Cardiovascular effects of prolonged milrinone inhalation in patients with pulmonary hypertension undergoing mitral valve replacement

Sultan, Sherif S; Abdelsalam, Khaled M.A.

doi:10.4103/1687-7934.172666

Cited by 3 publications

(6 citation statements)

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“…9 Intravenous milrinone in contrast, is distributed even in post-CPB atelectatic but perfused segments of the lungs, resulting in aggravation of preexisting intrapulmonary shunting. 9–11 , 16 This was confirmed by the significantly higher post-CPB intrapulmonary shunt fraction (Qs/Qt) in the IVMil group compared to the iMil group in our study. The PaO 2 /FiO 2 ratio was also increased significantly in the iMil group compared to the IVMil group, further suggesting reduced ventilation-perfusion mismatch by milrinone inhalation.…”

Section: Discussionsupporting

confidence: 70%

“…Milrinone has a rapid onset of action and has been proven in many studies to be effective in decreasing PAP after surgery. 16 , 17 Although the effect of inhaled milrinone lasts for only 20 to 30 min, 8 , 9 after cessation of inhalation, our findings indicate that the effect is sufficient to prevent an acute post-CPB rise in PAP. In our study, milrinone inhalation led to a significant reduction in systolic pulmonary artery pressure, MPAP, PVRI, and PVRI/SVRI ratio despite a decrease in SVRI, ultimately resulting in an increase in CI.…”

Section: Discussionmentioning

confidence: 62%

“…The reduction in PAP in our study was higher than in previously reported studies; this was because all patients included in our study had higher mean gradients across the mitral valve, as suggested by high PCWP, compared to those in previous studies. 10 , 11 , 16 High PCWP contributed to the higher passive component of PH that was completely reversible after mitral valve replacement. The significant reduction in TPG at timepoints T1 and T2 in the iMil group suggests a superior pulmonary vasodilatory effect on the pulmonary vasculature of inhaled milrinone.…”

Section: Discussionmentioning

confidence: 99%

“…Similar to the results of previous studies, we did not find any significant change in systemic arterial pressure due to either type of milrinone therapy. 10 , 16…”

Section: Discussionmentioning

confidence: 99%

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Inhaled versus intravenous milrinone in mitral stenosis with pulmonary hypertension

Patel

Garg

et al. 2020

Asian Cardiovasc Thorac Ann

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Objective To evaluate and compare the hemodynamic effects of intraoperative intravenous milrinone versus inhalational milrinone at two timepoints in patients with severe pulmonary hypertension undergoing mitral valve surgery. Methods A prospective observational study was performed in 100 patients with severe rheumatic mitral stenosis (with/without regurgitation) and right ventricular systolic pressure > 50 mm Hg. They were divided into two groups based on the strategy used to reduce pulmonary hypertension. Fifty patients had inhalational milrinone after sternotomy until initiation of cardiopulmonary bypass and after release of the aortic crossclamp until weaning off cardiopulmonary bypass. The other 50 patients received an intravenous loading dose of milrinone 50 µg·kg−1 over 10 min on release of the aortic crossclamp. Both groups received intravenous milrinone 0.5 µg·kg−1 during weaning from cardiopulmonary bypass. Hemodynamic data were evaluated at the 3 timepoints. Results Pulmonary artery pressures, central venous pressure, and pulmonary capillary wedge pressure decreased significantly in the inhalational milrinone group compared to the intravenous milrinone group. Systemic vascular resistance index and cardiac index were significantly higher and pulmonary vascular resistance index was significantly lower in the inhalational milrinone group. The mean arterial pressure-to-mean pulmonary artery pressure ratio was significantly lower in the intravenous milrinone group. Tricuspid annular plane systolic excursion and right ventricular fractional area change were increased significantly in the inhalational milrinone group. Conclusion Intraoperative inhalational milrinone before and after cardiopulmonary bypass is safe, easy to administer, and results in significant improvements in right ventricular hemodynamics, right ventricular function, and systemic hemodynamics.

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Section: Discussionsupporting

confidence: 70%

Section: Discussionmentioning

confidence: 62%

Section: Discussionmentioning

confidence: 99%

“…Similar to the results of previous studies, we did not find any significant change in systemic arterial pressure due to either type of milrinone therapy. 10 , 16…”

Section: Discussionmentioning

confidence: 99%

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Inhaled versus intravenous milrinone in mitral stenosis with pulmonary hypertension

