Bridging patients to cardiac transplantation

Effect of Milrinone Infusion on Pulmonary Vasculature and Stroke Work Indices: A Single-Center Retrospective Analysis in 69 Patients Awaiting Cardiac Transplantation

BACKGROUND

Although milrinone infusion is reported to benefit left ventricular function in chronic left heart failure, few insights exist regarding its effects on pulmonary circulation and right ventricular function.

METHODS

We retrospectively reviewed right heart catheterization data at baseline and during continuous infusion of milrinone in 69 patients with advanced heart failure and analyzed the effects on ventricular stroke work indices, pulmonary vascular resistance and pulmonary arterial compliance.

RESULTS

Compared to baseline, milrinone infusion after a mean 58 ± 61 days improved mean left ventricular stroke work index (1540 ± 656 vs. 2079 ± 919 mmHg·mL/m², p = 0.0007) to a much greater extent than right ventricular stroke work index (616 ± 346 vs. 654 ± 332, p = 0.053); however, patients with below median stroke work indices experienced a significant improvement in both left and right ventricular stroke work performance. Overall, milrinone reduced left and right ventricular filling pressures and pulmonary and systemic vascular resistance by approximately 20%. Despite an increase in pulmonary artery capacitance (2.3 ± 1.6 to 3.0 ± 2.0, p = 0.013) and a reduction in pulmonary vascular resistance (3.8 ± 2.3 to 3.0 ± 1.7 Wood units), milrinone did not reduce the transpulmonary gradient (13 ± 7 vs. 12 ± 6 mmHg, p = 0.252), the pulmonary artery pulse pressure (25 ± 10 vs. 24 ± 10, p = 0.64) or the pulmonary artery diastolic to pulmonary capillary wedge gradient (2.0 ± 6.5 vs. 2.4 ± 6.0, p = 0.353).

CONCLUSION

Milrinone improved left ventricular stroke work indices to a greater extent than right ventricular stroke work indices and had beneficial effects on right ventricular net input impedance, predominantly via augmentation of left ventricular stroke volume and passive unloading of the pulmonary circuit. Patients who had the worst biventricular performance benefited the most from chronic milrinone infusion.

‘A stony road… a 19 year journey’: ‘Bridging’ through late-stage Parkinson’s disease

Abstract

Studies reporting the lived experience of late-stage Parkinson’s disease are sparse. Using constructivist grounded theory and centre-stage storyline generation as the methodological approach, this study reports on 69 interviews with 13 people with late-stage Parkinson’s disease and their family carers who were recruited from the caseload of two specialist Parkinson’s disease nurses working in North Wales and one consultant geriatrician. The interviews were conducted longitudinally between June 2007 and April 2008, and all participants were diagnosed with late-stage idiopathic Parkinson’s disease using Brain Bank clinical criteria. All interviews and the subsequent sharing, modification and testing of the results of data analysis were conducted in the person’s home and with their participation as partners in the research process. From this process, bridging emerged as the centre-stage storyline in adjusting to life with late-stage Parkinson’s disease, and this consisted of three temporal stages, namely: 1) building on the past; 2) bridging the present and 3) broaching the future. These three stages were underpinned by three linked sequential foundations, namely biographical, situational and crumbling. These stages, foundations and properties of bridging have important implications for the understanding of late-stage Parkinson’s disease and informing the nursing role in developing and providing appropriate supportive interventions.

Cardiovascular pharmacotherapy update for the intensive care unit

Pharmacologic agents including vasodilators, inotropes, and vasopressors are frequently used in the critical care setting for management of the unstable cardiac patient. These medications are used to elicit varying effects on vascular resistance, myocardial contractility, and heart rate to help achieve desired hemodynamic and clinical endpoints. Therefore, it is important for the critical care nurse to have a practical understanding and working knowledge of cardiovascular pharmacotherapy in the intensive care unit setting. This article reviews the pharmacology and clinical utility of commonly used intravenous "vasoactive" medications encountered in the intensive care unit. We also highlight innovations in pharmacotherapy for this patient population, and provide practical considerations for the most appropriate and safe use of these medications.

