A comparison of inhaled nitric oxide and milrinone for the treatment of pulmonary hypertension in adult cardiac surgery patients

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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“…[6][7][8][9][10][11][12][13] In addition, milrinone has been shown to improve diastolic performance in patients with congestive heart failure.…”

Section: Méthode : Cinquante Patients Subissant Un Pac Ont éTé Randommentioning

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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“…The effects of intravenous milrinone include pulmonary vasodilatation, systemic vasodilatation and increased inotropy. Milrinone is more efficient than placebo in facilitating weaning from cardiopulmonary bypass (CPB) [11] and is widely used in post-CPB left ventricular dysfunction and low cardiac output [12,13]. However, intravenous milrinone is associated with systemic hypotension and increased vasoactive drug requirements [14].…”

Section: Introductionmentioning

confidence: 99%

Preliminary experience with inhaled milrinone in cardiac surgery☆

Lamarche

Perrault

Maltais

et al. 2007

European Journal of Cardio-Thoracic Surgery

101

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Background: Inhaled administration of milrinone reduces pulmonary artery pressure. Pulmonary hypertension (PH) and right heart failure are associated with difficult separation from cardiopulmonary bypass (CPB). Therefore, inhaled milrinone could facilitate separation from CPB. Objective: To determine the impact and timing of administration of inhaled milrinone. Methods: A retrospective analysis of our experience on high-risk patients receiving inhaled milrinone was conducted to evaluate the postoperative course after administration of the drug. Results: Seventy-three patients received inhaled milrinone from June 2002 to February 2005. Mean age was 64 AE 13 years, with a mean preoperative Parsonnet score of 27 AE 14. Inhaled milrinone (5 mg) was administered before (n = 30) or after (n = 40) CPB, three patients had off-pump procedures and were excluded. CPB time was 145 AE 78 min with cross-clamping times of 91 AE 56 min without any significant difference between groups. Fifty-four patients (74%) had difficult separation from CPB, 14 patients (19%) required an intra-aortic balloon pump and 10 patients (14%) needed emergency reinitiation of CPB for hemodynamic instability. Ten patients died in the perioperative period (13.7%). Patients receiving inhaled milrinone prior to CPB initiation had a lowering pulmonary artery pressure after CPB ( p < .01) and had less emergency reinitiation of CPB after weaning (3% vs 23%, p = .02) as compared to those with administration after CPB. No detectable side effects were directly linked to the administration of the drug. Conclusion: In this high-risk cohort, use of inhaled milrinone was well tolerated. Administration before initiation of CPB could help weaning from CPB. #

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“…No significant difference was observed between iNO and milrinone in terms of reduction in PVR and inotropic requirement. The same team compared 20 and 40 ppm of iNO to the same dose of intravenous milrinone in 45 patients after cardiac surgery (Solina et al, 2000). Study drugs were administered upon termination of CPB for a 24h-period in the intensive care unit (ICU).…”

Section: Cardiopulmonary Bypassmentioning

confidence: 99%

A Pathophysiological Approach to Understanding Pulmonary Hypertension in Cardiac Surgery

Nguyen¹,

Deschamps²,

Perrault³

et al. 2012

Perioperative Considerations in Cardiac Surgery

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A comparison of inhaled nitric oxide and milrinone for the treatment of pulmonary hypertension in adult cardiac surgery patients

Cited by 83 publications

References 11 publications

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

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

Preliminary experience with inhaled milrinone in cardiac surgery☆

A Pathophysiological Approach to Understanding Pulmonary Hypertension in Cardiac Surgery

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