Home continuous positive inotropic infusion as a bridge to cardiac transplantation in patients with end-stage heart failure.
BACKGROUND
The clinical use of positive inotropic therapy at home in patients awaiting cardiac transplantation has not been reported since United Network for Organ Sharing (UNOS) regulations were changed to allow home infusions in Status 1B patients.


METHODS
We observed 21 consecutive patients with UNOS 1B status during positive inotropic therapy at home. We used hemodynamic monitoring at the initiation of therapy to optimize dosing. We selected for home therapy patients with stable clinical status and improved functional capacity during inotropic treatment. Implantable cardioverter defibrillators were placed in all but 1 patient before discharge.


RESULTS
Initial positive inotropic therapy included dobutamine in 12 patients (mean dose, 4.5 mcg/kg/min; range, 2.5-7.5 mcg/kg/min), milrinone in 8 patients (mean dose, 0.44 mcg/kg/min; range, 0.375-0.55 mcg/kg/min), and dopamine at a dose of 3 mcg/kg/min in 1 patient. Patients had improved functional capacity (New York Heart Association Class 3.7 +/- 0.1 to 2.4 +/- 0.2, p < 0.01), improved renal function (serum creatinine, 1.5 +/- 0.1 to 1.3 +/- 0.1, p < 0.01), improved resting hemodynamics, and decreased number of hospitalizations during positive inotropic infusion therapy when compared with pre-treatment baseline. Implantable cardioverter defibrillator discharges were infrequent (0.19 per 100 patient days of follow-up). Actuarial survival to transplantation at 6 and 12 months was 84%.


CONCLUSIONS
Continuous positive inotropic therapy at home was safe and was associated with decreased health care costs in selected patients awaiting cardiac transplantation.
Upadya
Shrikanth
S
Yale University School of Medicine, Department of Internal Medicine, New Haven, Connecticut 06510, USA.
Lee
Forrester A
FA
Saldarriaga
Clara
C
Verma
Sumit
S
Sedrakyan
Artyom
A
Nystrom
Karin
K
Katz
Stuart D
SD
D000328:Adult; D002316:Cardiotonic Agents / Q000008:administration & dosage*; D017147:Defibrillators, Implantable / Q000191:economics; D004280:Dobutamine / Q000008:administration & dosage*; D004298:Dopamine / Q000008:administration & dosage*; D036262:Empirical Research; D005260:Female; D017048:Health Care Costs; D006333:Heart Failure / Q000191:economics / Q000401:mortality / Q000628:therapy*; D016027:Heart Transplantation; D018718:Home Infusion Therapy / Q000191:economics; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D020105:Milrinone / Q000008:administration & dosage*; D015996:Survival Rate; D014850:Waiting Lists
D002316:Cardiotonic Agents; D004280:Dobutamine; D020105:Milrinone; D004298:Dopamine