Purpose
Inhaled milrinone (iMil) has been used for the treatment of pulmonary hypertension (PH) but its efficacy, safety, and prophylactic effects in facilitating separation from cardiopulmonary ...bypass (CPB) and preventing right ventricular (RV) dysfunction have not yet been evaluated in a clinical trial. The purpose of this study was to investigate if iMil administered before CPB would be superior to placebo in facilitating separation from CPB.
Methods
High-risk cardiac surgical patients with PH were randomized to receive iMil or placebo after the induction of anesthesia and before CPB. Hemodynamic parameters and RV function were evaluated by means of pulmonary artery catheterization and transesophageal echocardiography. The groups were compared for the primary outcome of the level of difficulty in weaning from CPB. Among the secondary outcomes examined were the reduction in the severity of PH, the incidence of RV failure, and mortality.
Results
Of the 124 patients randomized, the mean (standard deviation SD) EuroSCORE II was 8.0 (2.6), and the baseline mean (SD) systolic pulmonary artery pressure (SPAP) was 53 (9) mmHg. The use of iMil was associated with increases in cardiac output (
P
= 0.03) and a reduction in SPAP (
P
= 0.04) with no systemic hypotension. Nevertheless, there was no difference in the combined incidence of difficult or complex separation from CPB between the iMil and control groups (30%
vs
28%, respectively; absolute difference, 2%; 95% confidence interval CI, −14 to 18;
P
= 0.78). There was also no difference in RV failure between the iMil and control groups (15%
vs
14%, respectively; difference, 1%; 95% CI, −13 to 12;
P
= 0.94). Mortality was increased in patients with RV failure
vs
those without (22%
vs
2%, respectively;
P
< 0.001).
Conclusion
In high-risk cardiac surgery patients with PH, the prophylactic use of iMil was associated with favourable hemodynamic effects that did not translate into improvement of clinically relevant endpoints. This trial was registered at ClinicalTrials.gov; identifier: NCT00819377.
The use of transesophageal echocardiography (TEE) in the operating room and intensive care unit can provide invaluable information on cardiac as well as abdominal organ structures and function. This ...approach may be particularly useful when the transabdominal ultrasound examination is not possible during intraoperative procedures or for anatomical reasons. This review explores the role of transgastric abdominal ultrasonography (TGAUS) in perioperative medicine. We describe several reported applications using 10 views that can be used in the diagnosis of relevant abdominal conditions associated with organ dysfunction and hemodynamic instability in the operating room and the intensive care unit.
To identify risk factors associated with radial-to-femoral pressure gradient during cardiac surgery with cardiopulmonary bypass (CPB).
This is a retrospective, observational study.
Single specialized ...cardiothoracic hospital in Montreal, Canada.
Consecutive patients that underwent heart surgery with CPB between 2005 and 2015 (n = 435).
None.
A radial-to-femoral pressure gradient occurred in 146 patients of the 435 patients (34%). Based on the 10,000 bootstrap samples, simple logistic regression models identified the 17 most commonly significant variables across the bootstrap runs. Using these variables, a backward multiple logistic model was performed on the original sample and identified the following independent variables: body surface area (m2) (odds ratio OR 0.08, 95% confidence interval CI 0.030-0.232), clamping time (minutes) (OR 1.01, 95% CI 1.007-1.018), fluid balance (for 1 liter) (OR 0.81, 95% CI 0.669-0.976), and preoperative hypertension (OR 1.801, 95% CI 1.131-2.868).
A radial-to-femoral pressure gradient occurs in 34% of patients during cardiac surgery. Patients at risk seem to be of smaller stature, hypertensive, and undergo longer and more complex surgeries.
Objective To retrospectively evaluate the effects of combined inhaled prostacyclin and milrinone to reduce the severity of pulmonary hypertension when administered prior to cardiopulmonary bypass. ...Design Retrospective case control analysis of high-risk patients undergoing cardiac surgery. Setting Single cardiac center. Participants Sixty one adult cardiac surgical patients with pulmonary hypertension, 40 of whom received inhalation therapy. Intervention Inhaled milrinone and inhaled prostacyclin were administered before cardiopulmonary bypass (CPB). Measurements and Main Results Administration of both inhaled prostacyclin and milrinone was associated with reductions in central venous pressure, and mean pulmonary artery pressure, increases in cardiac index, heart rate, and the mean arterial-to-mean pulmonary artery pressure ratio ( p < 0.05), with no significant change in mean arterial pressure. The rate of difficult and complex separation from CPB was 51% in the inhaled group and 70% in the control group (p = 0.1638). Postoperative vasoactive requirement was reduced at 12 hours (35.9 v 73.7% p <0.01) and 24 hours (25.6 v 57.9% p<0.05) postoperatively in the combined inhaled agent group. Hospital length of stay and mortality were similar between the groups. Conclusion Preemptive treatment of pulmonary hypertension with a combination of inhaled prostacyclin and milrinone before CPB was associated with a reduction in the severity of pulmonary hypertension. In addition, a significant reduction in vasoactive support in the intensive care unit during the first 24 hours after cardiac surgery was observed. The impact of this strategy on postoperative survival needs to be determined.
