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Ramponi F, Seco M, Bannon PG, Kritharides L, Qasabian R, Wilson MK, Vallely MP. Synchronous Carotid Endarterectomy and Anaortic Off-Pump Coronary Artery Bypass Surgery. Heart Lung Circ 2023; 32:645-651. [PMID: 36907665 DOI: 10.1016/j.hlc.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/26/2022] [Accepted: 01/29/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND There is ongoing debate regarding the optimal strategy and timing for the surgical management of patients with severe concomitant carotid and coronary artery disease. Anaortic off-pump coronary artery bypass (anOPCAB), which avoids aortic manipulation and cardiopulmonary bypass, has been shown to reduce the risk of perioperative stroke. We present the outcomes of a series of synchronous carotid endarterectomy (CEA) and anOPCAB. METHODS A retrospective review was performed. The primary endpoint was stroke at 30 days post-operation. Secondary endpoints included transient ischaemic attack, myocardial infarction and mortality 30 days post-operation. RESULTS From 2009 to 2016, 1,041 patients underwent anOPCAB with a 30-day stroke rate of 0.4%. The majority of patients had preoperative carotid-subclavian duplex ultrasound screening and 39 were identified with significant concomitant carotid disease who underwent synchronous CEA-anOPCAB. The mean age was 71±7.5 years. Nine patients (23.1%) had previous neurological events. Thirty (30) patients (76.9%) underwent an urgent operation. For CEA, a conventional longitudinal carotid endarterectomy with patch angioplasty was performed in all patients. For anOPCAB, total arterial revascularisation rate was performed in 84.6% and the mean number of distal anastomoses was 2.9±0.7. In the 30-day postoperative period, there was one stroke (2.63%), two deaths (5.26%), two transient ischemic attacks (TIAs) (5.26%) and no myocardial infarction. Two patients experienced acute kidney injury (5.26%), one of which required haemodialysis (2.63%). Mean length of stay was 11.37±7.9 days. CONCLUSION Synchronous CEA and anOPCAB is a safe and effective option for patients' severe concomitant disease. Preoperative carotid-subclavian ultrasound screening allows identification of these patients.
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Affiliation(s)
- Fabio Ramponi
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY, USA; Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
| | - Michael Seco
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Paul Gerard Bannon
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Leonard Kritharides
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Raffi Qasabian
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Michael Keith Wilson
- Department of Cardiothoracic Surgery, Liverpool Hospital, Sydney, NSW, Australia
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Ren YS, Li LF, Peng T, Tan YJ, Sun Y, Cheng GL, Zhang GM, Li J. The effect of milrinone on mortality in adult patients who underwent CABG surgery: a systematic review of randomized clinical trials with a meta-analysis and trial sequential analysis. BMC Cardiovasc Disord 2020; 20:328. [PMID: 32640988 PMCID: PMC7346403 DOI: 10.1186/s12872-020-01598-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 06/25/2020] [Indexed: 12/12/2022] Open
Abstract
Background As an inodilator, milrinone is commonly used for patients who undergo coronary artery bypass graft (CABG) surgery because of its effectiveness in decreasing the cardiac index and mitral regurgitation. The aim of this study was to perform a systematic review and meta-analysis of existing studies from the past 20 years to evaluate the impact of milrinone on mortality in patients who undergo CABG surgery. Methods We performed a systematic literature search on the application of milrinone in patients who underwent CABG surgery in studies published between 1997 and 2017 in BioMed Central, PubMed, EMBASE, and the Cochrane Central Register. The included studies evaluated milrinone groups compared to groups receiving either placebo or standard treatment and further compared the systemic administration. Results The network meta-analysis included 723 patients from 16 randomized clinical trials. Overall, there was no significant difference in mortality between the milrinone group and the placebo/standard care group when patients underwent CABG surgery. In addition, 9 trials (with 440 randomized patients), 4 trials (with 212 randomized patients), and 10 trials (with 470 randomized patients) reported that the occurrence of myocardial infarction (MI), myocardial ischemia, and arrhythmia was lower in the milrinone group than in the placebo/standard care group. Between the milrinone treatment and placebo/standard care groups, the occurrence of myocardial infarction, myocardial ischemia, and arrhythmia was significantly different. However, the occurrence of stroke and renal failure, the duration of inotropic support (h), the need for an intra-aortic balloon pump (IABP), and mechanical ventilation (h) between these two groups showed no differences. Conclusions Based on the current results, compared with placebo, milrinone might be unable to decrease mortality in adult CABG surgical patients but can significantly ameliorate the occurrence of MI, myocardial ischemia, and arrhythmia. These results provide evidence for the further clinical application of milrinone and of therapeutic strategies for CABG surgery. However, along with milrinone application in clinical use, sufficient data from randomized clinical trials need to be collected, and the potential benefits and adverse effects should be analyzed and reevaluated.
