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Canadian Journal of Cardiology

Inhaled Epoprostenol and Milrinone Effect on Right Ventricular Pressure Waveform Monitoring

Published:December 13, 2022DOI:https://doi.org/10.1016/j.cjca.2022.12.007

      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)
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