Milrinone Infusion Research Articles

Oral Enoximone as an Alternative to Protracted Intravenous Medication in Severe Pediatric Myocardial Failure.

Phosphodiesterase 3 inhibitors have been used successfully in pediatric patients with acute or chronic myocardial dysfunction over the last two decades. Their protracted continuous intravenous administration is associated with risk of infectious and thromboembolic complications. Weaning intravenous medication and starting oral angiotensin-converting enzyme (ACE) inhibitors and/or beta-blockers can be challenging. We reviewed retrospectively hospital records of 48 patients receiving oral enoximone treatment in a single tertiary pediatric cardiac center between November 2005 and April 2014. Failure to wean from intravenous milrinone infusion and/or intolerance of ACE inhibitors and/or beta-blockers was indications for oral enoximone treatment. Age of the patients ranged between 0.5 and 191months (median 7.5months) at the time of starting enoximone treatment. There were 14 patients (29%) with left ventricular dysfunction due to myocarditis or dilated cardiomyopathy and 34 patients (71%) with myocardial dysfunction complicating congenital heart disease. Fifteen (44%) of these 34 patients had left ventricular dysfunction, 13 (38%) right ventricular dysfunction, and in 6 (18%) both ventricles were failing. Duration of oral enoximone treatment was between 3days and 34months (median of 2.3months). Myocardial functional recovery allowed for weaning of enoximone treatment in 15 patients (31%) after 6days-15months (median 5 months). No adverse hemodynamic effects were noted. Blood stained gastric aspirates encountered in two patients resolved with concomitant milk administration. Based on our limited experience, oral enoximone is a well-tolerated and promising alternative to intravenous medication and/or other commonly used oral medications in selected pediatric patients with chronic heart failure.

36. Anesthesia for high risk patients undergoing percutaneous mitral valve repair with the mitraclip system in the catheterization laboratory

MitraClip system implantation is used inhigh-risk patients with severe mitral regurgitation.anesthetic management for mitral clip implantation. The study included 34patients scheduled for MitraClip implantations in the catheterization laboratory. An arterial line and central venous line were inserted under local anesthesia before induction. Epinephrine was started before induction and milrinone infusion was started after induction. The anesthetic technique for induction and maintenance was the same for all patients. All patients were hemodynamically stable intra- and postoperatively. The intervention was successful in 33 cases and aborted in one case because of severe posteromedial leaflet tethering. The epinephrine and milrinone were weaned and all patients were extubated, except, one case mortality happened within the first 8 hours postoperatively. Percutaneous mitral valve repair with MitraClip implantation is a successful alternative in high-risk patients with symptomatic severe mitral regurgitation. Starting epinephrine before anesthetic induction and milrinone infusion induction resulted in decreased pulmonary artery pressure, increased ejection fraction and maintained arterial blood pressure during procedure inspite of worse preoperative conditions.

Novel role of phosphodiesterase inhibitors in the management of end-stage heart failure.

In advanced heart failure (HF), chronic inotropic therapy with intravenous milrinone, a phosphodiesterase III inhibitor, is used as a bridge to advanced management that includes transplantation, ventricular assist device implantation, or palliation. This is especially true when repeated attempts to wean off inotropic support result in symptomatic hypotension, worsened symptoms, and/or progressive organ dysfunction. Unfortunately, patients in this clinical predicament are considered hemodynamically labile and may escape the benefits of guideline-directed HF therapy. In this scenario, chronic milrinone infusion may be beneficial as a bridge to introduction of evidence based HF therapy. However, this strategy is not well studied, and in general, chronic inotropic infusion is discouraged due to potential cardiotoxicity that accelerates disease progression and proarrhythmic effects that increase sudden death. Alternatively, chronic inotropic support with milrinone infusion is a unique opportunity in advanced HF. This review discusses evidence that long-term intravenous milrinone support may allow introduction of beta blocker (BB) therapy. When used together, milrinone does not attenuate the clinical benefits of BB therapy while BB mitigates cardiotoxic effects of milrinone. In addition, BB therapy decreases the risk of adverse arrhythmias associated with milrinone. We propose that advanced HF patients who are intolerant to BB therapy may benefit from a trial of intravenous milrinone as a bridge to BB initiation. The discussed clinical scenarios demonstrate that concomitant treatment with milrinone infusion and BB therapy does not adversely impact standard HF therapy and may improve left ventricular function and morbidity associated with advanced HF.