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Affiliation(s)
- Yu-Shan Ren
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,National Engineering and Technology Research Center of Chirality Pharmaceutica, Lunan Pharmaceutical Group Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Lan-Fang Li
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Tao Peng
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Yu-Jun Tan
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,National Engineering and Technology Research Center of Chirality Pharmaceutica, Lunan Pharmaceutical Group Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Ying Sun
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Guo-Liang Cheng
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Gui-Min Zhang
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,National Engineering and Technology Research Center of Chirality Pharmaceutica, Lunan Pharmaceutical Group Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Jie Li
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China. .,National Engineering and Technology Research Center of Chirality Pharmaceutica, Lunan Pharmaceutical Group Co, Ltd., Linyi, China. .,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China.
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Rong LQ, Rahouma M, Abouarab A, Di Franco A, Calautti NM, Fitzgerald MM, Arisha MJ, Ibrahim DA, Girardi LN, Pryor KO, Gaudino M. Intravenous and Inhaled Milrinone in Adult Cardiac Surgery Patients: A Pairwise and Network Meta-Analysis. J Cardiothorac Vasc Anesth 2019; 33:663-673. [DOI: 10.1053/j.jvca.2018.08.208] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Indexed: 01/23/2023]
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Ramponi F, Seco M, Edelman JB, Sherrah AG, Bannon PG, Brereton RJL, Wilson MK, Vallely MP. Dual inflow, total-arterial, anaortic, off-pump coronary artery bypass grafting: how to do it. Ann Cardiothorac Surg 2018; 7:552-560. [PMID: 30094221 DOI: 10.21037/acs.2018.06.17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Coronary surgery performed on an arrested heart, using one internal mammary artery and a saphenous vein carries two main potential drawbacks: the known failure rate of vein grafts and the relatively high rate of neurologic injury. To address these concerns, we describe a technique that achieves complete revascularization without manipulating the ascending aorta (anaortic, off-pump) and utilizing total arterial grafts. All patients undergo thorough preoperative investigation, including bilateral carotid, vertebral and subclavian artery Duplex ultrasounds. A pulmonary artery catheter, transoesophageal echocardiography, and point-of-care coagulation testing are used in each case. The left and right internal mammary arteries and non-dominant radial artery are harvested using a fully skeletonised technique. Wide bilateral extrapleural retrothymic tunnels are developed and the pericardium is opened widely to facilitate cardiac positioning. A tandem graft is constructed with the right internal mammary artery (RIMA) in situ and radial artery using an end-to-end anastomosis. This graft is brought into the pericardium and through the transverse sinus in order to graft the lateral and inferior walls with multiple sequential distal anastomoses. The left internal mammary artery (LIMA) in situ is used to graft the anterior wall. Four main cardiac positions (high and low lateral walls, inferior and anterior walls) are obtained using a combination of off-pump stabilizer positioning, alternate tension on pericardial 'heart-strings', table tilting and folded wet sponges. All distal anastomoses are performed using silastic intracoronary shunts and an off-pump myocardial stabilizer. All grafts are checked using transit-flow time measurements. Milrinone is continued overnight and dual antiplatelet therapy is continued for 3 months postoperatively.
