The choice of perioperative inotropic support impacts the outcome of small infants undergoing complex cardiac surgery: an observational study

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 morbimortality 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. (Cite this article as: Willems A, Havaux R, Schmartz D, Fils JF, De Pooter F, Van der Linden P. The choice of perioperative inotropic support impacts the outcome of small infants undergoing complex cardiac surgery: an observational study. Minerva Anestesiol 2023;89:753-61. DOI: 10.23736/S0375-9393.23.16622-3)

Automated summary

This study examined the impact of two different inotropic regimens on postoperative morbidity and mortality in infants undergoing complex cardiac surgery. The results showed that the use of milrinone combined with epinephrine was associated with a higher incidence of postoperative morbidity or mortality compared to dobutamine.