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Levosimendan or milrinone for right ventricular inotropic treatment?-A secondary analysis of a randomized trial

Journal article
Authors Martin Fredholm
Kirsten Jörgensen
Erik Houltz
Sven-Erik Ricksten
Published in Acta Anaesthesiologica Scandinavica
ISSN 0001-5172
Publication year 2019
Published at Institute of Clinical Sciences, Department of Anesthesiology and Intensive care
Language en
Links dx.doi.org/10.1111/aas.13486
Keywords cardiac surgery, diastole, levosimendan, milrinone, right ventricular, function, strain echocardiography, systole, congestive-heart-failure, effective arterial elastance, systolic, function, cardiac-surgery, pulmonary-hypertension, contractile pattern, performance, dobutamine, strain, index, Anesthesiology
Subject categories Anaesthetics

Abstract

Background The aim of the present study was to compare the effects of milrinone and levosimendan on right ventricular (RV) inotropy and lusitropy in patients after aortic valve replacement (AVR) for aortic stenosis, a procedure in which an abnormal postoperative RV function may be seen. Methods In a prospective, blinded trial, 31 patients were randomized to receive either milrinone (0.4 and 0.8 µg/kg/min, n = 16) or levosimendan (0.1 and 0.2 µg/kg/min, n = 15) after AVR for aortic stenosis. RV performance, afterload (pulmonary arterial elastance), RV strain, systolic (SR‐S) and early diastolic (SR‐E) strain rate were measured by pulmonary artery thermodilution catheterization and transoesophageal two‐dimensional speckle tracking echocardiography. To circumvent the indirect effects of inodilator‐induced hemodynamic changes on RV systolic and diastolic deformation, pulmonary arterial elastance, central venous pressure and heart rate were maintained constant by atrial pacing, plasma volume expansion with colloids and phenylephrine‐induced vasoconstriction during treatment with the inotropes. Results A dose‐dependent increase in stroke volume index and cardiac index by approximately 20% were seen with both agents at the highest doses, with no difference between groups (P = .792 and 0.744, respectively). In both groups, RV strain and SR‐S dose‐dependently increased by 20% and 15%‐19%, respectively, at the highest doses (P = .742 and 0.259, respectively) with no difference between groups. SR‐E improved by both agents 20%‐24% at the highest dose with no difference between groups (P = .714). Conclusions The direct RV inotropic and lusitropic effects of levosimendan and milrinone were comparable at clinically relevant infusion rates.

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