) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 (A, B) Kaplan-Meier survival curves after inhaled nitric oxide (iNO) therapy. (OHT = orthotopic heart transplantation; OLT = orthotopic lung transplantation; PHTN = pulmonary hypertension; Pre-Cap = precapillary; RVF = right ventricular failure; VAD = ventricular assist device.) The Annals of Thoracic Surgery 2006 82, 2161-2169DOI: (10.1016/j.athoracsur.2006.06.081) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A) Relationship between mortality after inhaled nitric oxide (iNO) therapy and risk score. The risk score was calculated using independent predictors of mortality from multivariate analysis (risk score = non–heart transplant diagnosis + respiratory failure). A risk score of greater than 1 is associated with high mortality after iNO therapy. (B) Non–heart transplant diagnosis and respiratory failure (independent risk factors on multivariate analysis) were used in a scoring system to generate an estimate of risk, validated by agreement measured by the area under the curve (AUC of the receiver operating characteristic curve). The Annals of Thoracic Surgery 2006 82, 2161-2169DOI: (10.1016/j.athoracsur.2006.06.081) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions