Preliminary experience with inhaled milrinone in cardiac surgery☆

Lamarche, Yoan; Perrault, Louis P.; Maltais, Simon; Tétreault, Karine; Lambert, Jean; Denault, André

doi:10.1016/j.ejcts.2007.02.019

Cited by 101 publications

(69 citation statements)

References 26 publications

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“…In contrast, SPAP remained unchanged in the control group (n=11) and no significant differences between groups were observed in decreased systemic arterial pressures. A retrospective study reporting the preliminary experience on the use of inhaled milrinone at the Montreal Heart Institute was conducted in 70 high risk patients with a mean Parsonnet Score of 27±14 (Bernstein & Parsonnet, 2000;Lamarche et al, 2007). Results were compared to those of a control group with similar baseline characteristics.…”

Section: Prevention Of Pulmonary Hypertension In Cardiac Surgerymentioning

confidence: 99%

“…At the Montreal Heart Institute, iPGI 2 (Hache et al, 2001;Hache et al, 2003) and inhaled milrinone (Lamarche et al, 2005;Lamarche et al, 2007) are commonly administered to patients when PH and RV dysfunction occur before or after cardiac surgery. Oral sildenafil and iNO are also used in refractory cases in the ICU.…”

Section: Experience At the Montreal Heart Institutementioning

confidence: 99%

See 1 more Smart Citation

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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Section: Prevention Of Pulmonary Hypertension In Cardiac Surgerymentioning

confidence: 99%

Section: Experience At the Montreal Heart Institutementioning

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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“…6 Until now, however, there has been a lack of prospective randomized-controlled trials evaluating the utility of iMil in this setting.…”

mentioning

confidence: 99%

“…7 Lamarche et al published retrospective data suggesting that the incidence of difficult weaning from CPB was reduced when iMil was administered before vs after CPB. 6 Until now, however, there has been a lack of prospective randomized-controlled trials evaluating the utility of iMil in this setting.…”

mentioning

confidence: 99%

“…2,6 Inhaled milrinone (iMil) has attracted attention in view of the preferred route of administration in the setting of PH and RV dysfunction. There is a reduction in systemic vasodilation with this approach when compared with the intravenous route, and there is evidence to suggest that iMil has superior ability to mitigate pulmonary endothelial dysfunction during cardiopulmonary bypass (CPB).…”

mentioning

confidence: 99%

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Inhaled milrinone for pulmonary hypertension in high-risk cardiac surgery: silver bullet or just part of a broader management strategy?

Bednarczyk

Strumpher

Jacobsohn

2016

Can J Anesth/J Can Anesth

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Pulmonary hypertension (PH) and right ventricular (RV) dysfunction are common and potentially devastating conditions in patients undergoing cardiac surgery. The prevalence of PH and elevated pulmonary vascular resistance (PVR) in patients with aortic stenosis and regurgitation is 15-30% and C 25%, respectively, and at least 40% in patients with mitral stenosis.1 In certain patients with pulmonary venous hypertension due to valvular cardiac disease, the elevated PVR persists or is slow to regress after valve replacement/repair as a result of remodelling of the pulmonary circulation.2 Preoperative PH is associated with prolonged mechanical ventilation, greater duration of hospital stay, and increased operative and long-term mortality.3 This is likely a consequence of the relationship between PH and the development of perioperative RV failure, a condition that, even with early recognition and treatment, has high morbidity and greater than 30% mortality. 4,5 Despite the critical importance of perioperative PH and RV dysfunction, there is a paucity of high-quality clinical trials addressing the perioperative management of these conditions.Milrinone, a phosphodiesterase-3 inhibitor, acts by augmenting cyclic adenosine monophosphate signalling to induce pulmonary and systemic vasodilation and to increase cardiac contractility -i.e., an inodilator.2,6 Inhaled milrinone (iMil) has attracted attention in view of the preferred route of administration in the setting of PH and RV dysfunction. There is a reduction in systemic vasodilation with this approach when compared with the intravenous route, and there is evidence to suggest that iMil has superior ability to mitigate pulmonary endothelial dysfunction during cardiopulmonary bypass (CPB). 7Lamarche et al. published retrospective data suggesting that the incidence of difficult weaning from CPB was reduced when iMil was administered before vs after CPB. 6 Until now, however, there has been a lack of prospective randomized-controlled trials evaluating the utility of iMil in this setting.In this issue of the Journal, Denault et al. present an important multicentre randomized-controlled trial examining a unique strategy for the management of perioperative PH and RV dysfunction.8 They posed the question: does prophylactic treatment with iMil before CPB facilitate separation from CPB in patients with preoperative PH? The authors studied 124 well-matched adult patients undergoing elective high-risk cardiac surgery with baseline mean pulmonary artery (PA) pressure [ 30 mmHg or a PA systolic pressure [ 40 mmHg. Patients were randomized to receive a single dose of either iMil (5 mg) or placebo through an in-line ultrasonic mesh nebulizer after induction of anesthesia. Detailed hemodynamic measurements and echocardiographic data were collected.

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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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Preliminary experience with inhaled milrinone in cardiac surgery☆

Cited by 101 publications

References 26 publications

A Pathophysiological Approach to Understanding Pulmonary Hypertension in Cardiac Surgery

A Pathophysiological Approach to Understanding Pulmonary Hypertension in Cardiac Surgery

Inhaled milrinone for pulmonary hypertension in high-risk cardiac surgery: silver bullet or just part of a broader management strategy?

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

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