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Abramov D, Haglund NA, Di Salvo TG. Effect of Milrinone Infusion on Pulmonary Vasculature and Stroke Work Indices: A Single-Center Retrospective Analysis in 69 Patients Awaiting Cardiac Transplantation. Am J Cardiovasc Drugs 2017; 17:335-342. [PMID: 28353026 DOI: 10.1007/s40256-017-0225-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Abstract
The function of the right ventricle (RV) in heart failure (HF) has been mostly ignored until recently. A 2006 report of the National Heart, Lung, and Blood Institute identified a gap between RV research efforts and its clinical importance compared with that of the left ventricle. This recent shift in paradigm is fueled by the prognostic value ascribed to RV failure in HF and morbidity/mortality after myocardial infarction and surgery. In this review, we examine the significance of RV failure in the HF setting, its clinical presentation and pathophysiology, and ways to evaluate RV function using echocardiographic measurements. Furthermore, we discuss the medical management of RV failure including traditional therapies like beta-blockers and newer options like nitric oxide, phosphodiesterase inhibitors, and calcium sensitizers. Mechanical support is also examined. Finally, this review places an emphasis on RV failure in the setting of left ventricular assist devices and heart transplantation.
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Guglin M, Win CM, Darbinyan N, Wu Y. Predictors of right ventricular systolic dysfunction in compensated and decompensated heart failure. ACTA ACUST UNITED AC 2012; 18:278-83. [PMID: 22994442 DOI: 10.1111/j.1751-7133.2012.00289.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Current understanding of the mechanisms of right ventricular (RV) systolic dysfunction in heart failure (HF) is limited. The authors analyzed a limited access dataset from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) provided by the National Heart, Lung, and Blood Institute (NHLBI). RV systolic function was measured by echocardiography at baseline and at 3-month follow-up using fractional area change. Univariate and multivariate analysis was performed with linear regression. Of 433 patients enrolled in the ESCAPE trial, 190 had RV systolic function measured at baseline (decompensated HF) and 147 had it measured at 3-month follow-up. On both occasions, parameters of congestion were associated with RV systolic function. Interestingly, lower hematocrit level was also associated with better RV systolic function. In multivariate analysis, only wedge pressure remained a statistically significant predictor of RV dysfunction. In summary, cardiac diastolic pressures and corresponding echocardiographic parameters, as well as hematocrit level, predicted RV systolic function in both compensated and decompensated systolic HF.
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Affiliation(s)
- Maya Guglin
- Department of Cardiology, University of South Florida, Tampa, FL 33606, USA.
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Mahmud M, Champion HC. Right ventricular failure complicating heart failure: pathophysiology, significance, and management strategies. Curr Cardiol Rep 2007; 9:200-8. [PMID: 17470333 DOI: 10.1007/bf02938351] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Right heart failure most commonly results from the complication of left heart failure (systolic or nonsystolic dysfunction) or pulmonary hypertension. Over the past decade, greater attention has been paid to the role of right ventricular failure in the morbidity and mortality associated with cardiomyopathy and pulmonary hypertension. The right ventricle is distinct from the left ventricle not only in its spatial localization, but also in its response to increased afterload and signaling mechanisms. This article discusses the role of right ventricular failure in the setting of heart failure as well as the clinical diagnosis and management of right ventricular failure.
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Affiliation(s)
- Mobusher Mahmud
- Division of Cardiology, Department of Medicine, Johns Hopkins University, 720 Rutland Avenue, Ross 850, Baltimore, MD 21205, USA
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Ishikawa S, Nakazawa K, Yokoyama K, Amaha K. Amrinone improves right ventricular ejection fraction and oxygen delivery without deterioration of extravascular lung water in canine oleic acid pulmonary injury. Anaesth Intensive Care 1998; 26:355-9. [PMID: 9743847 DOI: 10.1177/0310057x9802600402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Fourteen mongrel dogs were anaesthetized and mechanically ventilated with oxygen. After oleic acid was administered intravenously, amrinone 1 mg/kg was intravenously administered to one group followed by a continuous infusion of 10 micrograms/kg/min for one hour (amrinone group, n = 7). Isovolumetric saline was administered to the control group (n = 7). Amrinone slightly lowered PaO2 but significantly increased oxygen delivery and improved gastric intramucosal pH (pHi) during the first 30 minutes (7.33 +/- 0.13) compared with the control group (7.21 +/- 0.06, P < 0.05). The pHi remained higher in the amrinone group (7.30 +/- 0.15) than in the control group (7.16 +/- 0.06, P < 0.05) after the drug was withdrawn. Extravascular lung water was significantly augmented after oleic acid injection and sustained in all animals for the remainder of the study.
