The effect of milrinone on mortality in adult patients who underwent CABG surgery: A systematic review of randomized clinical trials with a meta-analysis and trial sequential analysis

Abstract

Background: As an inodilator, milrinone is commonly used for patients who undergo coronary artery bypass graft (CABG) surgery because of its effectiveness in decreasing the cardiac index and mitral regurgitation. The aim of this study was to perform a systematic meta-analysis of existing studies from the past 20 years to evaluate the impact of milrinone on mortality in patients who undergo CABG surgery.Methods: We performed a systematic literature search on the application of milrinone in patients who underwent CABG surgery in studies published between 1997 and 2017 in BioMed Central, PubMed, EMBASE, and the Cochrane Central Register. The included studies evaluated milrinone groups compared to groups receiving either placebo or standard treatment and further compared the systemic administration.Results: The network meta-analysis included 723 patients from 16 randomized clinical trials. Overall, there was no significant difference in mortality between the milrinone group and the placebo/standard care group when patients underwent CABG surgery. In addition, 9 trials (with 440 randomized patients), 4 trials (with 212 randomized patients), and 10 trials (with 470 randomized patients) reported that the occurrence of myocardial infarction (MI), myocardial ischemia, and arrhythmia was lower in the milrinone group than in the placebo/standard care group. Between the milrinone treatment and placebo/standard care groups, the occurrence of myocardial infarction, myocardial ischemia, and arrhythmia was significantly different. However, the occurrence of stroke and renal failure, the duration of inotropic support (h), the need for an intra-aortic balloon pump (IABP), and mechanical ventilation (h) between these two groups showed no differences.Conclusions: Based on the current results, compared with placebo, milrinone might be unable to decrease mortality in adult CABG surgical patients but can significantly ameliorate the occurrence of MI, myocardial ischemia, and arrhythmia. These results provide evidence for the further clinical application of milrinone and of therapeutic strategies for CABG surgery. However, along with milrinone application in clinical use, sufficient data from randomized clinical trials need to be collected, and the potential benefits and adverse effects should be analyzed and reevaluated.

An update on levosimendan in acute cardiac care: applications and recommendations for optimal efficacy and safety

“…Furthermore, the incidences of LCOS (OR 0.56, 95% CI 0.42-0.75; p< 0.0001), acute kidney injury (OR 0.63; 95% CI 0.46-0.86; p= 0.0039) and renal replacement therapy (OR 0.70; 95% CI 0.50-0.98; p= 0.0332) were also significantly decreased in the levosimendan group, suggesting beneficial effects from the prophylactic use of levosimendan in patients with severely impaired LVEF undergoing cardiac surgery. No comparable data are available for any other inotropes, several of which have been associated with detrimental effects on outcome [8,58].…”

“…Other inotropic agents, such as the phosphodiesterase (PDE)-III inhibitors milrinone and enoximone, have proved to be less than fully satisfactory alternatives to dobutamine [6][7][8], probably because these two drug families share a common denominator, namely that their inotropic action derives from calcium mobilization and hence an increase in myocardial oxygen consumption.…”

Oral milrinone for management of refractory right ventricular failure in patients with left ventricular assist devices

“…Milrinone is a phosphodiesterase III inhibitor used intravenously to optimize cardiac output, systemic and pulmonary pressures as a bridge to heart transplantation, 2 and to opti-mize ventricular function perioperatively. 3 In the UK, its use is reserved for inpatient therapy, although internationally, it has been delivered as an outpatient for some time. 4 Oral milrinone provides a means of delivering inotropic support without the requirement for intravenous (IV) lines and pumps.…”