Single institution experience with the Ladd's procedure in patients with heterotaxy and stage I palliated single-ventricle.

To investigate and describe our current institutional management protocol for single-ventricle patients who must undergo a Ladd's procedure. We retrospectively reviewed the charts of all patients from January 2005 to March 2014 who were diagnosed with heterotaxy syndrome and an associated intestinal rotation anomaly who carried a cardiac diagnosis of functional single ventricle and were status post stage I palliation. A total of 8 patients with a history of stage I single-ventricle palliation underwent Ladd's procedure during this time period. We reviewed each patients chart to determine if significant intraoperative or post-operative morbidity or mortality occurred. We also described our protocolized management of these patients in the cardiac intensive care unit, which included pre-operative labs, echocardiography, milrinone infusion, as well as protocolized fluid administration and anticoagulation regimines. We also reviewed the literature to determine the reported morbidity and mortality associated with the Ladd's procedure in this particular cardiac physiology and if other institutions have reported protocolized care of these patients. A total of 8 patients were identified to have heterotaxy with an intestinal rotation anomaly and single-ventricle heart disease that was status post single ventricle palliation. Six of these patients were palliated with a Blaylock-Taussig shunt, one of whom underwent a Norwood procedure. The two other patients were palliated with a stent, which was placed in the ductus arteriosus. These eight patients all underwent elective Ladd's procedure at the time of gastrostomy tube placement. Per our protocol, all patients remained on aspirin prior to surgery and had no period where they were without anticoagulation. All patients remained on milrinone during and after the procedure and received fluid administration upon arrival to the cardiac intensive care unit to account for losses. All 8 patients experienced no intraoperative or post-operative complications. All patients survived to discharge. One patient presented to the emergency room two months after discharge in cardiac arrest and died due to bowel obstruction and perforation. Protocolized intensive care management may have contributed to favorable outcomes following Ladd's procedure at our institution.

Compartment Syndrome as a Result of Systemic Capillary Leak Syndrome.

Objective. To describe a single case of Systemic Capillary Leak Syndrome (SCLS) with a rare complication of compartment syndrome. Patient. Our patient is a 57-year-old male, referred to our hospital due to polycythemia (hemoglobin (Hgb) of 220 g/L), hypotension, acute renal failure, and bilateral calf pain. Measurements and Main Results. The patient required bilateral forearm, thigh, and calf fasciotomies during his ICU stay and continuous renal replacement therapy was instituted following onset of acute renal failure and oliguria. Ongoing hemodynamic (Norepinephrine and Milrinone infusion) and respiratory (ventilator) support in the ICU was provided until resolution of intravascular fluid extravasation. Conclusions. SCLS is an extremely rare disorder characterized by unexplained episodic capillary hyperpermeability, which causes shift of volume and protein from the intravascular space to the interstitial space. Patients present with significant hypotension, hemoconcentration, hypovolemia, and oliguria. Severe edema results from leakage of fluid and proteins into tissue. The most important part of treatment is maintaining stable hemodynamics, ruling out other causes of shock and diligent monitoring for complications. Awareness of the clinical syndrome with the rare complication of compartment syndrome may help guide investigations and diagnoses of these critically ill patients.

A Case of Refractory Heart Failure in Becker Muscular Dystrophy Improved With Corticosteroid Therapy

The patient was a 26 year-old man who was referred to our hospital in June 2011 because of severe heart failure. At age 24 years, he was found to have Becker muscular dystrophy. He received enalapril for cardiac dysfunction; however, he had worsening heart failure and was thus referred to our hospital. Echocardiography showed enlargement of the left ventricle, with a diastolic dimension of 77 mm and ejection fraction of 19%. His condition improved temporarily after an infusion of dobutamine and milrinone. He was then administered amiodarone for ventricular tachycardia; however, he subsequently developed hemoptysis. Amiodarone was discontinued and corticosteroid pulse therapy was administered followed by oral prednisolone (PSL). His creatinine phosphokinase (CPK) level and cardiomegaly improved after the corticosteroid therapy. The PSL dose was reduced gradually, bisoprolol was introduced, and the catecholamine infusion was tapered. A cardiac resynchronization device was implanted; however, the patient's condition gradually worsened, which necessitated dobutamine infusion for heart failure. We readministered 30 mg PSL, which decreased the CPK level and improved the cardiomegaly. The dobutamine infusion was discontinued, and the patient was discharged. He was given 7.5 mg PSL as an outpatient, and he returned to normal life without exacerbation of the heart failure. There are similar reports showing that corticosteroids are effective for skeletal muscle improvement in Duchenne muscular dystrophy; however, their effectiveness for heart failure has been rarely reported. We experienced a case of Becker muscular dystrophy in which corticosteroid therapy was effective for refractory heart failure.