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Affiliation(s)
- S Ishikawa
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Tokyo Medical and Dental University, Japan
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Ochiai Y, Morita S, Tanoue Y, Kawachi Y, Tominaga R, Yasui H. Effects of amrinone, a phosphodiesterase inhibitor, on right ventricular/arterial coupling immediately after cardiac operations. J Thorac Cardiovasc Surg 1998; 116:139-47. [PMID: 9671908 DOI: 10.1016/s0022-5223(98)70252-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Amrinone, a selective phosphodiesterase III inhibitor, is reported to have a potent inotropic effect on the left ventricle, but the effects of this drug on right ventricular contractility in the clinical setting are unknown. The concept of ventricular/arterial coupling was applied to investigate the effects of amrinone on right ventricular contractility and afterload with transesophageal echocardiography. METHODS AND RESULTS The study was performed in the intensive care unit with 11 patients who had undergone cardiac operations. Right ventricular cross-sectional area was measured with transesophageal echocardiography equipped with a capability of automated border detection as a surrogate for right ventricular volume. Multiple pressure-area loops were obtained by reducing preload to measure end-systolic elastance and effective arterial elastance. External work and pressure-volume area were also measured to calculate the efficiency of energy transfer from pressure-volume area to external work. Nitroprusside (0.3 to 0.5 microg x kg(-1) x min(-1)) and amrinone (1 mg x kg(-1) intravenously followed by 10 microg x kg(-1) x min(-1)) were administered. With nitroprusside infusion, end-systolic elastance and effective arterial elastance remained unchanged (end-systolic elastance, 4.73 +/- 2.18 mm Hg/cm2 to 4.65 +/- 2.09 mm Hg/cm2; effective arterial elastance, 8.05 +/- 3.84 mm Hg/cm2 to 7.70 +/- 3.64 mm Hg/cm2). In contrast, amrinone reduced afterload (effective arterial elastance, 8.82 +/- 3.99 mm Hg/cm2 to 7.05 +/- 4.01 mm Hg/cm2, p = 0.004) and enhanced contractility (end-systolic elastance, 4.47 +/- 1.79 mm Hg/cm2 to 6.56 +/- 2.22 mm Hg/cm2, p = 0.007). Consequently, amrinone decreased the ventricular/arterial coupling ratio (effective arterial elastance/end-systolic elastance, 2.40 +/- 1.45 to 1.16 +/- 0.63, p = 0.009) and improved the efficiency of energy transfer (external work/pressure-volume area, 0.44 +/- 0.15 to 0.54 +/- 0.15, p = 0.013). CONCLUSIONS Right ventricular pressure-area relations obtained with transesophageal echocardiography could successfully separate the simultaneous change in right ventricular systolic mechanics and afterload caused by amrinone. Amrinone caused enhancement of right ventricular contractility and afterload reduction.
