Mitral kapak değişimi yapılan hastalarda milrinon kullanımının pulmoner basınç üzerine etkisi

Year 2019, Volume: 3 Issue: 10, 718 - 721, 01.10.2019

Ahmet Dolapoğlu , Eyüp Avcı

https://doi.org/10.28982/josam.631161

Abstract

Amaç: Pulmoner arter basıncının yüksek olduğu durumlarda mitral kapak değişimi operasyonlarında cerrahi risk yükselmektedir. Bu çalışmada mitral kapak hastalığı nedeniyle cerrahi tedavi uygulanan hastalarda milrinon kullanımının pulmoner basınlar üzerine etkisini araştırmayı amaçladık.

Yöntemler: Mitral kapak hastalığı nedeniyle kapak değişimi uygulanan 48 hasta çalışmaya dahil edildi. Hastalar cerahide milrinon kullanımına göre milrinon kullanılan (n=18) ve milrinon kullanılmayan (n=30) olarak ikiye gruba ayrıldı. Cerrahi sonrası 30 günlük süre içinde sistolik pulmoner arter basıncı ve sol ventrikül ejeksiyon fraksiyonları ile birlikte cerrahi sonrası mortalite, düşük kardiyak debi sendromu, inme, böbrek yetmezliği, kanama ve ventrikül aritmileri kaydedildi.

Bulgular: Milrinon kullanan grupta cerrahi öncesi sol ventrikül ejeksiyon fraksiyonu kullanmayan gruba göre daha düşükken (72,0 (6,1) vs 62,5 (8,4) P<0,001) sistolik pulmoner arter basınçları daha yüksekti (45,50 (7,0) vs 55,06 (5,5), P<0,001). Cerrahi sonrası milrinon kullanılan grupta düşük kardiyak debi sendromu daha az görülürken (P=0.007), yoğun bakımda kalış süreleri kullanmayan gruba göre daha kısaydı (4,7 (2,2) vs 3,2 (0,5), P=0,008). Hem cerrahi sonrası hem de 30. gün sistolik pulmoner arter basınçlarında ki düşme değerleri milrinon kullanılan grupta istatistik açıdan daha anlamlıydı [-11,40(-13,25-(-8,63)) vs -4,42(-5,89-(-2,80)), P<0,001; -13,6(-15,6-(-9,75)) vs -5,56 (-7,20-(-3,30)), P<0,001, sırasıyla].

Sonuç: Çalışmamızda milrinon kullanımı cerrahi sonrası pulmoner basınçları düşürürken düşük kardiyak debi oluşumun azalttığı gözlenmiştir. Bu sonuca göre pulmoner arter hipertansiyonu olan ve mitral kapak değişimi yapılacak hastalarda milrinon kullanımının pulmoner basınçları düşürmede etkili bir tedavi seçeneği olduğunu düşünmekteyiz.

Keywords

Mitral kapak hastalığı, Pulmoner arter basıncı, Mitral kapak değişimi

Effect of peri-operative milrinone on pulmonary artery pressure in patients undergoing mitral valve replacement

Abstract

Aim: Increased pulmonary artery pressure is associated with higher surgical risk in patients undergoing mitral valve replacement. The aim of this study was to investigate the effect of milrinone on the pulmonary artery pressures of patients with mitral valve disease (stenosis or regurgitation) who underwent mitral valve replacement surgery. 

Methods: In this case-control study, 48 patients with mitral valve disease who underwent mitral valve replacement surgery were included. The patients were divided into a control group of 30, who were not administered milrinone, and a study group of 18 who received milrinone perioperatively. Systolic pulmonary artery pressures (SPAP), left ventricle ejection fractions (LVEF) and the following postoperative outcomes were recorded: low cardiac output syndrome, stroke, renal failure, bleeding, ventricular arrhythmia and mortality occurring within 30 days of surgery either in or out of the hospital. 

Results: In the study group, preoperative LVEFs and postoperative low cardiac output syndrome were lower (72.0 (6.1) vs 62.5(8.4) P<0.001 and P=0.007, respectively), SPAPs were higher (45.50 (7.0) vs 55.06 (5.5), P<0.001), and length of stay in intensive care unit was significantly shorter (4.7 (2.2) vs 3.2 (0.5), P=0.008). Also, reduction in both postoperative SPAP and 30-day SPAP were significantly higher [-11.40(-13.25-(-8.63)) vs -4.42(-5.89-(-2.80)), P<0.001; -13.6(-15.6-(-9.75)) vs -5.56 (-7.20-(-3.30)), P<0.001, respectively].

Conclusion: We found that using perioperative milrinone reduces the systolic pulmonary artery pressure and lowers the rate of low cardiac output syndrome. Milrinone can be used as an effective therapy to reduce to pulmonary pressure in patients with pulmonary hypertension undergoing mitral valve replacement surgery.

