Inhaled nitroglycerin versus inhaled milrinone in children with congenital heart disease suffering from pulmonary artery hypertension.
OBJECTIVE
The aim of the present study was to compare the acute effects of inhaled milrinone and inhaled nitroglycerin on pulmonary and systemic hemodynamics in children with acyanotic congenital heart disease (left-to-right shunt) and pulmonary artery hypertension.


METHODS
Randomized clinical trial.


METHODS
Catheterization laboratory of a tertiary care hospital.


METHODS
Thirty-five children below the age of 12 years who were suffering from acyanotic congenital heart disease with left-to-right intracardiac shunt and pulmonary artery hypertension (mean PA pressure > 30 mmHg).


METHODS
Right-heart catheterization was done using an end-hole balloon wedge pressure catheter. Baseline pulmonary and systemic hemodynamic parameters were recorded for all patients while breathing room air. All patients then underwent pulmonary vasodilator testing with 100% oxygen. Following this, patients were randomized into two groups and received either inhaled milrinone (group M, n = 18) or inhaled nitroglycerin (group N, n = 17) in a 50% air-oxygen mixture. Oximetry data were used to calculate systemic and pulmonary cardiac output based on Fick's principle.


RESULTS
Systolic, diastolic, and mean pulmonary artery pressures decreased significantly in both the groups after drug nebulization, while there were no significant changes in systemic pressures. The percentage decrease from baseline in systolic (5.2% v 8.6%, p = 0.43), diastolic (19.5% v 16.8%, p = 0.19) and mean (14.9% v14.5%, p = 0.29) pulmonary artery pressures were comparable in both groups. The pulmonary vascular resistance index (PVRI) decreased from 9.0 ± 3.9 to 2.9 ± 1.7 Wood Units (WU)/m(2) in group M (p < 0.001) and from 8.6 ± 3.8 to 3.2 ± 3.3 WU/m(2) in group N (p < 0.001). The fall in pulmonary artery pressures after drug nebulization in both groups was comparable to the fall seen with 100% oxygen.


CONCLUSIONS
Both milrinone and nitroglycerin when given via the inhaled route significantly decrease systolic, diastolic and mean pulmonary artery pressures as well as PVRI without significant effects on systemic hemodynamics. Both the drugs given via inhaled route therefore can offer a good therapeutic choice and can help decrease the high inspired oxygen concentrations needed to treat pulmonary artery hypertensive episodes in perioperative settings.
Singh
Raveen
R
Department of Cardiac Anesthesia, All India Institute of Medical Sciences, New Delhi, India.
Choudhury
Minati
M
Saxena
Anita
A
Kapoor
Poonam Malhotra
PM
Juneja
Rajnish
R
Kiran
Usha
U
D000280:Administration, Inhalation; D002648:Child; D002675:Child, Preschool; D005260:Female; D006330:Heart Defects, Congenital / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology; D006801:Humans; D006976:Hypertension, Pulmonary / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology; D007223:Infant; D008297:Male; D020105:Milrinone / Q000008:administration & dosage*; D005996:Nitroglycerin / Q000008:administration & dosage*
D005996:Nitroglycerin; D020105:Milrinone