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Affiliation(s)
- Y Ochiai
- Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University, Fukuoka, Japan
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Ferlinz J. Right ventricular diastolic performance: compliance characteristics with focus on pulmonary hypertension, right ventricular hypertrophy, and calcium channel blockade. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 43:206-43. [PMID: 9488559 DOI: 10.1002/(sici)1097-0304(199802)43:2<206::aid-ccd22>3.0.co;2-k] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
MESH Headings
- Animals
- Calcium Channel Blockers/therapeutic use
- Coronary Disease/complications
- Coronary Disease/physiopathology
- Diastole
- Humans
- Hypertension/complications
- Hypertension/physiopathology
- Hypertension, Pulmonary/complications
- Hypertension, Pulmonary/physiopathology
- Hypertrophy, Right Ventricular/complications
- Hypertrophy, Right Ventricular/physiopathology
- Lung Diseases, Obstructive/complications
- Lung Diseases, Obstructive/physiopathology
- Ventricular Dysfunction, Right/complications
- Ventricular Dysfunction, Right/drug therapy
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Function, Right/drug effects
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Affiliation(s)
- J Ferlinz
- Department of Medicine, Aleda E. Lutz V.A. Medical Center, Saginaw, Michigan 48602, USA
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Quaife RA, Christian PE, Gilbert EM, Datz FL, Volkman K, Bristow MR. Effects of carvedilol on right ventricular function in chronic heart failure. Am J Cardiol 1998; 81:247-50. [PMID: 9591916 DOI: 10.1016/s0002-9149(97)00874-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This study investigated the effects of carvedilol on right ventricular (RV) volume and systolic function in chronic heart failure patients. Carvedilol treatment resulted in a significant improvement of RV ejection fraction and systolic performance, which paralleled the improvement of systolic function demonstrated in the left ventricle.
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Affiliation(s)
- R A Quaife
- Department of Medicine, University of Colorado Health Sciences Center, Denver 80262, USA
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Aris A, Cámara ML. As originally published in 1988: Long-term results of mitral valve surgery in patients with severe pulmonary hypertension. Updated in 1996. Ann Thorac Surg 1996; 61:1583-4. [PMID: 8633993 DOI: 10.1016/0003-4975(96)00114-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Mitral valve surgery was performed in 88 patients with severe pulmonary hypertension (average systolic pulmonary artery pressure, 94.7 +/- 22 mm Hg; range, 70-180 mm Hg) over a 10-year period. Sixty-four patients (73%) were in New York Heart Association Functional Class III or IV. There were 64 valve replacements and 24 open mitral commissurotomies. Operative mortality was 5.6% (5 patients) and was not related to the degree of pulmonary hypertension, surgical procedure performed, or type of valve lesion. A 100% follow-up was obtained, ranging from nine months to 10 years, with a mean of 44 months. Six late cardiac deaths (7.2%) occurred, 5 in patients with valve replacement and 1 in a patient who underwent a commissurotomy. Actuarial survival was 86 +/- 3% at five years and 83 +/- 4% at 10 years. Fourteen patients underwent right ventricular catheterization a mean of 24 months following operation. Systolic pulmonary artery pressure had decreased from a mean preoperative value of 101 +/- 22 to 40.5 +/- 7 mm Hg (p < 0.001). Cardiac index increased by 55% of the preoperative values. Functional status improved markedly; 71 survivors (93%) were in New York Heart Association Class I or II. These results indicate that, in patients with mitral valve lesions and severe pulmonary hypertension, (1) surgical procedures can be performed with an acceptable operative mortality; (2) excellent long-term survival and functional results can be obtained; and (3) pulmonary hypertension decreases significantly after operation. Patients with mitral valve disease may benefit from surgical treatment regardless of the degree of pulmonary hypertension.
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Affiliation(s)
- A Aris
- Cardiac Surgery Service, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Lee TS, Hou X. Comparative vasoactive effects of amrinone on systemic and pulmonary arteries in rabbits. Chest 1995; 108:1364-7. [PMID: 7587443 DOI: 10.1378/chest.108.5.1364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Amrinone has been increasingly used in management of low cardiac output syndrome during anesthesia, particularly when associated with right heart failure and pulmonary hypertension. This in vitro study was performed to determine and compare the direct vasoactive effects of amrinone on isolated rabbit systemic and pulmonary arteries. Responses of aortic and pulmonary artery rings from New Zealand white rabbits were assessed in the presence and absence of intact endothelium and with or without precontraction by norepinephrine (NE, 3 x 10(-6)M) or potassium chloride (KCl, 3 x 10(-2)M). Using a tissue bath preparation, cumulative concentration response curves of amrinone were obtained at different concentrations after a period of stabilization. Amrinone caused a dose-related vasodilation of NE-precontracted aortic and pulmonary arteries. It elicited about 65% and 90% relaxation, respectively, at a concentration of 300 mumol/L. Amrinone also induced a dose-related vasodilation of KCl-precontracted aortic and pulmonary arteries but to a lesser degree. All these effects were endothelium independent. By comparison, amrinone caused more relaxation in both NE- and KCl-precontracted pulmonary artery than aortic rings. In conclusion, amrinone has significant endothelium-independent, direct vasodilatory effects on isolated rabbit systemic and pulmonary arteries, more pronounced in the latter, particularly NE-precontracted vessels. Amrinone may have some calcium channel-blocking effect.
