Inhaled epoprostenol (prostacyclin) and pulmonary hypertension before cardiac surgery

Haché, Manon; Denault, André; Bélisle, Sylvain; Robitaille, Danielle; Couture, Pierre; Sheridan, Peter J.; Pellerin, Michel; Babin, Denis; Noël, Nicolas; Guertin, Marie-Claude; Martineau, Raymond; Dupuis, Jocelyn

doi:10.1067/mtc.2003.107

Cited by 86 publications

(71 citation statements)

References 30 publications

(36 reference statements)

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“…21,22 For patients with pulmonary hypertension, pulmonary vasodilators have been shown to improve outcomes. 23,24 For the restrictive LV, milrinone has had mixed results 25,26 whereas close monitoring and optimization of volume status and filling pressures remains the mainstay.…”

Section: Discussionmentioning

confidence: 99%

Incremental Value of the Preoperative Echocardiogram to Predict Mortality and Major Morbidity in Coronary Artery Bypass Surgery

et al. 2013

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Background— Although echocardiography is commonly performed before coronary artery bypass surgery, there has yet to be a study examining the incremental prognostic value of a complete echocardiogram. Methods and Results— Patients undergoing isolated coronary artery bypass surgery at 2 hospitals were divided into derivation and validation cohorts. A panel of quantitative echocardiographic parameters was measured. Clinical variables were extracted from the Society of Thoracic Surgeons database. The primary outcome was in-hospital mortality or major morbidity, and the secondary outcome was long-term all-cause mortality. The derivation cohort consisted of 667 patients with a mean age of 67.2±11.1 years and 22.8% females. The following echocardiographic parameters were found to be optimal predictors of mortality or major morbidity: severe diastolic dysfunction, as evidenced by restrictive filling (odds ratio, 2.96; 95% confidence interval, 1.59-5.49), right ventricular dysfunction, as evidenced by fractional area change <35% (odds ratio, 3.03; 95% confidence interval, 1.28-7.20), or myocardial performance index >0.40 (odds ratio, 1.89; 95% confidence interval, 1.13-3.15). These results were confirmed in the validation cohort of 187 patients. When added to the Society of Thoracic Surgeons risk score, the echocardiographic parameters resulted in a net improvement in model discrimination and reclassification with a change in c-statistic from 0.68 to 0.73 and an integrated discrimination improvement of 5.9% (95% confidence interval, 2.8%-8.9%). In the Cox proportional hazards model, right ventricular dysfunction and pulmonary hypertension were independently predictive of mortality over 3.2 years of follow-up. Conclusions— Preoperative echocardiography, in particular right ventricular dysfunction and restrictive left ventricular filling, provides incremental prognostic value in identifying patients at higher risk of mortality or major morbidity after coronary artery bypass surgery.

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Section: Discussionmentioning

confidence: 99%

Incremental Value of the Preoperative Echocardiogram to Predict Mortality and Major Morbidity in Coronary Artery Bypass Surgery

et al. 2013

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“…Our inter-observer variability for the assessment of systolic and diastolic function has been published previously. 1,2,4,20,21 The use of the LV diastolic dysfunction and right ventricular diastolic dysfunction criteria were previously validated 2 using Cohen's kappa values. 22 The kappa values were 0.77 and 0.82 for inter-observer agreement for the left and right ventricular evaluations respectively.…”

Section: Transesophageal Echocardiographic Measurementsmentioning

confidence: 99%

Milrinone enhances systolic, but not diastolic function during coronary artery bypass grafting surgery

Couture

Denault

Pellerin

et al. 2007

Can J Anesth/J Can Anesth

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Purpose:To evaluate the effect of milrinone on diastolic function during coronary artery bypass grafting surgery (CABG). Methods:Fifty patients undergoing CABG were randomized to receive a bolus and infusion of milrinone or placebo before cardiopulmonary bypass (CPB) until skin closure. Hemodynamic and transesophageal echocardiographic measurements of systolic and diastolic function were obtained. Pulsed wave Doppler measurements of the early (E wave) and atrial components (A wave) of the transmitral (TMF) and transtricuspid (TTF) flows, and systolic (S wave), diastolic (D wave) and atrial components (Ar) of the pulmonary (PVF) and hepatic venous blood flow (HVF) velocities were performed. Early and atrial components of the mitral (Em and Am waves) and tricuspid annulus velocities (Et and At waves) were assessed by tissue Doppler imaging (TDI). Assessment of diastolic dysfunction was graded from normal to severe using a scale score.Results: Cardiac index and heart rate were higher in the milrinone group compared to placebo after the administration of study drug (2.8 ± 0.6 vs 2.1 ± 0.5 L·min -1 m -2 ) (P < 0.0001) and (67 ± 8 vs 60 ± 12 beats·min -1 ) (P < 0.05) respectively. There were no changes in left and right ventricular diastolic dysfunction scores between study groups. Higher PVF S wave, HVF S wave, TTF A wave and At measured by TDI in the milrinone group compared with placebo suggested an improvement in ventricular systolic and atrial contraction. Conclusion:Distinct from its effects on systolic function, milrinone administered before CPB is not with associated improved biventricular diastolic function in patients undergoing CABG. Objectif : Evaluer l'effet de la milrinone sur la fonction diastolique durant un pontage aortocoronarien (PAC). Méthode : Cinquante patients subissant un PAC ont été randomisés à recevoir soit une dose bolus et une perfusion de milrinone, soit un placebo avant la circulation extracorporelle (CEC) jusqu'à fermeture de la peau. Les mesures hémodynamiques et échocardiographiques transoesophagiennes des fonctions systolique et diastolique ont été obtenues. Les mesures Doppler pulsées des composantes précoces (onde E) et auriculaires (onde A) des débits transmitral (TMF) et transtricuspide (TTF), et les composantes systolique (onde S) diastolique (onde D) et auriculaires (Ar) des vélocités du débit sanguin veineux pulmonaire (PVF) et hépatique (HVF) ont été prises. Les composantes précoces et auriculaires des vélocités de l'anneau mitral (ondes Em et Am) et de l'anneau tricuspide (ondes Et et At) ont été mesurées par Doppler tissulaire (TDI