Epinephrine induced cardiomyopathy in a child with anaphylaxis

Transient cardiomyopathy is an uncommon occurrence in patients with anaphylaxis. Catecholamine induced direct toxicity is one of the proposed mechanisms. We report a case of cardiomyopathy in a child with anaphylaxis who was treated with multiple doses of epinephrine as well as a continuous infusion of epinephrine. A twenty one month old girl with egg allergy presented to our hospital with anaphylaxis, after multiple doses of epinephrine injections, developed cardiorespiratory dysfunction and required endotracheal intubation and mechanical ventilation. Work up showed depressed cardiac function, which improved with milrinone and furosemide infusions. Conclusion: Epinephrine is the treatment of choice for anaphylaxis however caution should be exercised when administering multiple doses of epinephrine. Myocardial function needs to be assessed in children with persistent hypotension after anaphylaxis and catecholamine-induced cardiomyopathy should be considered in children with anaphylaxis when severe myocardial dysfunction is present.

Effect of milrinone on cardiac functions in patients undergoing coronary artery bypass graft: a meta-analysis of randomized clinical trials.

Background and aimInotropes are commonly used to treat myocardial dysfunction, which is the major complication after coronary artery bypass graft (CABG). Milrinone, a phosphodiesterase 3 inhibitor, is one of these inotropes. Recently, a number of clinical studies have been carried out to evaluate the effects of milrinone on cardiac function in patients with low ventricular ejection fraction undergoing CABG. However, it has been inconclusive because of the inconsistent results. In addition, some studies found that milrinone increased the incidence of postoperative atrial arrhythmias and did not show any long-term beneficial effects on survival. Therefore, it is very important to perform a meta-analysis to summarize the results so as to determine the clinical efficacy and safety of milrinone.MethodSeveral databases and websites for clinical trials were searched until October 2015 for prospective clinical studies comparing milrinone versus placebo on cardiac functions in patients undergoing CAGB.ResultsFour articles were identified by our search strategy. 1) Milrinone decreased incidence of myocardial ischemia and myocardial infarction (15.6% versus 44.4%; 4.7% versus 18% in milrinone and control group, respectively). 2) Milrinone decreased duration of inotropic support (95% confidence interval [CI]: −6.52 to −1.68; P=0.0009) and mechanical ventilation (h) support (95% CI −5.00 to −0.69; P=0.010), but did not decrease the requirement for intra-aortic balloon pump or inotropic support (P>0.05). 3) Milrinone did not decrease the overall mortality or morbidity, intensive care unit stay (P>0.05).ConclusionPerioperative continuous infusion of milrinone is effective to lower incidence of myocardial ischemia and myocardial infarction in patients post-CABG, but it was unable to improve the overall morbidity and mortality or decreased duration of intensive care unit stay. The available sample size is small; therefore, future studies should be directed toward a better understanding of the benefit of milrinone to CABG patients.

Abstract 17908: Milrinone Lacks Acute Inotropic And Lusitropic Effects Under Constant Afterload Conditions

Introduction: Phosphodiesterase III inhibitors are known to improve cardiac output in patients with heart failure. Whether this is due to a reduction in afterload, a positive inotropic effect, or an interaction of these factors is uncertain. We compared the inotropic and lusitropic effects of milrinone to those of commonly used catecholamines in a working Langendorff model under constant loading conditions. Methods: Sprague Dawley rats (n=35, 350-400 grams) were anesthetized and heparinized for cardiac explantation. The aorta and left atrium were immediately cannulated by a single experimenter. Left atrial pressure (10 mmHg) and aortic pressure (90 mmHg) were fixed. A conductance catheter (Millar) was inserted into the left ventricle. Following baseline measurements, infusions of milrinone, dopamine, dobutamine, epinephrine, or norephinephrine, alone and in commonly-used combinations, were initiated into the left atrium for 10 minute periods. Changes in cardiac output, contractility (dP/dTmax), diastolic performance (-dP/dT and Tau) relative to baseline were compared between groups by linear regression analysis. Results: Cardiac output increased in linear fashion for each of the catecholamines: Dobutamine>>Dopamine>Norepinephrine>Epinephrine (P<0.001 for each). Dobutamine, Norepinephrine, and Dopamine (P<0.05) significantly increased diastolic function, including negative dP/dT (C) and Tau (D), none of which were changed by Milrinone infusion. Conclusions: When afterload is fixed using a Starling resistor, milrinone at commonly used doses does not acutely change systolic or diastolic performance or cardiac output. It is possible that clinical improvements are due to milrinone’s vasodilatory properties.