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Affiliation(s)
- Fabio Ramponi
- Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.,The University of Sydney, Sydney, Australia.,Coronary Artery Disease Institute, Sydney, Australia
| | - Michael Seco
- Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.,The University of Sydney, Sydney, Australia.,Coronary Artery Disease Institute, Sydney, Australia
| | - James B Edelman
- Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.,The University of Sydney, Sydney, Australia.,Coronary Artery Disease Institute, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia
| | - Andrew G Sherrah
- Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.,Coronary Artery Disease Institute, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia
| | - Paul G Bannon
- Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.,The University of Sydney, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,Sydney Heart and Lung Surgeons, Sydney, Australia
| | - R John L Brereton
- Cardiothoracic Surgical Unit, Royal North Shore Hospital, Sydney, Australia
| | - Michael K Wilson
- Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.,Coronary Artery Disease Institute, Sydney, Australia.,Cardiothoracic Surgical Unit, Royal North Shore Hospital, Sydney, Australia.,Macquarie University Hospital, Sydney, Australia
| | - Michael P Vallely
- Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia.,The University of Sydney, Sydney, Australia.,Coronary Artery Disease Institute, Sydney, Australia.,Sydney Heart and Lung Surgeons, Sydney, Australia.,Macquarie University Hospital, Sydney, Australia
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5
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Majure DT, Greco T, Greco M, Ponschab M, Biondi-Zoccai G, Zangrillo A, Landoni G. Meta-analysis of Randomized Trials of Effect of Milrinone on Mortality in Cardiac Surgery: An Update. J Cardiothorac Vasc Anesth 2013; 27:220-9. [PMID: 23063100 DOI: 10.1053/j.jvca.2012.08.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Indexed: 02/08/2023]
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6
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Zangrillo A, Biondi-Zoccai G, Ponschab M, Greco M, Corno L, Covello RD, Cabrini L, Bignami E, Melisurgo G, Landoni G. Milrinone and Mortality in Adult Cardiac Surgery: A Meta-analysis. J Cardiothorac Vasc Anesth 2012; 26:70-7. [PMID: 21943792 DOI: 10.1053/j.jvca.2011.06.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Indexed: 02/08/2023]
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Song JW, Jo YY, Jun NH, Kim HK, Kwak YL. The effect of milrinone on the intraoperative hemodynamics during off-pump coronary bypass surgery in patients with an elevated echocardiographic index of the ventricular filling pressure. Korean J Anesthesiol 2011; 60:185-91. [PMID: 21490820 PMCID: PMC3071482 DOI: 10.4097/kjae.2011.60.3.185] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Revised: 07/28/2010] [Accepted: 08/11/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemodynamic derangement during off-pump coronary artery bypass surgery (OPCAB) is mainly attributed to impaired filling and diastolic dysfunction. An elevated ratio of the mitral velocity to the early-diastolic velocity of the mitral annulus (E/e' > 15) is a relatively new indicator of diastolic function, and this was reported to be associated with impaired hemodynamics during OPCAB. We investigated the efficacy of milrinone on the perioperative hemodynamics and short term outcomes of patients with an E/e' > 15 and who underwent OPCAB. METHODS The patients were randomly allocated into either group C (control, n = 31) or group M (n = 31) and they were treated with the same amount of either normal saline or milrinone (0.5 µg/kg/min) without bolus loading after completion of internal mammary artery harvest until the end of operation. Hemodynamic measurements were recorded after the induction of anesthesia (T1), 5 min after starting each distal anastomosis of the left anterior descending artery (T2), left circumflex artery (T3) and right coronary artery (T4), and 5 min after sternum closure (T5). RESULTS The mixed venous oxygen saturation (SvO(2)) was lower through T2-T4 compared to the baseline value in both groups, while the degree of the decrease was significantly less in group M than that in group C. The other hemodynamic variables, the operative data and the postoperative outcomes were similar between the two groups. CONCLUSIONS Intraoperative infusion of milrinone did not significantly improve the perioperative hemodynamics and the subsequent short term outcomes for the patients with preexisting diastolic dysfunction as represented by an elevated E/e' value, although it reduced the degree of decrease of the SvO(2) during OPCAB.
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Affiliation(s)
- Jong Wook Song
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
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Anaortic, Total-arterial, Off-pump Coronary Artery Bypass Surgery: How To Do It. Heart Lung Circ 2010; 19:555-60. [PMID: 20447865 DOI: 10.1016/j.hlc.2010.04.078] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2010] [Accepted: 04/01/2010] [Indexed: 11/21/2022]
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Denault AY, Lamarche Y, Couture P, Haddad F, Lambert J, Tardif JC, Perrault LP. Inhaled milrinone: a new alternative in cardiac surgery? Semin Cardiothorac Vasc Anesth 2007; 10:346-60. [PMID: 17200091 DOI: 10.1177/1089253206294400] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The administration of milrinone through inhalation has been studied in only a few animal and human studies. Compared to the intravenous administration, inhaled milrinone has been shown to reduce pulmonary artery pressure without systemic hypotension. Therefore, this approach could represent an alternative to nitric oxide. This current state of knowledge of intravenous and inhaled milrinone is presented and summarized.