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Affiliation(s)
- T S Lee
- Harbor-UCLA Medical Center, Torrance 90509-2910, USA
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Chang AC, Atz AM, Wernovsky G, Burke RP, Wessel DL. Milrinone: systemic and pulmonary hemodynamic effects in neonates after cardiac surgery. Crit Care Med 1995; 23:1907-14. [PMID: 7587268 DOI: 10.1097/00003246-199511000-00018] [Citation(s) in RCA: 214] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To evaluate the hemodynamic effects of intravenous milrinone in neonates with low cardiac output after cardiac surgery. DESIGN Prospective cohort study. SETTING Pediatric cardiac intensive care unit. PATIENTS Ten neonates with low cardiac output (cardiac index of < or = 3.0 L/min/m2) after corrective cardiac surgery were enrolled in the study. The neonates' ages ranged from 3 to 27 days (median 5) and their weights ranged from 2.0 to 4.8 kg (median 3.7). The diagnoses were: transposition of the great arteries (n = 6, including two with ventricular septal defect), tetralogy of Fallot (n = 2), truncus arteriosus (n = 1), and total anomalous pulmonary venous connection (n = 1). INTERVENTIONS Milrinone was intravenously administered in three stages: a) baseline stage, in which patients had a stable hemodynamic status, ventilation and gas exchange, hemostasis, and body temperature; b) loading stage, in which a 50 microgram/kg intravenous loading dose of milrinone was administered over 15 mins; and c) infusion stage, in which milrinone was continuously infused at 0.50 microgram/kg/min for 30 mins. MEASUREMENTS AND MAIN RESULTS The mean heart rate increased after the loading stage (149 +/- 13 to 163 +/- 12 beats/min, p < .01) but slowed during the infusion stage (154 +/- 11 beats/min, p < .01 vs. loading stage). Both right and left atrial pressures were lowered in all ten neonates. Compared with baseline, mean arterial pressure decreased after the loading stage (66 +/- 12 to 57 +/- 10 mm Hg, p < .01) but did not decrease further at the infusion stage (59 +/- 12 mm Hg); changes in mean pulmonary arterial pressure were comparable. Cardiac index increased from a baseline mean of 2.1 +/- 0.5 to 3.0 +/- 0.8 L/min/m2 (p < .01) with the loading stage, and was maintained at 3.1 +/- 0.6 L/min/m2 during the infusion stage. Systemic vascular resistance index decreased below baseline values with loading, from 2136 +/- 432 to 1336 +/- 400 dyne.sec/cm5.m2 (p < .01), and pulmonary vascular resistance index also decreased with loading dose of milrinone, from 488 +/- 160 to 360 +/- 120 dyne.sec/cm5.m2 (p < .01). There was no change in the rate pressure index, an indirect measurement of myocardial oxygen consumption, throughout the study. CONCLUSIONS Administration of milrinone in neonates with low cardiac output after cardiac surgery lowers filling pressures, systemic and pulmonary arterial pressures, and systemic and pulmonary vascular resistances, while improving cardiac index. Milrinone increases heart rate without altering myocardial oxygen consumption. While milrinone appears to be effective and safe during short-term use, the relative distribution of inotropic and vasodilatory properties of milrinone remains to be elucidated.