The Effect of Milrinone on Splanchnic and Cerebral Perfusion in Infants With Congenital Heart Disease Prior to Surgery: An Observational Study.

Despite the advancement in the postoperative care of neonates with congenital heart disease (CHD), there is little information on preoperative management of systemic and regional hemodynamics, which may be related to outcomes. We aimed to determine the preoperative effect of milrinone, a phosphodiesterase III inhibitor, on cardiac output and splanchnic and cerebral perfusion in neonates with CHD. Neonates with CHD requiring cardiac surgery were enrolled in a prospective, single-blinded study once a clinical decision of starting milrinone (0.75 μg/kg per minute intravenously) using institutional criteria was made. Demographic and clinical variables and outcomes were recorded. Combined cardiac output and measures of splanchnic (superior mesenteric and celiac arteries) and cerebral (anterior and middle cerebral arteries) perfusion were determined by Doppler studies at 0, 6, 24, and 48 h after milrinone infusion. Investigators were unaware of intervention time points and patients in analyzing blood flow measurements. Seventeen term (39.2 ± 1.3 weeks) neonates were included with hypoplastic left-sided heart syndrome (78.5%) as the most common diagnosis. Combined cardiac output increased by 28% within 48 h (613 ± 154 vs. 479 ± 147 mL/kg per minute at baseline, P < 0.05). Superior mesenteric artery mean velocity increased at 6 h and throughout 48 h of milrinone infusion (P < 0.05). Peak and mean velocities at cerebral arteries increased with milrinone infusion (P < 0.05~0.08), and the corresponding changes at celiac artery were modest. There were no significant changes in splanchnic and cerebral resistive and pulsatility indices during milrinone infusion. Milrinone increases cardiac output with concurrent effects on splanchnic and cerebral blood flows during the short-term preoperative use in neonates with CHD.

Effects of various cardiovascular drugs on indices obtained with two-dimensional speckle tracking echocardiography of the left atrium and time-left atrial area curve analysis in healthy dogs.

To evaluate the effects of dobutamine, esmolol, milrinone, and phenylephrine on left atrial phasic function of healthy dogs. 9 healthy Beagles. Following sedation with propofol on each of 4 experimental days, dogs were administered a constant rate infusion of dobutamine (5 μg/kg/min), esmolol (500 μg/kg/min), milrinone (25 μg/kg, IV bolus, followed by 0.5 μg/kg/min), or phenylephrine (2 μg/kg/min). There was at least a 14-day interval between experimental days. Each drug was administered to 6 dogs. Conventional and 2-D speckle tracking echocardiography were performed before (baseline) and after administration of the cardiovascular drug, and time-left atrial area curves were derived to calculate indices for left atrial reservoir, conduit, and booster pump functions (left atrial phasic function) and left ventricular contractility and lusitropy. Compared with baseline values, indices for left atrial reservoir and booster pump functions and left ventricular contractility and lusitropy were significantly increased following dobutamine administration; indices for left atrial phasic function and left ventricular lusitropy were changed insignificantly, and indices for left ventricular contractility were significantly impaired following esmolol administration; indices for left atrial phasic function and left ventricular relaxation were changed insignificantly, and indices for left ventricular systolic function were significantly augmented following milrinone administration; and indices for left atrial phasic function and left ventricular lusitropy were changed insignificantly, and indices of ventricular contractility were significantly impaired following phenylephrine administration. Results indicated that, following administration of dobutamine, esmolol, milrinone, or phenylephrine to healthy dogs, left atrial phasic function indices were fairly stable and did not parallel changes in left ventricular function indices.

Intensive symptom control of opioid-refractory dyspnea in congestive heart failure: Role of milrinone in the palliative care unit.

