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15 September 1994 | Volume 121 Issue 6 | Pages 409-415
Objective: To evaluate the effects of long-term intravenous infusion of prostacyclin on exercise capacity, hemodynamics, and survival in patients with primary pulmonary hypertension.
Design: Open, multicenter, uncontrolled trial.
Setting: Four referral centers.
Patients: 18 patients with primary pulmonary hypertension: 1 New York Heart Association (NYHA) class II patient, 13 NYHA class III patients, and 4 NYHA class IV patients.
Interventions: Continuous intravenous prostacyclin administered by portable infusion pumps. All patients were treated with anticoagulant agents.
Measurements and Main Results: With the 6-minute walk used to evaluate exercise capacity, patients could walk on average more than 100 meters farther after prostacyclin therapy was initiated (distance at 6 months, 370 ±119 meters compared with 264 ±160 meters at baseline; P < 0.001; distance at 18 months, 408 ±138 meters; P = 0.02 compared with baseline). Hemodynamics were improved at 6 months: The cardiac index increased 18% (95% CI, 0.1% to 36.7%; P = 0.02), and mean pulmonary artery pressure and total pulmonary resistance decreased 9% (CI, 1.4% to 15.7%; P = 0.03) and 26% (CI, 6.1% to 46.3%; P = 0.02), respectively, compared with baseline. The improvements in cardiac index and total pulmonary resistance were maintained at 12 months (27% increase [CI, 1.3% to 51.9%; P = 0.05] and 32% decrease [CI, 9.7% to 53.6%; P = 0.02] compared with baseline, respectively). Survival was improved in NYHA class III and IV patients who received continuous prostacyclin (n = 17; follow-up, 37 to 69 months) when compared with historical controls who received standard therapy (National Institutes of Health Primary Pulmonary Hypertension Registry, n = 31, P = 0.045). Kaplan-Meier estimates of 1-, 2-, and 3-year survival rates for the patients treated with prostacyclin were 86.9%, 72.4%, and 63.3%, respectively, compared with 77.4%, 51.6%, and 40.6% for the historical control group (hazard ratio, 2.9 [CI, 1.0 to 8.0; P = 0.045]). Serious complications attributable to the drug and delivery system included two deaths and seven episodes of nonfatal sepsis in three patients.
Conclusions: Continuous intravenous prostacyclin resulted in sustained clinical and hemodynamic improvement and probably in improved survival in patients with severe primary pulmonary hypertension. Despite potentially serious complications, long-term prostacyclin may be especially helpful in seriously ill patients awaiting transplantation.
Author and Article Information
From the Columbia University College of Physicians and Surgeons, New York, New York; the University of Maryland Medical System, Baltimore, Maryland; Mayo Clinic, Rochester, Minnesota; Maine Medical Center, Portland, Maine; Burroughs Wellcome Co., Research Triangle Park, North Carolina; University of Illinois, Chicago, Illinois.
ARTICLE
Survival in Primary Pulmonary Hypertension with Long-Term Continuous Intravenous Prostacyclin
Requests for Reprints: Robyn J. Barst, MD, Columbia University College of Physicians and Surgeons, Division of Pediatric Cardiology, 3959 Broadway, New York, NY 10032.
Acknowledgments: The authors thank Jillian Kirkpatrick, Michele Hood, Lori Hartle, Cathy Severson, and Beth Vogel for technical assistance.
Grant Support: In part by a grant from Burroughs Wellcome Co., Research Triangle Park, North Carolina. Dr. Rubin is the recipient of an Academic Award in Vascular Disease from the National Heart, Lung, and Blood Institute, National Institutes of Health.
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D. Wax, R. Garofano, and R. J. Barst Effects of Long-term Infusion of Prostacyclin on Exercise Performance in Patients With Primary Pulmonary Hypertension Chest, October 1, 1999; 116(4): 914 - 920. [Abstract] [Full Text] [PDF]
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S. Kesten, J. Dainauskas, V. McLaughlin, and S. Rich Development of Nonspecific Interstitial Pneumonitis Associated With Long-term Treatment of Primary Pulmonary Hypertension With Prostacyclin Chest, August 1, 1999; 116(2): 566 - 569. [Abstract] [Full Text] [PDF]
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H. OLSCHEWSKI, H. ARDESCHIR GHOFRANI, D. WALMRATH, R. SCHERMULY, B. TEMMESFELD-WOLLBRÜCK, F. GRIMMINGER, and W. SEEGER Inhaled Prostacyclin and Iloprost in Severe Pulmonary Hypertension Secondary to Lung Fibrosis Am. J. Respir. Crit. Care Med., August 1, 1999; 160(2): 600 - 607. [Abstract] [Full Text]
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R. J. Barst, G. Maislin, and A. P. Fishman Vasodilator Therapy for Primary Pulmonary Hypertension in Children Circulation, March 9, 1999; 99(9): 1197 - 1208. [Abstract] [Full Text] [PDF]