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Affiliation(s)
- A C Chang
- Department of Cardiology, Children's Hospital, Boston, MA 02115, USA
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Saal JP, Habbal R, Estagnasie P, Lellouche D, Castaigne A, Dubois-Randé JL. Effects of piroximone on the right ventricular function in severe heart failure patients. Intensive Care Med 1994; 20:341-7. [PMID: 7930028 DOI: 10.1007/bf01720906] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To assess the effects of piroximone, a phosphodiesterase inhibitor, on right ventricular function in patients with heart failure. DESIGN Randomized study: patients were randomly assigned to the piroximone infusion rate of 5 or 10 micrograms/kg/min. SETTING Cardiologic intensive care unit. PATIENTS 12 consecutive patients with severe heart failure. INTERVENTIONS Right heart catheterization was performed using a Swan-Ganz ejection fraction thermodilution catheter. MEASUREMENTS AND RESULTS Measurements of right ventricular ejection fraction (RVEF), end-diastolic and end-systolic right ventricular volumes were obtained using the thermodilution principle. To determine contractility indexes, the relationships between end-systolic pulmonary arterial pressure (ESPAP) over right ventricular end-systolic volume (RVESV) and ESPAP over RVEF were calculated during the infusion of prostacyclin at incremental infusion rates of 2, 4, 6 and 8 ng/kg/min. The slope of the relation between ESPAP over RVESV shifted during piroximone therapy from 7.635 +/- 1.632 to 1.975 +/- 0.432 (p < 0.01) and from 6.092 +/- 1.99 to 1.028 +/- 0.853 (p < 0.05) at 5 and 10 micrograms/kg/min piroximone infusion, respectively. The slope of the relation between ESPAP over RVEF decreased from -0.414 +/- 0.296 to -0.821 +/- 0.257 (p < 0.01) and from -0.127 +/- 0.048 to - 0.533 +/- 0.135 (p < 0.05) at 5 and 10 micrograms/kg/min piroximone infusion, respectively. CONCLUSIONS This study suggests a positive action of piroximone on right ventricular contractility at these 2 dosages. This approach using this type of catheter allowed us to determine right ventricular inotropic indexes.
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Affiliation(s)
- J P Saal
- Département de Cardiologie, INSERM U2, Hôpital Henri Mondor, Créteil, France
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Martin C, Perrin G, Saux P, Papazian L, Albanese J, Gouin F. Right ventricular end-systolic pressure-volume relation during propofol infusion. Acta Anaesthesiol Scand 1994; 38:223-8. [PMID: 8023660 DOI: 10.1111/j.1399-6576.1994.tb03878.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The effects of propofol on right ventricular function were studied in 11 ICU patients who needed sedation for acute respiratory failure or neurological diseases. Right ventricular function was studied using a thermodilution method at patients' bedside. Right ventricular ejection fraction (RVEF), cardiac output (CO), right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume (RVESV), right ventricular end-systolic pressure (RVESP) and pulmonary capillary wedge pressure (PCWP) were obtained from a modified Swan-Ganz catheter. Calculation of right ventricular end-systolic pressure-volume relation (ESPVR) allowed to assess changes in right ventricular inotropic state. A baseline ESPVR was obtained before propofol infusion: RVESP = 0.21 RVESV + 2.4, r = 0.83, P < 0.0001. Then, patients were given an induction dose of 1 to 2.5 mg.kg-1 propofol over 1 min followed by a continuous infusion of 3 mg.kg-1.h-1. During propofol infusion heart rate, mean arterial pressure, PCWP, CO, systemic vascular resistance and RVEF significantly decreased. No change in RVEDV and RVESV was observed. ESPVR was significantly altered with a dramatic decrease in the slope of the relation: RVESP = 0.12 RVESV + 6.9 (P < 0.001 from baseline). Dobutamine was used in five patients with clinically significantly cardiac dysfunction and restored the slope of the ESPVR to the baseline value: RVESP = 0.22 RVESV + 6.3 (NS from baseline). In the study patients, propofol altered the inotropic state of the right ventricle.