We describe an exemplary case of congestive heart failure (CHF) symptoms controlled with milrinone. We also analyze the benefits and risks of milrinone administration in an unmonitored setting. We describe the case of a patient with refractory leukemia and end-stage CHF who developed severe dyspnea after discontinuation of milrinone. At that point, despite starting opioids, she had been severely dyspneic and anxious, requiring admission to the palliative care unit (PCU) for symptom control. After negotiation with hospital administrators, milrinone was administered in an unmonitored setting such as the PCU. A multidisciplinary team approach was also provided. Milrinone produced a dramatic improvement in the patient's symptom scores and performance status. The patient was eventually discharged to home hospice on a milrinone infusion with excellent symptom control. This case suggests that milrinone may be of benefit for short-term inpatient administration for dyspnea management, even in unmonitored settings and consequently during hospice in do-not-resuscitate (DNR) patients. This strategy may reduce costs and readmissions to the hospital related to end-stage CHF.

A Neonate with Acute Heart Failure: Chromosomally Integrated Human Herpesvirus 6–Associated Dilated Cardiomyopathy

A 4-day-old neonate was transferred to a tertiary heart center for further evaluation and management of sudden-onset acute heart failure (HF). The birth history was significant for being born at 37 weeks’ gestation to a 26-year-old mother with a probability 2 A0 blood type. There were no prenatal sonographic screenings of fetal cardiac status available. The mother had no history of smoking, diabetes, thyroid disease, autoimmune disorders, fever, or rash during pregnancy or before delivery. At birth, the patient’s Apgar scores were 8 and 8 at 1 and 5 minutes, respectively, weight was 3200 g (25th percentile), length 48 cm (10th percentile), and head circumference 36 cm (80th percentile). He developed respiratory distress on day 1 of life and was treated empirically to rule out sepsis. There was no history of fever, skin rash, nasal congestion, diarrhea, or sick contact noted. His respiratory status improved by day 2 of life, and he began oral feeding and otherwise progressed well until day 4 of life, when he was scheduled for discharge home but was noted to have a gallop rhythm. His echocardiogram showed a structurally normal heart but markedly dilated left ventricle (LV end-diastolic diameter was 3.24 cm (Z-score 6.7) with moderate mitral regurgitation and severely decreased systolic function, shortening fraction (SF) 11% (mean normal SF value is 36% with 95% predicted limits of 28% to 44%; Figure 1). When the patient arrived in cardiac intensive care unit, no dysmorphic features were noted on examination, his heart rate was 174 beats/min, he had delayed capillary refill (>5 seconds), diminished oxygenation (by near infrared spectroscopy), and had hypotension (systolic blood pressure in the range of 40-50 mm Hg). His S1 and S2 were normal, but a grade 1/6 systolic murmur at the left sternal border and gallop rhythm were noted. His lungs were clear to auscultation, but mild subcostal retractions were noted. The liver was palpable 3 cm below the right subcostal margin. The findings of his neurologic examination were normal, with normal muscle tone noted. He required resuscitation with inotropic support to achieve hemodynamic stability. Subsequently, a milrinone infusion was started for additional

Anesthesia for high-risk patients undergoing percutaneous mitral valve repair with the MitraClip system in the catheterization laboratory

Background MitraClip system implantation is a new technique for high-risk patients with severe mitral regurgitation and patients risky for surgical repair or replacement of mitral valve through cardiopulmonary bypass. Aim The aim of this study was to evaluate the anesthetic experience in high-risk patients undergoing MitraClip implantation. Setting Madinah Cardiac Center, Saudi Arabia. Patients and methods The study included 34 patients scheduled for MitraClip implantations in the catheterization laboratory. An arterial line and a central venous line were inserted before induction. Epinephrine was started before induction and milrinone infusion was started after induction. The anesthetic technique for induction and maintenance was the same for all patients. Monitors included the heart rate, the arterial blood pressure, the central venous pressure, arterial blood gases, the temperature, and the urine output. Results All patients were hemodynamically stable intraoperatively and postoperatively. The intervention was successful in 33 cases and aborted in one case because of severe posteromedial leaflet tethering. Epinephrine and milrinone were weaned, and all patients were extubated, except for one mortality case that happened within the first 8 h postoperatively. Conclusion Percutaneous mitral valve repair with MitraClip implantation is a successful alternative in high-risk patients with symptomatic severe mitral regurgitation. Proper preoperative evaluation of the patients by an anesthetist and a cardiologist is very important. Starting epinephrine before anesthetic induction and milrinone infusion after induction resulted in a decreased pulmonary artery pressure, an increased ejection fraction, and maintained the arterial blood pressure during the procedure.

