ABSTRACT
Background
Pulmonary hypertension (PH) and right ventricular (RV) dysfunction are major complications
in cardiac surgery. This study aimed to evaluate the change in RV pressure waveform
in patients receiving a combination of inhaled epoprostenol and inhaled milrinone
(iE&iM) before cardiopulmonary bypass (CPB), and to assess the safety of this approach
with a matched case-control group.
Methods
A prospective single-centre cohort study of adult patients undergoing cardiac surgery
administered iE&iM through an ultrasonic mesh nebulizer. RV pressure waveform monitoring
was obtained by continuously transducing the RV port of the pulmonary artery (PA)
catheter.
Results
The final analysis included 26 patients receiving iE&iM. There was a significant drop
in mean PA pressure (MPAP) (-4.78±8.70, P=0.010), systolic PA pressure (SPAP) (-8.24±12.80, P=0.003), RV end-diastolic pressure (RVEDP) (-2.09±2.84, P<0.001) and RV diastolic pressure gradient (RVDPG) (-1.74±1.36, P<0.001) after 17+9 min of iE&iM administration. Patients also had a significant increase
in RV outflow tract (RVOT) gradient (3.71±4.72, P<0001), RV maximal rate of pressure rise during early systole (dP/dt max)(68.3±144.7,
P=0.024), and left ventricular (LV) dP/dt max (66.4±90.1, P<0.001). Change in RVOT gradient was only observed in those with a positive pulmonary
vasodilator response to treatment. Treatment with iE&iM did not present adverse effects
when compared to a matched case-control group.
Conclusions
Coadministration of iE&iM in cardiac surgery patients presenting with PH or signs
of RV dysfunction is a safe and effective treatment approach in improving RV function.
Appearance of a transient increase in RVOT gradient after iE&iM could be useful to
predict response to treatment.
GLOSSARY:
CPB (cardiopulmonary bypass), dP/dt max (maximal rate of pressure rise during early systole), EuroSCORE II (European System for Cardiac Operative Risk Evaluation score II), iE&iM (inhaled epoprostenol and inhaled milrinone), iEpo (inhaled epoprostenol), iMil (inhaled milrinone), LV (left ventricular), LVEF (left ventricular ejection fraction), MAP (mean arterial pressure), MAP/MPAP (mean arterial pressure over mean pulmonary artery pressure ratio), MD (mean difference), MPAP (mean pulmonary artery pressure), NYHA (New York Heart Association), PA (pulmonary artery), PH (pulmonary hypertension), RV (right ventricular), RVDPG (right ventricular diastolic pressure gradient), RVEDP (right ventricular end-diastolic pressure), RVOT (right ventricular outflow tract), SPAP (systolic pulmonary artery pressure), TEE (transesophageal echocardiography), TPOD (duration (in hours) of invasive life support after cardiac surgery)To read this article in full you will need to make a payment
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Article info
Publication history
Accepted:
December 3,
2022
Received in revised form:
November 10,
2022
Received:
August 15,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
Financial Disclosure: Supported by the Montreal Heart Institute Foundation and the Richard I. Kaufman Endowment Fund in Anesthesia and Critical Care. The funding sources had no role in the design of the study and collection, analysis, and interpretation of data or in writing the manuscript.
Conflicts of Interest: A.Y. Denault is a speaker and consultant for CAE Healthcare and speaker for Edwards and Masimo. He received a research grant from Edwards (2019).
Financial Disclosure: Supported by the Montreal Heart Institute Foundation and the Richard I. Kaufman Endowment Fund in Anesthesia and Critical Care. The funding sources had no role in the design of the study and collection, analysis, and interpretation of data or in writing the manuscript.
Conflicts of Interest: A.Y. Denault is a speaker and consultant for CAE Healthcare and speaker for Edwards and Masimo. He received a research grant from Edwards (2019).
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© 2022 Published by Elsevier Inc. on behalf of the Canadian Cardiovascular Society.