Keywords

Mitral valve disease, Pulmonary artery pressure, Mitral valve replacement

References

• 1. Maeder MT, Weber L, Buser M, Gerhard M, Haager PK, Maisano F, et al. Pulmonary Hypertension in Aortic and Mitral valve Disease. Front Cardiovasc Med. 2018;5:40.
• 2. Ghoreishi M, Evans CF, DeFilippi CR, Hobbs G, Young CA, Griffith BP, et al. Pulmonary hypertension adversely affects short- and long-term survival after mitral valve operation for mitral regurgitation: implications for timing of surgery. J Thorac Cardiovasc Surg. 2011;142(6):1439-52.
• 3. Hernandez AF, Li S, Dokholyan RS, O'Brien SM, Ferguson TB, Peterson ED. Variation in perioperative vasoactive therapy in cardiovascular surgical care: data from the society of thoracic surgeons. Am Heart J. 2009;158:47–52.
• 4. Zangrillo A, Biondi-Zoccai G, Ponschab M, Greco M, Corno L, Covello RD, et al. Milrinone andmortality in adult cardiac surgery:a meta-analysis. J Cardiothorac Vasc Anesth. 2012;26:70–7.
• 5. Le Tourneau T, Richardson M, Juthier F, Modine T, Fayad G, Polge AS, et al. Echocardiography predictors and prognostic value of pulmonary artery systolic pressure in chronic organic mitral regurgitation. Heart. 2010;96(16):1311-7.
• 6. Alsancak Y, Gurbus AS, Duzenli MA.Transcatheter mitral valve repair and replacement; current therapies and general evaluation of new approaches. J Surg Med. 2017;1(3):56-8.
• 7. Landoni G, Lomivorotov VV, Alvaro G, Lobreglio R, Pisano A, Guarracino F, et al. Levosimendan for hemodynamic support after cardiac surgery. N Engl J Med. 2017;376:2021–31.
• 8. Feneck RO, Sherry KM, Withington PS, Oduro-Dominah A, European Milrinone Multicenter Trial Group. Comparison of the hemodynamic effects of milrinone with dobutamine in patients after cardiac surgery. J Cardiothorac Vasc Anesth. 2001;15:306–15.
• 9. Carmona MJ, Martins LM, Vane MF, Longo BA, Paredes LS, Malbouisson LM. Comparison of the effects of dobutamine and milrinone on hemodynamic parameters and oxygen supply in patients undergoing cardiac surgery with low cardiac output after anesthetic induction. Rev Bras Anestesiol. 2010;60:237–46.
• 10. Sardo S, Osawa EA, Finco G, Gomes Galas FRB, de Almeida JP, Cutuli SL, et al. Nitric Oxide in Cardiac Surgery: A Meta-Analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth. 2018;32(6):2512-9.
• 11. Indolfi C, Piscione F, Perrone-Filardi P, Prastaro M, Di Lorenzo E, Sacco L, et al. Inotropic stimulation by dobutamine increases left ventricular regional function at the expense of metabolism in hibernating myocardium. Am Heart J. 1996;132:542–9.
• 12. Schulz R, Rose J, Martin C, Brodde OE, Heusch G. Development of short-term myocardial hibernation. its limitation by the severity of ischemia and inotropic stimulation. Circulation. 1993;88:684–95.
• 13. Levy JH, Bailey JM, Deeb GM. Intravenous milrinone in cardiac surgery. Thorac Surg. 2002;73(1):325-30.
• 14. Burkhardt BE, Rücker G, Stiller B. Prophylactic milrinone for the prevention of low cardiac output syndrome and mortality in children undergoing surgery for congenital heart disease.Cochrane Database Syst Rev. 2015;(3):CD009515.
• 15. Hashim T, Sanam K, Revilla-Martinez M, Morgan CJ, Tallaj JA, Pamboukian SV, et al. Clinical Characteristics and Outcomes of Intravenous Inotropic Therapy in Advanced Heart Failure.Circ Heart Fail. 2015;8(5):880-6.
• 16. Oztekin I, Yazıcı S, Oztekin DS, Goksel O, Issever H, Canık S. Effects of low-dose milrinone on weaning from cardiopulmonary bypass and after in patients with mitral stenosis and pulmonary hypertension. Yakugaku Zasshi. 2007;127(2):375-83.
• 17. Wang H, Gong M, Zhou B, Dai A. Comparison of inhaled and intravenous milrinone in patients with pulmonary hypertension undergoing mitral valve surgery. Adv Ther. 2009;26(4):462-8.
• 18. Ushio M, Egi M, Wakabayashi J, Nishimura T, Miyatake Y, Obata N, et al. Impact of Milrinone Administration in Adult Cardiac Surgery Patients: Updated Meta-Analysis. Cardiothorac Vasc Anesth. 2016;30(6):1454-60.