to facilitate weaning from cardiopulmonary bypass (CPB). Inhaled epoprostenol and inhaled milrinone (iE&iM) administered in combination before CPB may represent an effective strategy to facilitate separation from CPB and reduce requirements for intravenous inotropes during cardiac surgery. Our primary objective was to report the rate of positive pulmonary vasodilator response to iE&iM and, second, how it relates to perioperative outcomes in cardiac surgery. METHODS: This is a retrospective cohort study of consecutive patients with PH or RV dysfunction undergoing on-pump cardiac surgery at the Montreal Heart Institute from July 2013 to December 2018 (n = 128). iE&iM treatment was administered using an ultrasonic mesh nebulizer before the initiation of CPB. Demographic and baseline clinical data, as well as hemodynamic, intraoperative, and echocardiographic data, were collected using electronic records. An increase of 20% in the mean arterial pressure (MAP) to mean pulmonary artery pressure (MPAP) ratio was used to indicate a positive response to iE&iM. RESULTS: In this cohort, 77.3% of patients were responders to iE&iM treatment. Baseline systolic pulmonary artery pressure (SPAP) (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.24–2.16 per 5 mm Hg; P = .0006) was found to be a predictor of pulmonary vasodilator response, while a European System for Cardiac Operative Risk Evaluation (EuroSCORE II) score >6.5% was a predictor of nonresponse to treatment (≤6.5% vs >6.5% [reference]: OR, 5.19; 95% CI, 1.84–14.66; P = .002). Severity of PH was associated with a positive response to treatment, where a higher proportion of responders had MPAP values >30 mm Hg (42.4% responders vs 24.1% nonresponders; P = .0237) and SPAP values >55 mm Hg (17.2% vs 3.4%; P = .0037). Easier separation from CPB was also associated with response to iE&iM treatment (69.7% vs 58.6%; P = .0181). A higher proportion of nonresponders had a very difficult separation from CPB and required intravenous inotropic drug support compared to responders, for whom easy separation from CPB was more frequent. Use of intravenous inotropes after CPB was lower in responders to treatment (8.1% vs 27.6%; P = .0052). CONCLUSIONS: A positive pulmonary vasodilator response to treatment with a combination of iE&iM before initiation of CPB was observed in 77% of patients. Higher baseline SPAP was an independent predictor of pulmonary vasodilator response, while EuroSCORE II >6.5% was a predictor of nonresponse to treatment....

中文翻译：

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联合吸入依前列醇和吸入米力农对心脏手术患者的肺血管扩张反应

以促进脱离体外循环 (CPB)。在 CPB 前联合使用吸入依前列醇和吸入米力农 (iE&iM) 可能是促进与 CPB 分离并减少心脏手术期间对静脉内正性肌力药物需求的有效策略。我们的主要目标是报告对 iE&iM 的肺血管扩张剂阳性反应率，其次，它与心脏手术围手术期结果的关系。方法：这是一项回顾性队列研究，研究对象为 2013 年 7 月至 2018 年 12 月期间在蒙特利尔心脏研究所接受体外循环心脏手术的 PH 或 RV 功能障碍患者（n = 128）。iE&iM 治疗在 CPB 开始前使用超声波网雾化器进行。人口统计学和基线临床数据，以及血液动力学、术中、和超声心动图数据，使用电子记录收集。平均动脉压 (MAP) 与平均肺动脉压 (MPAP) 之比增加 20% 用于指示对 iE&iM 的阳性反应。结果：在该队列中，77.3% 的患者对 iE&iM 治疗有反应。基线肺动脉收缩压 (SPAP)（比值比 [OR]，1.63；95% 置信区间 [CI]，1.24–2.16/5 mm Hg；P = .0006）被发现是肺血管扩张剂反应的预测因子，而欧洲心脏手术风险评估系统 (EuroSCORE II) 评分 >6.5% 是对治疗无反应的预测因子（≤6.5% 与 >6.5% [参考]：OR，5.19；95% CI，1.84–14.66；P = . 002). PH 的严重程度与对治疗的积极反应相关，其中更高比例的反应者具有 MPAP 值 > 30 毫米汞柱（42.4% 对 24.1% 无应答者；P = .0237）和 SPAP 值 >55 毫米汞柱（17.2% 对 3.4%；P = .0037）。更容易从 CPB 分离也与对 iE&iM 治疗的反应相关（69.7% 对 58.6%；P = .0181）。较高比例的无反应者与 CPB 分离非常困难并且需要静脉内正性肌力药物支持，而响应者更容易与 CPB 分离。CPB 后静脉内正性肌力药物的使用在治疗反应者中较低（8.1% 对 27.6%；P = .0052）。结论：在 77% 的患者中观察到在 CPB 开始前对 iE 和 iM 联合治疗的积极肺血管扩张剂反应。较高的基线 SPAP 是肺血管扩张剂反应的独立预测因子，而 EuroSCORE II >6.5% 是对治疗无反应的预测因子…… 4% 的响应者 vs 24.1% 的无响应者；P = .0237) 和 SPAP 值 >55 mm Hg（17.2% 对 3.4%；P = .0037）。更容易从 CPB 分离也与对 iE&iM 治疗的反应相关（69.7% 对 58.6%；P = .0181）。较高比例的无反应者与 CPB 分离非常困难并且需要静脉内正性肌力药物支持，而响应者更容易与 CPB 分离。CPB 后静脉内正性肌力药物的使用在治疗反应者中较低（8.1% 对 27.6%；P = .0052）。结论：在 77% 的患者中观察到在 CPB 开始前对 iE 和 iM 联合治疗的积极肺血管扩张剂反应。较高的基线 SPAP 是肺血管扩张剂反应的独立预测因子，而 EuroSCORE II >6.5% 是对治疗无反应的预测因子…… 4% 的响应者 vs 24.1% 的无响应者；P = .0237) 和 SPAP 值 >55 mm Hg（17.2% 对 3.4%；P = .0037）。更容易从 CPB 分离也与对 iE&iM 治疗的反应相关（69.7% 对 58.6%；P = .0181）。较高比例的无反应者与 CPB 分离非常困难并且需要静脉内正性肌力药物支持，而响应者更容易与 CPB 分离。CPB 后静脉内正性肌力药物的使用在治疗反应者中较低（8.1% 对 27.6%；P = .0052）。结论：在 77% 的患者中观察到在 CPB 开始前对 iE 和 iM 联合治疗的积极肺血管扩张剂反应。较高的基线 SPAP 是肺血管扩张剂反应的独立预测因子，而 EuroSCORE II >6.5% 是对治疗无反应的预测因子……