Inhaled Milrinone After Left Ventricular Assist Device Implantation

Haglund, Nicholas; Burdorf, A.; Jones, Todd; Shostrom, Valerie; Um, J.; Ryan, Timothy; Shillcutt, Sasha K.; Fischer, Pamela J.; Cox, Zachary L.; Raichlin, Eugenia; Lowes, Brian D.; Dumitru, Ioana

doi:10.1016/j.cardfail.2015.04.011

Cited by 34 publications

(19 citation statements)

References 19 publications

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“…Exposure to iMil has been reported in 279 patients in small unblinded trials, 10,11,[13][14][15][16] retrospective analyses, 12,19 in combination with iPGI 2 , 18 and in case reports. [20][21][22][23][24][25][26] One trial involving 21 patients compared iMil (n = 11) with placebo.…”

Section: Discussionmentioning

confidence: 99%

“…51 As we were able to confirm, iMil levels \ 100 ngÁmL -1 are unlikely to induce significant systemic hypotension in cardiac patients. 50 Nguyen, 22 Gavra, 29,30 and Haglund 19 have measured iMil concentrations following nebulization in patients with an LV assist device. It is possible that the limited effect of iMil on PH could be secondary to a lower and ineffective concentration in some patients.…”

Section: Discussionmentioning

confidence: 99%

“…7 The use of inhaled milrinone (iMil) has been described in several animal 8,9 and human reports. [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] Compared with its alternatives [i.e., inhaled nitric oxide (iNO) and inhaled prostacyclin (iPGI 2 )], iMil possesses inotropic properties, is less expensive, does not require a complex administration system, and does not have toxic metabolites. Furthermore, contrasted with iPGI 2 , iMil is readily available in most cardiac operating rooms and needs no special preparation.…”

Section: Résumémentioning

confidence: 99%

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A multicentre randomized-controlled trial of inhaled milrinone in high-risk cardiac surgical patients

Denault

Bussières

Arellano

et al. 2016

Can J Anesth/J Can Anesth

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Purpose Inhaled milrinone (iMil) has been used for the treatment of pulmonary hypertension (PH) but its efficacy, safety, and prophylactic effects in facilitating separation from cardiopulmonary bypass (CPB) and preventing right ventricular (RV) dysfunction have not yet been evaluated in a clinical trial. The purpose of this study was to investigate if iMil administered before CPB would be superior to placebo in facilitating separation from CPB.Methods High-risk cardiac surgical patients with PH were randomized to receive iMil or placebo after the induction of anesthesia and before CPB. Hemodynamic parameters and RV function were evaluated by means of pulmonary artery catheterization and transesophageal echocardiography. The groups were compared for the primary outcome of the level of difficulty in weaning from CPB. Among the secondary outcomes examined were the reduction in the severity of PH, the incidence of RV failure, and mortality. Results Of the 124 patients randomized, the mean (standard deviation [SD]) EuroSCORE II was 8.0 (2.6), and the baseline mean (SD) systolic pulmonary artery pressure (SPAP) was 53 (9) mmHg. The use of iMil was associated with increases in cardiac output (P = 0.03) and a reduction in SPAP (P = 0.04) with no systemic hypotension. Nevertheless, there was no difference in the combined incidence of difficult or complex separation from CPB between the iMil and control groups (30% vs 28%, respectively; absolute difference, 2%; 95% confidence interval [CI], -14 to 18; P = 0.78). There was also no difference in RV failure between the iMil and control groups (15% vs 14%, respectively; difference, 1%; 95% CI, -13 to 12; P = 0.94). Mortality was increased in patients with RV failure vs those without (22% vs 2%, respectively; P \ 0.001). Conclusion In high-risk cardiac surgery patients with PH, the prophylactic use of iMil was associated with favourable hemodynamic effects that did not translate into improvement of clinically relevant endpoints. This trial was registered at ClinicalTrials.gov; identifier: NCT00819377. RésuméObjectif La milrinone inhalée est utilisée pour traiter l'hypertension pulmonaire (HP) mais son efficacité, son innocuité et ses effets prophylactiques pour faciliter le sevrage de la circulation extracorporelle (CEC) et prévenir la dysfonction ventriculaire droite (VD) n'ont pas encore été évalués dans le cadre d'une étude clinique. L'objectif de cette étude était d'examiner si la milrinone inhalée avant la CEC serait supérieure à un placebo pour faciliter le sevrage de la CEC. Méthode Des patients de chirurgie cardiaque à risque élevé et souffrant d'HP ont été randomisés à recevoir de la milrinone inhalée ou un placebo après l'induction de l'anesthésie et avant la CEC. Les paramètres hémodynamiques et la fonction VD ont été évalués à l'aide d'un cathéter de l'artère pulmonaire et d'une échocardiographie transoesophagienne. Les groupes ont été comparés selon notre critère d'évaluation principal, soit le niveau de difficulté du sevrage de la CEC. Parmi les critères...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Résumémentioning

confidence: 99%

See 1 more Smart Citation

A multicentre randomized-controlled trial of inhaled milrinone in high-risk cardiac surgical patients