Technological adjuncts have been developed to improve the accuracy of fluid removal goals in maintenance dialysis recipients. We aimed to determine whether the introduction of these tools has been ...shown to impact clinical outcomes.
We performed a systematic review and meta-analysis of randomized controlled trials that compared fluid management guided by technological adjuncts to standard care in hemodialysis and peritoneal dialysis. The primary outcome was all-cause mortality. Secondary outcomes were cardiovascular events, hospitalizations, intradialytic hypotension, blood pressure, symptoms, antihypertensive medications. and left ventricular mass index.
Of the 2940 citations retrieved, we identified a total of 12 eligible trials comprising 2406 participants. In the 10 studies (n = 2111) with data on mortality, the use of adjunct technologies was not associated with a reduction of mortality (rate ratio RR: 0.92; confidence interval CI: 0.57–1.51; I2 = 36%). The intervention conferred a reduction in systolic arterial pressure (mean difference: −3.14; CI: −5.89 to −0.38; I2 = 39%) but did not affect other outcomes. In a subgroup analysis, bioimpedance was associated with a reduced risk of hospitalization (RR: 0.68; CI: 0.46–0.99; I2 = 55%). The risk of bias was high or unclear in most studies and the quality of evidence was judged to be low.
Among maintenance dialysis recipients, technological adjuncts for fluid management did not improve survival. Trials mostly investigated the use of bioimpedance, whereas the evidence for use of other technologies remain very scarce. Future adequately powered trials should assess a broader array of promising technologies using meaningful clinical outcomes over a prolonged follow-up duration.
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Little is known about changes in portal, splenic, and hepatic vein flow patterns in children undergoing congenital heart surgery. This study aimed to determine the characteristics of portal, splenic, ...and hepatic vein flow patterns using ultrasonography in children undergoing cardiac surgery.
Single-center, prospective observational study.
Tertiary children's hospital, operating room.
Children undergoing cardiac surgery.
The authors obtained ultrasound data from the heart, inferior vena cava, portal, splenic, and hepatic veins before and after surgeries. In the biventricular group, which included children with atrial and ventricular septal defects and pulmonary stenosis (n = 246), the portal pulsatility index decreased from 38.7% to 25.6% (p < 0.001) after surgery. The preoperative portal pulsatility index was significantly higher in patients with pulmonary hypertension (43.3% v 27.4%; p < 0.001). In the single-ventricle group (n = 77), maximum portal vein flow velocities of Fontan patients were significantly lower (13.5 cm/s) compared with that of patients with modified Blalock-Taussig shunt (19.7 cm/s; p = 0.035) or bidirectional cavopulmonary shunt (23.1 cm/s; p < 0.001). The cardiac index was inversely correlated with the portal pulsatility index in the bidirectional cavopulmonary shunt and Fontan circulation. (β = -5.693, r2 = 0.473; p = 0.001) The portal pulsatility index was correlated with splenic venous pulsatility and hepatic venous atrial reverse flow velocity in biventricular and single-ventricle groups.
The characteristics of venous Doppler patterns in the portal, splenic, and hepatic veins differed according to congenital heart disease. Further studies are required to determine the association between splanchnic venous Doppler findings and clinical outcomes in this population.