How Can a Large Left Atrial Myxoma Cause a Selective Mid-Diastolic Right-to-Left Atrial Shunt?

A 76-YEAR-OLD MAN was admitted to the authors’ institution for evaluation of syncope. The patient suffered a witnessed, brief (15 to 20 seconds) loss of consciousness after standing up from a seated position in his home. The patient’s wife called emergency medical services. The patient had no neurologic deficits or other injuries related to the fall, but persistent hypotension was observed in the emergency department that was unresponsive to volume administration. An intravenous infusion of dopamine was required to increase his arterial blood pressure to the normal range. The patient anecdotally reported gradually worsening dyspnea on exertion, lower extremity swelling, and modest weight gain. The past medical history was notable for atrial fibrillation, which was first recognized 1 week before the current admission; treatment with digoxin and furosemide was begun at that time. Transthoracic echocardiography was performed as part of the diagnostic evaluation and revealed a 7.6×4.0 cm smooth, highly mobile mass with a broad-based pedicle attachment to the atrial septum that prolapsed through the mitral valve into the left ventricle during diastole. Computed tomography verified these findings. The imaging studies suggested that the mass was most likely a left atrial myxoma. The patient suffered another episode of near-syncope in the hospital during which, his wife reported, he “turned blue.” He spontaneously recovered after assuming a recumbent position. The patient subsequently was transported to the operating room for resection of the presumed myxoma. After anesthetic induction and endotracheal intubation, transesophageal echocardiography (TEE) confirmed the preoperative diagnosis (Fig 1, Fig 2, Fig 3). The left ventricle was relatively underfilled and the right ventricle was markedly dilated (Fig 4). A pulmonary artery catheter was inserted. Central venous and mean pulmonary arterial pressures were elevated (average values of 28 and 36 mmHg, respectively) despite administration of an intravenous infusion of milrinone. An atrial right-to-left shunt tracking along the mass’s anterior-superior surface was observed during mid-diastole (Fig 5). The shunt was absent throughout the remainder of the cardiac cycle. Two additional images were obtained (Fig 6, Fig 7). What is the diagnosis? Fig 2Midesophageal four-chamber transesophageal echocardiography view obtained during systole showing large left atrial mass occupying the majority of the left atrium. View Large Image Figure Viewer Download Hi-res image Fig 3Midesophageal four-chamber transesophageal echocardiography view obtained during mid-diastole showing large left atrial mass prolapsing through the mitral valve into the left ventricle. View Large Image Figure Viewer Download Hi-res image Fig 4Midesophageal transgastric short-axis transesophageal echocardiography view obtained at end-diastole showing marked right ventricular dilatation. View Large Image Figure Viewer Download Hi-res image Fig 5Modified midesophageal aortic valve short-axis color Doppler transesophageal echocardiography view obtained during mid-diastole showing a right-to-left atrial shunt (red) tracking along the anterior-superior border of the left atrial mass. View Large Image Figure Viewer Download Hi-res image Fig 6Modified midesophageal aortic valve short-axis transesophageal echocardiography view obtained during early diastole showing deformation of the anterior atrial septum (white arrow) by the movement of the left atrial mass. View Large Image Figure Viewer Download Hi-res image Fig 7Modified midesophageal aortic valve short-axis transesophageal echocardiography view obtained during mid-diastole showing transient opening in the anterior atrial septum (white arrow) as a result of deformation by movement of the left atrial mass. View Large Image Figure Viewer Download Hi-res image

Elevated PVR Is Associated with Improved 6-Month Survival in Patients on Continuous Milrinone Infusion as Destination Therapy

Elevated PVR Is Associated with Improved 6-Month Survival in Patients on Continuous Milrinone Infusion as Destination Therapy

Hemodynamic Response to Continuous Outpatient Milrinone Infusion in Advanced Heart Failure Patients with Mixed Pulmonary Hypertension

Hemodynamic Response to Continuous Outpatient Milrinone Infusion in Advanced Heart Failure Patients with Mixed Pulmonary Hypertension

