Original articleEffects of Milrinone Versus Epinephrine on Left Ventricular Relaxation After Cardiopulmonary Bypass Following Myocardial Revascularization: Assessment by Color M-Mode and Tissue Doppler
Section snippets
Methods
After approval of the local institutional review board and signed informed consent, 45 patients scheduled for coronary artery bypass grafting were enrolled. Anesthesia was accomplished with sodium thiopental (2–4 mg/kg) or etomidate (0.2–0.3 mg/kg), fentanyl (total dose 20–25 μg/kg), midazolam (total dose 0.05–0.15 mg/kg), and pancuronium (0.1 mg/kg) supplemented with isoflurane and oxygen. Intraoperative monitoring included placement of radial artery and pulmonary artery catheters.
Results
Demographic characteristics were similar among the 3 groups (Table 1), with the exception that there were significantly fewer hypertensive patients on chronic beta-blockade in the epinephrine group (7 of 12 v 11 of 13 in the milrinone group and 11 of 11 controls). Hemodynamic comparisons are shown in Table 2. All groups showed significant increases in heart rate in the post-CPB period. The epinephrine group did not reach statistical significance until after the epinephrine infusion was started.
Discussion
The present results show that there is an improvement in LV relaxation immediately post-CPB, which is unchanged by the administration of either epinephrine or milrinone. On reviewing the most specific echocardiographic indicators of LV relaxation (color M-mode and TDe), the authors noted a return to baseline function early in the post-CPB period by the time of chest closure. The color M-mode plots (Fig 3) show a more dramatic (but not statistically significant) return to baseline in the control
References (29)
- et al.
Increased left ventricular diastolic chamber stiffness immediately after coronary artery bypass surgery
J Am Coll Cardiol
(1994) - et al.
Left ventricular diastolic function after coronary artery bypass graftingA correlative study with three different myocardial protection techniques
J Thorac Cardiovasc Surg
(1997) - et al.
Increased left ventricular diastolic chamber stiffness immediately after coronary artery bypass surgery
J Am Coll Cardiol
(1994) - et al.
Transesophageal echocardiographic area and Doppler flow velocity measurementsComparison with hemodynamic changes in coronary artery bypass surgery
J Cardiothorac Vasc Anesth
(1999) - et al.
Clinical and haemodynamic effects of milrinone in the treatment of low cardiac output after cardiac surgery
Br J Anaesth
(1991) Intravenous milrinone following cardiac surgery: II: Influence of baseline hemodynamics and patient factors on therapeutic response
J Cardiothorac Vasc Anesth
(1992)- et al.
Left ventricular function and relaxationeffects of inotropic stimulation
J Thorac Cardiovasc Anesth
(1992) - et al.
Effects of milrinone versus epinephrine on grafted internal mammary artery flow
J Cardiothorac Vasc
(2000) - et al.
Milrinone, not epinephrine, improves left ventricular compliance after cardiopulmonary bypass
J Cardiothorac Vasc Anesth
(2000) - et al.
Clinical application of pulsed Doppler tissue imaging for assessing abnormal left ventricular relaxation
Am J Cardiol
(1997)
Doppler tissue imagingA noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures
J Am Coll Cardiol
Color M-mode Doppler flow propagation velocity is a preload insensitive index of left ventricular relaxationAnimal and human validation
J Am Coll Cardiol
New Doppler echocardiographic applications for the study of diastolic function
J Am Coll Cardiol
Early effects of coronary artery bypass surgery and cold cardioplegic ischemia on left ventricular diastolic functionEvaluation by computer-assisted transesophageal echocardiography
J Cardiothorac Vasc Anesth
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2019, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :Two of the RCTs compared IvMil with amrinone, 2 with epinephrine, 2 with levosimendan, 1 with nesiritide, and 1 with nifedipine, whereas the remaining studies compared IvMil with placebo. Two RCTs had 3 arms comparisons (Tables 1 and 2)18-46. The mean age among all included studies ranged from 37 to 75 years, the percentage of female patients ranged from 13% to 70%, and the percentage of patients with diabetes ranged from 16% to 45%.
European Resuscitation Council Guidelines for Resuscitation 2015. Section 6. Paediatric life support.
2015, ResuscitationCitation Excerpt :Myocardial dysfunction is common after cardiopulmonary resuscitation.374–378 Parenteral fluids and vasoactive drugs (adrenaline, dobutamine, dopamine and noradrenaline) may improve the child's post-arrest haemodynamic status and should be titrated to maintain a systolic blood pressure of at least >5th centile for age.29,379–390 Although the measurement of blood pressure has limitations in determining perfusion of vital organs, it is a practical and valued measurement of haemodynamic status.
Utility of a simple algorithm to grade diastolic dysfunction and predict outcome after coronary artery bypass graft surgery
2011, Annals of Thoracic SurgeryCitation Excerpt :Nevertheless, these investigations have proved valuable for establishing feasibility of detecting intraoperative diastolic dysfunction with TEE. Studies have also reported perioperative changes in diastolic function by TEE and the impact of pharmacologic intervention on perioperative diastolic function [14–18]. Whereas two groups examined several echocardiographic measures of diastolic function that were similar to our study, their cumulative subject populations were limited to 74 patients, and outcome was not studied [14, 15].
European Resuscitation Council Guidelines for Resuscitation 2010 Section 6. Paediatric life support
2010, ResuscitationCitation Excerpt :Myocardial dysfunction is common after cardiopulmonary resuscitation.345–348 Vasoactive drugs (adrenaline, dobutamine, dopamine and noradrenaline) may improve the child's post-arrest haemodynamic values but the drugs must be titrated according to the clinical condition.349–359 Hypothermia is common in the child following cardiopulmonary resuscitation.360
Part 10: Paediatric basic and advanced life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations
2010, ResuscitationCitation Excerpt :Evidence from six LOE 5 animal studies594–599 documented haemodynamic improvement when vasoactive medications (dobutamine, milrinone, levosimendan) were given in the post-cardiac arrest period. Evidence from one large LOE 5 paediatric444 and four LOE 5 adult600–603 studies of patients with low cardiac output or at risk for low cardiac output following cardiac surgery documented consistent improvement in haemodynamics when vasoactive medications were administered. It is reasonable to administer vasoactive medications to infants and children with documented or suspected cardiovascular dysfunction after cardiac arrest.