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Affiliation(s)
- André Y Denault
- Department of Cardiac Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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Sidi A, Muehlschlegel JD, Muehschlegel JD, Kirby DS, Lobato EB. Treating metabolic impairment and myocardial stunning with phosphodiesterase inhibitor type III, milrinone, administered prior to coronary artery occlusion in the presence of calcium channel blockade in pigs. Ann Card Anaesth 2007; 10:34-41. [PMID: 17455406 DOI: 10.4103/0971-9784.37922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This study examined milrinone effects on ischaemic myocardial metabolism and function with calcium blockade. We studied 15 pigs in 3 groups: group C received no drugs; group D received diltiazem 5 mg bolus followed by infusion; group D+M received diltiazem and milrinone (50microg/Kg). The left anterior descending (LAD) artery was then occluded for 15 minutes. Left ventricular (LV) function data obtained included rate, pressures, output, Emax, and dP/dT. Blood lactate was obtained from the LAD and circumflex vessels at baseline, end of occlusion, early (15 min) and late (1 hour) reperfusion. In group D+M, less depression of LV function occurred during ischaemia and early reperfusion. Lactate extraction in the LAD region was less negative in D+M group than in the group without milrinone during ischaemia and late reperfusion. We conclude the preemptive administration of milrinone prior to ischaemia added to calcium blockade improved myocardialfunction and ischaemic metabolic effects.
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Affiliation(s)
- Avner Sidi
- Department of Anesthesiology, University of Florida College of Medicine and Anesthesia Service, Malcom Randall Veterans Administration Medical Center, Gainesville, Florida, USA.
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Sidi A, Muehlschlegel JD, Kirby DS, Lobato EB. Treatment of ischaemic left ventricular dysfunction with milrinone or dobutamine administered during coronary artery stenosis in the presence of beta blockade in pigs †. Br J Anaesth 2006; 97:799-807. [PMID: 17035336 DOI: 10.1093/bja/ael276] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND This study examines the effects of phosphodiesterase type III (PDEIII) inhibition vs beta stimulation on global function of the left ventricle (LV) and systemic haemodynamics in a porcine model of acute coronary stenosis with beta blockade. METHODS A total of 18 adult swine were anaesthetized. Micromanometer-tipped catheters were placed in the ascending aorta and LV. Two pairs of ultrasonic dimension transducers were placed in the subendocardium on the short axis proximal to a left anterior descending (LAD) artery occluder and the long axis of the LV. Before ischaemia, i.v. esmolol was infused to decrease baseline heart rate (HR) by approximately 25%, and all animals received an esmolol infusion (150 microg kg(-1) min(-1)). Ischaemia was produced by reducing the flow in the LAD artery by approximately 80%, from 17(4) to 3(2) ml min(-1). Animals were randomized to receive (after esmolol) one of the following: no drug, sham only (Group 1, n=6), control (C); 50 microg kg(-1) i.v. milrinone (Group 2, n=6) followed by 0.375 microg kg(-1) min(-1) (M); or incremental doses of dobutamine (Group 3, n=6) every 10 min (5, 10 and 20 microg kg(-1) min(-1)) (D). Left ventricular function data obtained included HR, arterial and LV pressures, cardiac output (CO), Emax and dP/dT. Measurements were taken during five time periods: before ischaemia (at baseline, after esmolol) and every 10 min during ischaemia (at 10, 20 and 30 min). RESULTS The effects of beta blockade and ischaemia had a significant impact on contractility (Emax) in Group M and myocardial performance (left ventricular end-diastolic pressure, LVEDP) in all groups. Left ventricular function (Emax, CO, LVEDP and SVR) was better preserved when milrinone was added in Group M. A moderate dose of dobutamine (10 microg kg(-1) min(-1)) increased CO. Only the high dose (20 microg kg(-1) min(-1)) improved contractility (Emax), but at the expense of increased SVR. Also, LVEDP with either dose of dobutamine remained high and unchanged. CONCLUSIONS From our limited findings, it would appear that there may, theoretically, be some benefit for using milrinone in preference to other inotropic drugs in the presence of beta blockade. Milrinone administration should be considered in patients with acute ischaemic LV dysfunction and preexisting beta blockade before using other inotropic drugs such as beta stimulants.
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Affiliation(s)
- A Sidi
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, FL, USA.
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