Denault

Bussières

Arellano

et al. 2016

Can J Anesth/J Can Anesth

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“…In these cases, inhaled milrinone was used to facilitate weaning from CPB and administration was not repeated. One group described prolonged use of inhaled milrinone after CF‐LVAD placement . The authors diluted milrinone in normal saline to a concentration of 0.5 mg/ml and administered a fixed rate of 12 ml/hour via an infusion pump connected to a vibrating‐mesh nebulizer.…”

Section: Dosing and Administration Of Inhaled Pulmonary Vasodilatorsmentioning

confidence: 99%

“…A prospective study described the use of inhaled milrinone in 10 patients after CF‐LVAD placement . Cardiac index and right atrial pressure improved after inhaled milrinone initiation as compared to baseline.…”

Section: Summary Of the Evidencementioning

confidence: 99%

Inhaled Pulmonary Vasodilator Therapy for Management of Right Ventricular Dysfunction after Left Ventricular Assist Device Placement and Cardiac Transplantation

et al. 2017

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Right ventricular failure (RVF) after cardiac transplant (CTX) or implantation of a continuous-flow left ventricular assist device (CF-LVAD) is associated with significant postoperative morbidity and mortality. A variety of modalities have been used to treat postoperative RVF, including management of volume status, intravenous inotropes and vasodilators, and right-sided mechanical support. Inhaled vasodilator agents are a unique treatment option aimed at minimizing systemic absorption by delivering therapy directly to the pulmonary vasculature. Current LVAD and CTX guidelines endorse inhaled vasodilators for managing postoperative RVF; however, no guidance is offered regarding agent selection, dosing, or administration. A review of the current literature confirms that inhaled pulmonary vasodilator agents have been shown to decrease pulmonary artery pressure when used in the perioperative period of CF-LVAD implant or CTX. However, the literature regarding the potential impact on clinical outcomes (e.g., survival or risk of developing RVF) is lacking with these medications. Based on our assessment of the literature, we suggest that when RVF occurs in the setting of a normal pulmonary vascular resistance (PVR), traditional inotropic therapy (e.g., dobutamine) should be used. Conversely, if the PVR is elevated (> 250 dynes/sec/cm 5 or 3 Wood units), or the patient has other evidence of a high right ventricular afterload (i.e., a transpulmonary gradient > 12 mm Hg), then an inhaled pulmonary vasodilator would be the preferred initial pharmacologic agent. Drug selection depends largely on the institution's capacity to safely prepare and administer the medication, along with formulary considerations, such as the high costs associated with inhaled iloprost and inhaled nitric oxide. KEY WORDS heart transplantation, left ventricular assist device, right heart failure, pulmonary arterial hypertension, inhaled pulmonary vasodilators. (Pharmacotherapy 2017;37(8):944-955)

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Right heart dysfunction and failure in heart failure with preserved ejection fraction: mechanisms and management. Position statement on behalf of the Heart Failure Association of the European Society of Cardiology

Gorter

Veldhuisen

Bauersachs

et al. 2017

European J of Heart Fail

270

223

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There is an unmet need for effective treatment strategies to reduce morbidity and mortality in patients with heart failure with preserved ejection fraction (HFpEF). Until recently, attention in patients with HFpEF was almost exclusively focused on the left side. However, it is now increasingly recognized that right heart dysfunction is common and contributes importantly to poor prognosis in HFpEF. More insights into the development of right heart dysfunction in HFpEF may aid to our knowledge about this complex disease and may eventually lead to better treatments to improve outcomes in these patients. In this position paper from the Heart Failure Association of the European Society of Cardiology, the Committee on Heart Failure with Preserved Ejection Fraction reviews the prevalence, diagnosis, and pathophysiology of right heart dysfunction and failure in patients with HFpEF. Finally, potential treatment strategies, important knowledge gaps and future directions regarding the right side in HFpEF are discussed.

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Inhaled Milrinone After Left Ventricular Assist Device Implantation

Cited by 34 publications

References 19 publications

A multicentre randomized-controlled trial of inhaled milrinone in high-risk cardiac surgical patients

A multicentre randomized-controlled trial of inhaled milrinone in high-risk cardiac surgical patients

Inhaled Pulmonary Vasodilator Therapy for Management of Right Ventricular Dysfunction after Left Ventricular Assist Device Placement and Cardiac Transplantation

Right heart dysfunction and failure in heart failure with preserved ejection fraction: mechanisms and management. Position statement on behalf of the Heart Failure Association of the European Society of Cardiology

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