Tratamiento inotrópico en la insuficiencia cardíaca: aspectos generales y resultados clínicos

Classic inotropic agents such as beta-adrenergic agonists and phosphodiesterase III inhibitors have beneficial but transitory hemodynamic effects in patients with acute and chronic heart failure. In this context, the available data suggest that long term inotropic therapy has a negative impact on morbidity and mortality in patients with heart failure. For this reason, these agents are mainly used for the treatment of refractory episodes of decompensation and they are also used as a "bridge" (transplant, revascularization, recovery) or as a palliative measure. We present a revision of the general aspects of inotropes including main published clinical trials and some findings of its combined use with beta blockers. Furthermore, we describe a promising and differential therapeutic approach represented by calcium sensitizer agents (levosimendan).

Comparison of dobutamine versus milrinone therapy in hospitalized patients awaiting cardiac transplantation: a prospective, randomized trial

BACKGROUND

The use of dobutamine or milrinone for inotropic support in patients with heart failure awaiting cardiac transplantation is largely arbitrary and based on institutional preference. The costs and effectiveness of these drugs have yet to be compared in a prospective, randomized study.

METHODS

We compared clinical outcomes and costs associated with the use of dobutamine or milrinone in 36 hospitalized patients awaiting cardiac transplantation. Patients were randomly assigned to receive either dobutamine or milrinone at the time of initial hospitalization and were followed until death, transplantation, or placement of mechanical cardiac support (intra-aortic balloon pump or left ventricular assist device).

RESULTS

Seventeen patients were randomly assigned to receive dobutamine (mean dose 4.1 +/- 1.4 microg/kg/min) and 19 patients received milrinone (mean dose 0.39 +/- 1.0 microg/kg/min). Therapy lasted 50 +/- 46 days for those in the dobutamine group and 63 +/- 45 days in the milrinone group. We did not detect differences between the 2 groups in right heart hemodynamics, death, need for additional vasodilator/inotropic therapy, or need for mechanical cardiac support before transplantation. Ventricular arrhythmias requiring increased antiarrhythmic therapy occurred frequently in both groups. Total acquisition cost of milrinone was significantly higher than that of dobutamine (16,270 dollars +/- 1334 vs 380 dollars +/- 533 P <.00001).

CONCLUSIONS

Both dobutamine and milrinone can be used successfully as pharmacologic therapy for a bridge to heart transplantation. Despite similar clinical outcomes, treatment with milrinone incurs greater cost.

Comparison of dobutamine-based and milrinone-based therapy for advanced decompensated congestive heart failure: Hemodynamic efficacy, clinical outcome, and economic impact

BACKGROUND

The use of parenteral positive inotropic agents still remains a major component of therapy for patients with advanced decompensated congestive heart failure (CHF). However, no consensus guidelines have been developed for the appropriate selection of a first-line inotropic therapy. We sought to compare the clinical outcome and economic cost of dobutamine-based and milrinone-based therapy in patients with acute exacerbation of CHF.

METHODS AND RESULTS

We retrospectively analyzed the outcome of 329 patients admitted to the heart failure unit with acute exacerbation of CHF. More patients were treated with dobutamine-based therapy (269/329, 81.7%) than with milrinone-based therapy (60/329, 18.3%). Both groups had similar baseline characteristics and similar hemodynamic profiles at baseline, with the exception of higher mean pulmonary arterial pressure in the milrinone group (47 mm Hg vs 42 mm Hg, P <.001). One hundred nine patients (40%) of the dobutamine group required parenteral nitroprusside for hemodynamic optimization compared with 11 patients (18%) in the milrinone group (P <.001). The use of parenteral nitroglycerin and dopamine was similar in both groups. There was no significant difference in the in-hospital mortality rate (dobutamine 7.8% vs milrinone 10%) or clinical outcome between the 2 groups. However, the average direct drug cost per patient was significantly reduced in the dobutamine group compared with the milrinone group ($45 +/- $10 vs $1855 +/- $350, P <.0001).

CONCLUSION

Dobutamine-based therapy is an attractive approach for the treatment of decompensated advanced heart failure, achieving comparable clinical efficacy to milrinone with a significantly reduced economic cost.