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Affiliation(s)
- C Martin
- Department of Anaesthesia and Intensive Care, Hôpital Sainte-Marguerite, Marseille, France
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Berger JI, Gibson RL, Clarke WR, Standaert TA, Redding GJ, Henderson WR, Truog WE. Effect of amrinone during group B Streptococcus-induced pulmonary hypertension in piglets. Pediatr Pulmonol 1993; 16:303-10. [PMID: 8255635 DOI: 10.1002/ppul.1950160506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Intravenous infusion of group B Streptococcus (GBS) into neonatal animals produces pulmonary hypertension, ventilation/perfusion (VA/Q) mismatch, and an increase in serum levels of thromboxane B2 (TxB2) and tumor necrosis factor (TNF) alpha. The vasodilator amrinone (amr) is a cGMP-inhibited phosphodiesterase inhibitor and is reported to inhibit thromboxane A2 and TNF production. We hypothesized that infusion of amr would cause pulmonary vasodilation and reduce serum TxB2 and TNF levels in piglets with late phase GBS-induced pulmonary hypertension. The effect of amr on gas exchange was also determined. A continuous infusion of GBS was administered for 5 hr to 4 groups of anesthetized, mechanically ventilated neonatal piglets. An amr bolus of 8 mg/kg was given at 4 hr followed by a 1 hr continuous infusion of either 10 or 20 micrograms/kg/min of amr (amr 10 and amr 20, respectively). Control piglets received a bolus and 1 hr infusion of amr carrier. The infusion of amr, but not of carrier reversed late phase GBS-induced pulmonary hypertension. Piglets infused with amr 20 showed transient selective pulmonary vasodilation, based on a reduced ratio of pulmonary to systemic vascular resistance (PVR/SVR ratio) value at 30 min but not at 1 hr, compared to pre-amr treatment values. The PVR/SVR ratio values for amr 10 and control group did not change after treatment with either amr or carrier. Treatment with amr 10 or 20 did not decrease serum TxB2 or TNF levels or increase VA/Q mismatch.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J I Berger
- Department of Pediatrics, RD-20, University of Washington School of Medicine, Seattle 98195
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Abstract
Milrinone is shown in 10 patients to be a valuable pharmacological bridge to heart transplantation; it can stabilize and improve decompensated chronic heart failure (CHF) in cases where the response to beta-agonists is inadequate. One patient who had suffered an acute myocardial infarction with heart failure resistant to vasodilators, beta-agonists, and balloon counterpulsation was stabilized with milrinone for 21 days. He was then maintained on ACE inhibitors until heart transplantation 3 months later. The other nine patients with severe decompensated CHF were stabilized on milrinone for between 11 and 51 days. Seven of them received a donor heart. Two patients died of bacteremic shock and terminal heart failure before a suitable organ could be found (31 and 51 days). All patients were clinically improved within 48 hours of the addition of IV milrinone to their therapy. In 55 patients following cardiac surgery, the efficacy and safety of milrinone in the treatment of low cardiac output states is demonstrated. Milrinone has a useful role in the management of patients with circulatory failure both before and after cardiac surgery, and this paper reviews the relevant current literature.
