Key result
In infants undergoing complex cardiac surgery, milrinone combined with epinephrine was associated with higher severe postoperative morbidity or mortality compared to dobutamine (27.4% vs 13.9%; P=0.016).
Why the study?
Comparative studies of vaso-inotropic agents to prevent or treat low cardiac output syndrome in infants undergoing congenital heart disease surgery are lacking, leaving use dependent on physician and center preferences.
Does milrinone combined with epinephrine improve postoperative outcomes compared to dobutamine in young infants undergoing complex cardiac surgery?
Observational (n=250)
Does milrinone combined with epinephrine improve postoperative outcomes compared to dobutamine in young infants undergoing complex cardiac surgery?
Absolute Event Rate: 27.4% vs 13.9%
p-value: p=0.016
In young infants undergoing complex cardiac surgery, perioperative inotropic support with milrinone and epinephrine is associated with higher postoperative morbidity and mortality compared to dobutamine.
May warrant caution with milrinone-epinephrine in infant cardiac surgery; leaves open optimal inotrope choice pending randomized trials.
BACKGROUND: Vaso-inotropic agents are frequently used to prevent and/or treat low cardiac output syndrome in infants undergoing surgery for congenital heart disease. Due to the lack of comparative studies, their use is largely dependent on physician- and center preferences. The aim was to assess the impact of two different inotropic regimens, milrinone-epinephrine versus dobutamine on postoperative morbi-mortality in young children undergoing complex cardiac surgery. METHODS: All consecutive children younger than one year of age admitted for complex cardiac surgery (Risk Adjustment in Congenital Heart Surgery-1 [RACHS-1] score ≥3) with cardiopulmonary bypass (CPB) from January 2008 to December 2018 were included. Children received either milrinone in association with low dose epinephrine (milrinone-epinephrine group) or dobutamine (dobutamine group) groups were matched and compared using a propensity score. Our primary outcome was a composite measure including either hospital death and/or the presence of at least two of the following events: respiratory failure, prolonged inotropic support, or renal failure. RESULTS: Two hundred and fifty patients were included in the analysis. Children in the milrinone-epinephrine group (N.=184) suffered more frequently from a cyanotic heart disease and had longer surgery, CPB, and aortic cross clamp times than those in the dobutamine group (N.=66). After matching, children in the milrinone-epinephrine group had a higher incidence of severe postoperative morbidity or mortality compared to those in the dobutamine group (27.4 versus 13.9%; P=0.016). Respiratory failure (28% vs. 12%), prolonged inotropic support (71% vs. 35%) and in-hospital death (3 vs. 0%) were more frequent in the milrinone-epinephrine group. CONCLUSIONS: In young infants undergoing complex cardiac surgery, milrinone combined with epinephrine is associated with a higher incidence of postoperative morbidity or mortality compared to dobutamine for perioperative inotropic support. Further prospective randomized studies are required to confirm this finding.
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Willems et al. (2023) conducted an observational in complex congenital heart disease requiring surgery (n=250). Milrinone combined with epinephrine vs. Dobutamine was evaluated on composite measure including either hospital death and/or the presence of at least two of the following events: respiratory failure, prolonged inotropic support, or renal failure (p=0.016). In infants undergoing complex cardiac surgery, milrinone combined with epinephrine was associated with higher severe postoperative morbidity or mortality compared to dobutamine (27.4% vs 13.9%; P=0.016).
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