Mean arterial pressure to mean pulmonary arterial pressure ratio (mAP/mPAP) has been identified as a strong predictor of perioperative complications in cardiac surgery. We therefore investigated the ...pharmacokinetic/pharmacodynamic (PK/PD) relationship of inhaled milrinone in these patients using this ratio (R) as a PD marker. Following approval by the ethics and research committee and informed consent, we performed the following experiment. Before initiation of cardiopulmonary bypass in 28 pulmonary hypertensive patients scheduled for cardiac surgery, milrinone (5 mg) was nebulized, plasma concentrations measured (up to 10 h) and compartmental PK analysis carried out. Baseline (R
) and peak (R
) ratios as well as magnitude of peak response (∆
) were measured. During inhalation, individual area under effect-time (AUEC) and plasma concentration-time (AUC) curves were correlated. Potential relationships between PD markers and difficult separation from bypass (DSB) were explored. In this study, we observed that milrinone peak concentrations (41-189 ng ml
) and Δ
(- 0.12-1.5) were obtained at the end of inhalation (10-30 min). Mean PK parameters agreed with intravenous milrinone published data after correction for the estimated inhaled dose. Paired comparisons yielded a statistically significant increase between R
and R
(mean difference, 0.58: 95% CI 0.43-0.73; P < 0.001). Individual AUEC correlated with AUC (r = 0.3890, r
= 0.1513; P = 0.045); significance increased after exclusion of non-responders (r = 4787, r
= 0.2292; P = 0.024). Individual AUEC correlated with ∆R
(r = 5973, r
= 0.3568; P = 0.001). Both ∆R
(P = 0.009) and CPB duration (P < 0.001) were identified as predictors of DSB. In conclusion, both magnitude of peak response of the mAP/mPAP ratio and CPB duration were associated with DSB.
Objective To evaluate intratracheal milrinone (tMil) administration for rapid treatment of right ventricular (RV) dysfunction as a novel route after cardiopulmonary bypass. Design Retrospective ...analysis. Setting Single-center study. Participants The study comprised 7 patients undergoing cardiac surgery who exhibited acute RV dysfunction after cardiopulmonary bypass. Interventions After difficult weaning caused by cardiopulmonary bypass–induced acute RV dysfunction, milrinone was administered as a 5-mg bolus inside the endotracheal tube. Measurements and Main Results RV function improvement, as indicated by decreasing pulmonary artery pressure and changes of RV waveforms, was observed in all 7 patients. Adverse effects of tMil included dynamic RV outflow tract obstruction (2 patients) and a decrease in systemic mean arterial pressure (1 patient). Conclusions tMil may be an effective, rapid, and easily applicable therapeutic alternative to inhaled milrinone for the treatment of acute RV failure during cardiac surgery. However, sufficiently powered clinical trials are needed to confirm these findings.
Purpose
Transthoracic examination of the heart and great vessels is an essential skill that allows the anesthesiologist to evaluate cardiac function. In this article, we describe a pragmatic ...technique to obtain the essential views to evaluate normal or abnormal cardiac function and to appreciate great vessel anatomy and physiology.
Principal findings
The cardiac anatomy and function can be described using standard parasternal, apical, and subcostal views. These windows can also be used to assess the aorta, pulmonary artery, and vena cavae; however, other transthoracic and abdominal windows can be used to complete the evaluation of the great vessels.
Conclusions
The integration of the echocardiographic information particularly from the heart and great vessels with the case story, physical examination, laboratory data, and other relevant clinical information should become the way of the future, and this will benefit the patients under our care.
Aims
Venous congestion is a major determinant of worsening renal function (WRF) in acute decompensated heart failure (ADHF), particularly when associated with right ventricular (RV) dysfunction. ...Whether the individual impacts of hemodynamic variables on renal outcomes in ADHF is modified according to RV function remains unclear. We aimed to determine the association between hemodynamic parameters and early changes in renal function during depletive therapy and explore the association of these changes with clinical outcomes.
Methods and results
WRF was defined as any increase in creatinine after 24 h of depletive therapy and improvement in renal function (IRF) as any decrease. Assessments were prospectively obtained on admission, 24 h later and at discharge. Out of the 105 patients enrolled, 45% had IRF, and 41% had poor RV. At baseline, patients evolving towards IRF had a lower mean arterial pressure (84.7 ± 13.9 vs. 90.9 ± 15.2 mmHg), a lower renal perfusion pressure (69.4 ± 16.2 vs. 75.4 ± 15.1 mmHg), and a poorer RV function (tricuspid annular plan systolic excursion 16.5 ± 6.0 vs. 18.8 ± 5.6 mm) in comparison with those with WRF (all P < 0.05). In a multivariate linear regression model, tricuspid annular plane systolic excursion was the dominant parameter correlated with early changes in creatinine when RV was poor (β = 0.337), whereas mean arterial pressure (β = −0.334) and cardiac output (β = −0.298) were the only parameters correlated with renal function in patients with preserved RV function (all P < 0.05). RV dysfunction, but not early changes in renal function, was associated with post‐discharge clinical events.
Conclusions
RV dysfunction is a predictor of an early but transient progression to IRF during depletive therapy. RV dysfunction modifies the individual impact of various hemodynamic variables on the early trajectory of renal function in ADHF.
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