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Affiliation(s)
- K M Sherry
- Northern General Hospital, Sheffield, UK
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Abstract
Intensive care patients often require inotropic support to stabilise circulation and to optimise oxygen supply. In this context, the catecholamines norepinephrine (noradrenaline), epinephrine (adrenaline), dopamine and dobutamine are still the mainstay of therapy. They provide, to different extents, a variety of adrenoceptor-mediated actions comprising vasoconstriction (via alpha-receptors) as well as vasodilatation (via beta 1-receptors), and an increase in cardiac output by enhancing inotropy and heart rate (again via beta 1-receptors). Because of their favourable pharmacokinetic profile (plasma half-lives of about 2 minutes) their actions can easily be controlled. Combinations of different catecholamines with each other or with other drugs such as phosphodiesterase inhibitors or nitrates lead to a broad spectrum of possible haemodynamic actions. However, the use of catecholamines is limited by side effects like tachycardia, hypertension and disturbances of organ perfusion caused by vasoconstriction. Furthermore, as a result of receptor downregulation during long term therapy, the efficacy of catecholamine treatment decreases. These shortfalls stimulated the search for alternatives to catecholamine treatment. Among these, phosphodiesterase inhibitors (e.g. enoximone and amrinone) appear to be the most promising drugs which have been introduced into acute clinical practice up to now. They act via inhibition of the phosphodiesterase isoenzyme III, leading to higher intracellular calcium levels by increasing cyclic adenosine monophosphate (cAMP) levels. These agents improve cardiac performance by enhancing contractility, reducing left ventricular afterload and improve diastolic relaxation. In cases of failing catecholamine therapy due to receptor downregulation, treatment with phosphodiesterase inhibitors may still be effective since their action is not receptor-mediated. Inhibition of the phosphodiesterase enzyme in vascular smooth muscle leads to vasodilatation. Therefore, in low cardiac output states combined with increased total peripheral or pulmonary vascular resistance, phosphodiesterase inhibitor therapy is particularly effective. Depending on the dosage and the speed of intravenous administration, the use of phosphodiesterase inhibitors sometimes results in pronounced decrease of blood pressure which may require vasopressor therapy. Other drugs including histamine H2-agonists are currently under investigation. Their value in the treatment of intensive care patients has still to be evaluated.
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Affiliation(s)
- P J Kulka
- Universitätsklinik für Anaesthesiologie, Intensiv- und Schmerztherapie, Berufsgenossenschaftliche Krankenanstalten Bergmannsheil, Bochum, Federal Republic of Germany
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19
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Affiliation(s)
- R Bondy
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
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20
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Abstract
Phosphodiesterase inhibitors that are selective for cAMP-specific cardiac and vascular PDE III comprise a new group of agents for the treatment of heart failure, which at present are limited to clinical shortterm intravenous use and research uses only. Although both intravenous amrinone and milrinone are FDA approved, only amrinone is available for general clinical use. Selective phosphodiesterase inhibition produces beneficial actions of positive inotropy and peripheral vasodilation that result from increased cardiac and vascular muscle concentrations of intracellular cAMP and ionic calcium. In addition, a positive lusitropic action (enhancement of cardiac relaxation) has been observed. Neither beta-adrenergic agonist activity nor inhibition of the sodium-potassium ATPase is produced by these agents. The magnitude of hemodynamic improvement generally exceeds that of the cardiac glycosides and is comparable with that of intravenous catecholamines such as dobutamine. The different pharmacodynamic profile of the PDE inhibitors is additive to the effects of cardiac glycosides, complementary and synergistic to the actions of catecholamines, and has been shown to have favorable effects on coronary hemodynamics. As a result there is continued enthusiasm for the short-term intravenous use of amrinone and potentially milrinone in the setting of acute heart failure resulting from systolic dysfunction (after myocardial infarction, open heart surgery, or infectious or toxic myocarditis), heart failure resulting from right ventricular systolic dysfunction, and when patients with severe heart failure await cardiac transplantation. Initiation of treatment with an intravenous bolus followed by a maintenance infusion provides prompt increases in stroke volume and cardiac output and simultaneous reductions in right and left ventricular filling pressures and systemic vascular resistance.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R DiBianco
- Division of Cardiology, Washington Adventist Hospital, Takoma Park, MD 20912
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Affiliation(s)
- M Jessup
- Heart Failure and Transplantation Center, Temple University Hospital, Philadelphia
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Abstract
Unlike the left ventricle, the right ventricle is a thin-walled, low-pressure, volume-displacement pump that ensures adequacy of left ventricular filling and maintains a low pressure in the venous system. In healthy human subjects, there is no burden for right ventricular systolic emptying, because normal pulmonary vessels have a low impedance and show a passive recruitment when cardiac output increases. However, under a pathological condition like right-sided heart failure, the right ventricle may exert profound influences on the circulatory state. Right-sided heart failure most often results from primary or secondary pulmonary arterial hypertension. Pharmacologic vasodilation of the hypertensive pulmonary vascular bed is an ideal therapy for right-sided heart failure. The bipyridine derivative amrinone has positive inotropic and direct vasodilator properties, and therefore seems suitable for the therapy of right ventricular dysfunction accompanied by pulmonary arterial hypertension. In one study, 12 patients with right ventricular failure due to mitral valve stenosis were evaluated, and it was found that amrinone increased cardiac output by 25% and decreased pulmonary artery pressure by 30% to 50%. In a second study, the hemodynamic properties of amrinone versus sodium nitroprusside were compared in patients with aortic or mitral valve failure (n = 17), when both agents lowered systemic vascular resistance equally. Pulmonary vascular resistance decreased significantly (25%) only in the amrinone group.