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 Y. Numaguchi, K. Naruse, M. Harada, H. Osanai, S. Mokuno, K. Murase, H. Matsui, Y. Toki, T. Ito, K. Okumura, et al. Prostacyclin Synthase Gene Transfer Accelerates Reendothelialization and Inhibits Neointimal Formation in Rat Carotid Arteries After Balloon Injury Arterioscler. Thromb. Vasc. Biol., March 1, 1999; 19(3): 727 - 733. [Abstract] [Full Text] [PDF]
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 S. G Haworth Primary pulmonary hypertension in childhood Arch. Dis. Child., November 1, 1998; 79(5): 452 - 455. [Full Text]
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M. J. Ricciardi, B. P. Knight, F. J. Martinez, and M. Rubenfire Inhaled nitric oxide in primary pulmonary hypertension: A safe and effective agent for predicting response to nifedipine J. Am. Coll. Cardiol., October 1, 1998; 32(4): 1068 - 1073. [Abstract] [Full Text] [PDF]
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H. S. Mueller, K. Chatterjee, K. B. Davis, M. A. Fifer, C. Franklin, M. A. Greenberg, A. J. Labovitz, P. K. Shah, K. J. Tuman, M. H. Weil, et al. Present use of bedside right heart catheterization in patients with cardiac disease J. Am. Coll. Cardiol., September 1, 1998; 32(3): 840 - 864. [Full Text] [PDF]
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 I. M. Robbins, L. L. Cuiper, C. M. Stein, A. J. J. Wood, H. B. He, R. Parker, and B. W. Christman Angiotensin II mediates systemic rebound hypertension after cessation of prostacyclin infusion in sheep J Appl Physiol, August 1, 1998; 85(2): 731 - 737. [Abstract] [Full Text] [PDF]
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C. A Keller The donor lung: conservation of a precious resource Thorax, June 1, 1998; 53(6): 506 - 513. [Full Text]
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T W Higenbottam, A Y Butt, A T Dinh-Xaun, M Takao, G Cremona, and S Akamine Treatment of pulmonary hypertension with the continuous infusion of a prostacyclin analogue, iloprost Heart, February 1, 1998; 79(2): 175 - 179. [Abstract] [Full Text]
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V. V. McLaughlin, D. E. Genthner, M. M. Panella, and S. Rich Reduction in Pulmonary Vascular Resistance with Long-Term Epoprostenol (Prostacyclin) Therapy in Primary Pulmonary Hypertension N. Engl. J. Med., January 29, 1998; 338(5): 273 - 277. [Abstract] [Full Text] [PDF]
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 M. M. Höper, N. F. Voelkel, T. O. Bates, J. D. Allard, M. Horan, D. Shepherd, and R. M. Tuder Prostaglandins Induce Vascular Endothelial Growth Factor in a Human Monocytic Cell Line and Rat Lungs via cAMP Am. J. Respir. Cell Mol. Biol., December 1, 1997; 17(6): 748 - 756. [Abstract] [Full Text]
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R. Friedman, J. G. Mears, and R. J. Barst Continuous Infusion of Prostacyclin Normalizes Plasma Markers of Endothelial Cell Injury and Platelet Aggregation in Primary Pulmonary Hypertension Circulation, November 4, 1997; 96(9): 2782 - 2784. [Abstract] [Full Text]
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 H. Schütte, F. Grimminger, J. Otterbein, R. Spriestersbach, K. Mayer, D. Walmrath, and W. Seeger Efficiency of Aerosolized Nitric Oxide Donor Drugs to Achieve Sustained Pulmonary Vasodilation J. Pharmacol. Exp. Ther., August 1, 1997; 282(2): 985 - 994. [Abstract] [Full Text]
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 Y. Sasaki, T. Takahashi, I. Tanaka, K. Nakamura, Y. Okuno, O. Nakagawa, S. Narumiya, and K. Nakao Expression of Prostacyclin Receptor in Human Megakaryocytes Blood, August 1, 1997; 90(3): 1039 - 1046. [Abstract] [Full Text] [PDF]
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M. HUMBERT, S. M. TRE, F. CAPRON, B. RAIN, D. MUSSET, and G. SIMONNEAU Pulmonary Edema Complicating Continuous Intravenous Prostacyclin in Pulmonary Capillary Hemangiomatosis Am. J. Respir. Crit. Care Med., May 1, 1997; 157(5): 1681 - 1685. [Abstract] [Full Text]
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L. J. Rubin Primary Pulmonary Hypertension N. Engl. J. Med., January 9, 1997; 336(2): 111 - 117. [Full Text] [PDF]
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I. Schulze-Neick, P. E. Lange, N. A. Haas, T. Higenbottam, R. J. Barst, and L. J. Rubin Intravenous Epoprostenol for Primary Pulmonary Hypertension N. Engl. J. Med., May 30, 1996; 334(22): 1477 - 1478. [Full Text]
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R. J. Barst, L. J. Rubin, W. A. Long, M. D. McGoon, S. Rich, D. B. Badesch, B. M. Groves, V. F. Tapson, R. C. Bourge, B. H. Brundage, et al. A Comparison of Continuous Intravenous Epoprostenol (Prostacyclin) with Conventional Therapy for Primary Pulmonary Hypertension N. Engl. J. Med., February 1, 1996; 334(5): 296 - 301. [Abstract] [Full Text] [PDF]
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