Milrinone versus Dobutamine as Supportive Agent for Right Ventricular Dysfunction after Cardiopulmonary Bypass: A...

To compare milrinone versus dobutamine for right ventricular (RV) dysfunction after cardiopulmonary bypass (CPB).

Randomized, open-label, parallel-group controlled trial.

A tertiary cardiac surgery center.

Adults (N = 88) with new RV systolic dysfunction (tricuspid annular plane systolic excursion [TAPSE] ≤17 mm) post-CPB.

Milrinone (loading 50 µg/kg over 10 minutes, then 0.3-0.8 µg/kg/min) or dobutamine (2-10 µg/kg/min).

The co-primary outcomes were duration of mechanical ventilation (clinical) and change in TAPSE over 24 hours (echocardiographic). Secondary outcomes included RV fractional area change, pulmonary artery systolic pressure (PASP), left ventricular outflow tract velocity-time integral, intensive care unit stay, arrhythmias, hypotension, and vasopressor need. Both groups had similar baseline characteristics. TAPSE improved significantly over 24 hours in both groups (p < 0.001). After adjustment for baseline TAPSE and left ventricular ejection fraction, milrinone was associated with modestly higher TAPSE at 24 hours (adjusted difference 1.82 mm, 95% CI 0.72-2.92, p = 0.001), though the clinical significance of this difference is uncertain. Milrinone required more norepinephrine than dobutamine (93.2% v 72.7%, p = 0.021). Other clinical outcomes did not differ significantly. In an exploratory subgroup analysis of patients with baseline post-CPB PASP >40 mmHg (n = 30), milrinone produced greater TAPSE improvement at 1, 6, and 24 hours (p < 0.05 for each), with a statistically significant interaction (p = 0.010); norepinephrine use was similar between groups in this subgroup (93.8% v 85.7%, p = 0.586). In patients with PASP ≤40 mmHg (n = 58), the drugs were equivalent.

Milrinone and dobutamine provide comparable overall RV recovery, though milrinone was associated with modestly higher adjusted TAPSE at 24 hours of uncertain clinical significance and increased norepinephrine requirements. An exploratory subgroup analysis suggests milrinone may provide superior RV functional recovery in patients with elevated post-CPB PASP (>40 mmHg), though this hypothesis-generating finding requires prospective validation.