Patel

Garg

et al. 2020

Asian Cardiovasc Thorac Ann

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“…In a multicenter randomized clinical trial of high-risk cardiac surgical patients, Denault et al 8 showed that iM alone did not improve clinically relevant endpoints such as difficult or complex separation from CPB despite being associated with favorable hemodynamic effects. 8,39 Similarly, in 2 other multicenter trials, neither the prophylactic inhalation of iloprost, 9 a prostacyclin analog, nor the intravenous perfusion of tezosentan, 3 a competitive endothelin-receptor antagonist, improved clinical outcomes in high-risk cardiac surgical patients. The use of CPB is associated with induction of inflammatory responses through various pathophysiological mechanisms that can lead to multiorgan dysfunction, including coagulopathy, endothelial dysfunction, ischemia-reperfusion injury, myocardial dysfunction, renal complications, and neurocognitive decline.…”

Section: Discussionmentioning

confidence: 99%

Pulmonary Vasodilator Response of Combined Inhaled Epoprostenol and Inhaled Milrinone in Cardiac Surgical Patients

Elmi-Sarabi

Jarry

Couture

et al. 2022

Anesthesia &Amp; Analgesia

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BACKGROUND: Pulmonary hypertension (PH) and right ventricular (RV) dysfunction are major complications in cardiac surgery. Intraoperative management of patients at high risk of RV failure should aim to reduce RV afterload and optimize RV filling pressures, while avoiding systemic hypotension, to facilitate weaning from cardiopulmonary bypass (CPB). Inhaled epoprostenol and inhaled milrinone (iE&iM) administered in combination before CPB may represent an effective strategy to facilitate separation from CPB and reduce requirements for intravenous inotropes during cardiac surgery. Our primary objective was to report the rate of positive pulmonary vasodilator response to iE&iM and, second, how it relates to perioperative outcomes in cardiac surgery. METHODS: This is a retrospective cohort study of consecutive patients with PH or RV dysfunction undergoing on-pump cardiac surgery at the Montreal Heart Institute from July 2013 to December 2018 (n = 128). iE&iM treatment was administered using an ultrasonic mesh nebulizer before the initiation of CPB. Demographic and baseline clinical data, as well as hemodynamic, intraoperative, and echocardiographic data, were collected using electronic records. An increase of 20% in the mean arterial pressure (MAP) to mean pulmonary artery pressure (MPAP) ratio was used to indicate a positive response to iE&iM. RESULTS: In this cohort, 77.3% of patients were responders to iE&iM treatment. Baseline systolic pulmonary artery pressure (SPAP) (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.24-2.16 per 5 mm Hg; P = .0006) was found to be a predictor of pulmonary vasodilator response, while a European System for Cardiac Operative Risk Evaluation (EuroSCORE II) score >6.5% was a predictor of nonresponse to treatment (≤6.5% vs >6.5% [reference]: OR, 5.19; 95% CI, 1.84-14.66; P = .002). Severity of PH was associated with a positive response to treatment, where a higher proportion of responders had MPAP values >30 mm Hg (42.4% responders vs 24.1% nonresponders; P = .0237) and SPAP values >55 mm Hg (17.2% vs 3.4%; P = .0037). Easier separation from CPB was also associated with response to iE&iM treatment (69.7% vs 58.6%; P = .0181). A higher proportion of nonresponders had a very difficult separation from CPB and required intravenous inotropic drug support compared to responders, for whom easy separation from CPB was more frequent. Use of intravenous inotropes after CPB was lower in responders to treatment (8.1% vs 27.6%; P = .0052). CONCLUSIONS: A positive pulmonary vasodilator response to treatment with a combination of iE&iM before initiation of CPB was observed in 77% of patients. Higher baseline SPAP was an independent predictor of pulmonary vasodilator response, while EuroSCORE II >6.5% was a predictor of nonresponse to treatment. (Anesth Analg 2023;136:282-94) KEY POINTS• Question: Can a combination of inhaled epoprostenol and inhaled milrinone (iE&iM) administered before cardiopulmonary bypass (CPB) provide a positive pulmonary vasodilator response? • Findings: A positive pul...

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Early and mid-term outcome of inhaled versus intravenous milrinone in patients with rheumatic mitral stenosis and pulmonary hypertension undergoing mitral valve surgery

Patel,

Garg,

Madkaiker

et al. 2024

HVT

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Cardiovascular effects of prolonged milrinone inhalation in patients with pulmonary hypertension undergoing mitral valve replacement

Cited by 3 publications

References 0 publications

Inhaled versus intravenous milrinone in mitral stenosis with pulmonary hypertension

Inhaled versus intravenous milrinone in mitral stenosis with pulmonary hypertension

Pulmonary Vasodilator Response of Combined Inhaled Epoprostenol and Inhaled Milrinone in Cardiac Surgical Patients

Early and mid-term outcome of inhaled versus intravenous milrinone in patients with rheumatic mitral stenosis and pulmonary hypertension undergoing mitral valve surgery

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