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“…Aerosolized PGI 2 selectively dilates the pulmonary circulation and redistributes PBF away from nonventilated lung regions (19) and has been shown to improve oxygenation in patients with ARDS or acute lung injury (19 -21). Aerosolized PGI 2 reduced pulmonary pressures and improved right ventricular stroke volume in patients with PH undergoing cardiac surgery (22). The data on the effects in the neonate are anecdotal (5,23,24).…”

Section: Discussionmentioning

confidence: 99%

Effects of Prostacyclin and Milrinone on Pulmonary Hemodynamics in Newborn Lambs With Persistent Pulmonary Hypertension Induced by Ductal Ligation

et al. 2006

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Prostacyclin (PGI 2 ) stimulates adenyl cyclase to synthesize cAMP within the vascular smooth muscle resulting in vasodilatation. Milrinone inhibits cAMP clearance by phosphodiesterase type III. We studied the dose response of pulmonary and systemic hemodynamics to intratracheal (IT) PGI 2 in newborn lambs with pulmonary hypertension (PH) and whether intravenous milrinone potentiate these effects. IT-PGI 2 at varying doses was administered to lambs with PH induced by prenatal ductal ligation. IT-PGI 2 doses were repeated in the presence of intravenous milrinone (bolus-100 g/kg followed by infusion at 1 g/kg/min). Increasing doses of IT-PGI 2 significantly decreased mean pulmonary arterial pressures (PAP) and pulmonary vascular resistance (PVR) and increased pulmonary blood flow (PBF). Intravenous milrinone by itself produced a significant reduction in PVR and a significant increase in PBF. Intravenous milrinone significantly shortened the onset, prolonged the duration and degree of pulmonary vasodilation produced by PGI 2 . We conclude that intravenous milrinone potentiates the pulmonary vasodilator effects of PGI 2 at lower doses. (Pediatr Res 60: 624-629, 2006) P PHN is a disorder of term and near term infants with significant morbidity and mortality. PPHN results from disruption of the normal decrease in PVR at birth. PGI 2 , the main cyclo-oxygenase product of arachidonic acid in the vascular tissue, is a potent vasodilator and its actions are mediated by cAMP (1,2). It is one of the important mediators of the decrease in PVR at birth (3,4). PGI 2 has been used widely in the treatment of adults with PH. Although there are reports of PGI 2 being used anecdotally in human infants (5,6), systematic studies on the dose response effects of PGI 2 in PPHN are lacking. Milrinone selectively inhibits PDE3, resulting in accumulation of cAMP in myocardium and vascular smooth muscle, improving myocardial performance and producing vasodilation. Milrinone has been used in patients to improve pulmonary hemodynamics in association with systemic hemodynamic dysfunction (7,8). Studies on the use of milrinone in neonates are lacking. Figure 1 shows the PGI 2 -cAMP signal transduction pathway in the vascular smooth muscle. PGI 2 and milrinone in combination can act synergistically in increasing cAMP levels and hence enhance the relaxation of the vascular smooth muscle.The newborn pulmonary circulation is different from the adult pulmonary circulation in its anatomy and physiology (9,10). The response of the infant with PPHN to NO is closer to that of newborn lambs with persistent pulmonary hypertension induced by ligation of the ductus arteriosus (11) than it is to the response of adult humans with PH. Examination of the responses to manipulating cAMP with PGI 2 and milrinone in such lambs seemed warranted in advance of clinical trials. Thus we studied the dose response to IT PGI 2 , the response to intravenous milrinone and enhancement of the effect of PGI 2 by milrinone in newborn lambs with PH induced by ligation o...

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Inhaled epoprostenol (prostacyclin) and pulmonary hypertension before cardiac surgery

Cited by 86 publications

References 30 publications

Incremental Value of the Preoperative Echocardiogram to Predict Mortality and Major Morbidity in Coronary Artery Bypass Surgery

Incremental Value of the Preoperative Echocardiogram to Predict Mortality and Major Morbidity in Coronary Artery Bypass Surgery

Milrinone enhances systolic, but not diastolic function during coronary artery bypass grafting surgery

Effects of Prostacyclin and Milrinone on Pulmonary Hemodynamics in Newborn Lambs With Persistent Pulmonary Hypertension Induced by Ductal Ligation

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