Efficacy of levosimendan vs.milrinone in decompensated heart failure patients

Objective To evaluate the short-term clinical efficacy and safety of administration of levosimendan or milrinone added to conventional therapy in patients with decompensated heart failure.Methods A total of 180 patients admitted due to heart failure [NYHA (New York Heart Association) class Ⅲ or Ⅳ] were randomly (random number) divided into control group,milrinone group and levosimendan group (n =60,each group).A continuous infusion of milrinone added to conventional therapy was administered for 72 hours in milrinone group,while administration of levosimendan for 24 hours in levosimendan group.The changes in left ventricular ejection fraction (LVEF),left ventricle end-diastolic diameter (LVDD) and B-type natriuretic peptide (BNP) plasma level were compared between before and after treatment,respectively,and comparisons of improvement in cardiac function (NYHA class) and hospital mortality were carried out among three groups.Patients were further followed up at 3 months after treatment.Results The LVEF in levosimendan group after treatment had significantly more increased than that in control group [(32.0±6.3)％ vs.(30.6 ±5.5)％,P =0.007].Compared BNP before treatment,the sums of BNP deducted were 444.0 (-74.0,1068.0) pg/mL,469.0 (141.5,1151.5) pg/mL and 936.5 (437.8,1566.8) pg/mL in control group,milrinone group and levosimendan group,respectively after treatment (all P ＜ 0.01).Moreover,the deduction in BNP was more dramatic in levosimendan group compared with control or milrinone group (t =3.256 or 2.665,P =0.004 or 0.026).After treatment for 5 days,the probability at least of achieving more effectively better improvement in NYHA class (cardiac function) in levosimendan group was 2.036 times that of control group (95％ CI:1.030-4.028,P =0.041).The incidence of combined end point events (death or readmission) in levosimendan group was significantly lower than that in milrinone group (50％ vs.70％,HR =0.573,95％ CI:0.358-0.917,P=0.020),while in hospital mortality,readmission or 3-month mortality incidence was similar among 3 groups (P ＞ 0.05).Conclusions The short-term clinical efficacy of levosimendan is superior to that of milrinone or conventional therapy in patients with decompensated heart failure. Key words: Heart failure; Levosimendan; Milrinone ; Treatment; Prognosis

Milrinone Via Lumbar Subarachnoid Catheter for Vasospasm After Aneurysmal Subarachnoid Hemorrhage

Delayed ischemic neurological deficit (DIND) due to symptomatic vasospasm is a major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to elucidate the safety and feasibility of intrathecal milrinone infusion via lumber subarachnoid catheter for prevention of DIND after aSAH. We diagnosed 425 consecutive patients with aSAH who received clipping or coil embolization within 48h after arrival. Patients with the evidence of vasospasm on CT angiography (CTA) received the milrinone therapy via lumbar subarachnoid catheter. DIND, delayed cerebral infarction (DCI), and modified Rankin scale at 3months after SAH were used for the assessment of outcome. Of 425 patients, 170 patients (40.0%) with CTA-proven vasospasm received the milrinone therapy. DIND was observed in 68 patients (16.0%), DCI in 30 patients (7.1%), and the overall mortality was 7.2%. In patients with WFNS grade IV and V aSAH, 26 out of 145 patients (17.9%) were presented with DIND, 12 (8.3%) with DCI, and the mortality was 16.0%. No major complication related to the milrinone injection was observed. Intrathecal milrinone injection via lumbar catheter was safe and feasible, and further randomized prospective studies are needed to confirm the effectiveness of this regimen in the patients with SAH.

Tako-Tsubo cardiomyopathy presenting with cardiogenic shock successfully treated with milrinone: A case report

We report the case of a middle age patient presenting with Tako-Tsubo cardiomyopathy (TTC) complicated by cardiogenic shock that was successfully handled with milrinone. A 64-year old man presented with cardiogenic shock after benzodiazepine and alcohol intoxication. A slight elevation of troponin and typical left ventricular ballooning without coronary lesions suggested TTC. Within a few hours milrinone infusion normalized the cardiac index. TTC is responsible for severe transient left ventricular dysfunction occurring after physical or psychological stress. The major pathophysiological mechanism involved is disproportionate catecholamine secretion, which may stun the myocardium. We considered if treatment of this unique physiopathology with catecholamines could be dangerous in these patients and if alternative inotropes such as milrinone should be preferred.