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Affiliation(s)
- W Hess
- Department of Anesthesia, Krankenhaus St Georg, Hamburg, Federal Republic of Germany
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Affiliation(s)
- S Rich
- Department of Medicine, University of Illinois College of Medicine, Chicago
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Clark NJ, Martin RD. Anesthetic considerations for patients undergoing cardiac transplantation. ACTA ACUST UNITED AC 1988; 2:519-42. [PMID: 17171939 DOI: 10.1016/0888-6296(88)90235-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- N J Clark
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
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Eichhorn EJ, Konstam MA, Weiland DS, Roberts DJ, Martin TT, Stransky NB, Salem DN. Differential effects of milrinone and dobutamine on right ventricular preload, afterload and systolic performance in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol 1987; 60:1329-33. [PMID: 3687783 DOI: 10.1016/0002-9149(87)90616-3] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
To compare the effects of intravenous dobutamine and milrinone on right ventricular (RV) systolic function, 14 patients with severe congestive heart failure underwent simultaneous radionuclide-hemodynamic study. Patients were randomized to receive intravenous milrinone (50 micrograms/kg bolus then 0.5 microgram/kg/min) or dobutamine (2.5 to 15 micrograms/kg/min) to achieve equal increases in cardiac output. Both drugs significantly improved cardiac performance, with identical 24% increases in mean cardiac index (p less than 0.05 vs baseline; difference not significant for milrinone vs dobutamine) and no change in heart rate. Neither drug substantially altered RV preload, as reflected by mean right atrial pressure and RV end-diastolic volume. Both drugs caused similar increases in RV ejection fraction (mean +/- standard deviation; dobutamine: 0.32 +/- 0.09 to 0.40 +/- 0.11; p less than 0.05; milrinone: 0.35 +/- 0.19 to 0.43 +/- 0.21; p less than 0.05) resulting from reductions in RV end-systolic volume. RV afterload reduction contributed substantially to drug effect on RV systolic performance in patients treated with milrinone but not those treated with dobutamine. With doses effecting equal increases in cardiac index and RV systolic performance, pulmonary artery end-systolic pressure was significantly reduced by milrinone (40 +/- 12 to 33 +/- 12 mm Hg; p less than 0.05), but not by dobutamine. Thus, in patients with congestive heart failure milrinone's effect on RV systolic function is explainable, at least in part, by RV afterload reduction, whereas RV inotropic augmentation contributed more strongly to dobutamine's effect.
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Affiliation(s)
- E J Eichhorn
- Department of Medicine, Tufts University, New England Medical Center, Boston, Massachusetts 02111
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Abstract
Despite improvements in surgical technique and intraoperative myocardial protection, certain patients have need for inotropic drug support after cardiac surgery. This review examines drugs that are currently in use for inotropic support of the heart, including calcium, epinephrine, dopamine, dobutamine, isoproterenol, and amrinone. Patient factors that may have an impact on the selection of appropriate drugs are also examined. Application of these data to specific patients must be guided by the particular hemodynamic derangements present. Careful analysis of the specific hemodynamic disorder and tailoring of inotropic therapy to these abnormalities are crucial. Such a rational approach to the selection of inotropic agents requires continuous hemodynamic assessment and recognition that the patient's condition and needs may change rapidly early after heart surgery dictating adjustment of subsequent therapy.
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Affiliation(s)
- V J DiSesa
- Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts 02115
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