Long-term milrinone therapy as a bridge to heart transplantation: Safety, efficacy, and predictors of failure

Long-Term Ambulatory Intravenous Milrinone Therapy in Advanced Heart Failure

BACKGROUND

The role of intravenous (IV) inotropes in the treatment of ambulatory patients with advanced heart failure (HF) remains controversial.

METHODS

This was a retrospective study of patients with advanced HF. Patients on home IV milrinone, who remained on it for at least 3 months, were included. We compared the data from 3 months before starting IV milrinone to 3 months after initiating therapy. A subset of patients who remained on milrinone for 6 months or longer was analysed separately.

RESULTS

A total of 90 patients remained on continuous IV milrinone for 3 months, and 55 patients were treated for 6 months or longer. In both groups, improvements in cardiac index (1.86-2.25, p<0.001 and 1.9-2.38, p<0.0001), New York Heart Association (NYHA) class (3.32-2.76, p<0.0001 and 3.25-2.72, p=0.001), and liver function were noted. In the 6-month group, there was also a decrease in mean hospitalised days per patient (9.40 vs 4.12, p<0.001) and an improved tolerance of beta blocker therapy (83.3% vs 98.1%, p=0.006).

CONCLUSION

Long-term IV use of milrinone is associated with improvement in haemodynamics, functional class, tolerance of medical therapy, and decrease in hospitalised days.

Oral milrinone for management of refractory right ventricular failure in patients with left ventricular assist devices

AIMS

We present a single-centre retrospective experience using oral milrinone in patients with a left ventricular assist device (LVAD) and concurrent refractory right ventricular failure.

METHODS AND RESULTS

All patients implanted with LVAD between January 2013 and July 2021 from a high-volume advanced heart failure service were reviewed. Eight patients were initiated on oral milrinone during this period. Oral milrinone was started 1.5 [inter-quartile range (IQR) 1-2.3] years after LVAD implantation and continued for 1.2 (IQR 0.5-2.8) years. Therapeutic milrinone levels were achieved (232.2 ± 153.4 ng/mL) with 62.4 ± 18% of time within the therapeutic range. Two patients had adverse events (non-sustained ventricular tachycardia and ventricular fibrillation effectively treated by internal cardioverter defibrillator) but did not require milrinone discontinuation. Four deaths occurred, one after transplant and three from disease progression determined to be unrelated to oral milrinone use. Three patients continue oral milrinone therapy in the community. There was no significant difference found after the initiation of oral milrinone on any of the physiological measures; however, there were trends in reduction of New York Heart Association class from 3.4 ± 0.5 to 3.0 ± 0.8 (P = 0.08), reduction of right atrial/wedge pressure from 0.9 ± 0.3 to 0.5 ± 0.2 (P = 0.08), and improvement of right ventricular stroke work index from 3.8 ± 2 to 5.8 ± 2.7 (P = 0.16).

CONCLUSIONS

Oral milrinone appears safe for long-term use in the outpatient setting when combined with therapeutic monitoring in this complex medical cohort with limited management options. Further study is needed to ascertain whether this treatment is effective in reducing heart failure symptoms and admissions.

Special Considerations in the Care of Women With Advanced Heart Failure

Advanced heart failure (AHF) is associated with increased morbidity and mortality, and greater healthcare utilization. Recognition requires a thorough clinical assessment and appropriate risk stratification. There are persisting inequities in the allocation of AHF therapies. Women are less likely to be referred for evaluation of candidacy for heart transplantation or left ventricular assist device despite facing a higher risk of AHF-related mortality. Sex-specific risk factors influence progression to advanced disease and should be considered when evaluating women for advanced therapies. The purpose of this review is to discuss the role of sex hormones on the pathophysiology of AHF, describe the clinical presentation, diagnostic evaluation and definitive therapies of AHF in women with special attention to pregnancy, lactation, contraception and menopause. Future studies are needed to address areas of equipoise in the care of women with AHF.