Efficacy of milrinone and dobutamine in low cardiac output states: Systematic review and meta-analysis.

PURPOSE: Patients in cardiac intensive care units (ICU) are admitted with increasingly higher disease acuity and a larger burden of non-cardiac critical illness. Accordingly, positive inotropes are being used with increased frequency and little comparative data to support drug selection. We compared the effectiveness and safety of dobutamine and milrinone in low cardiac output states (LCOS) and/or cardiogenic shock (CS). METHODS: We performed a systematic review comparing dobutamine to milrinone on all-cause mortality, length of stay in the ICU (LOS-ICU), length of stay in hospital (LOS-H) and significant arrhythmias in hospitalized patients with LCOS and/or CS. RESULTS: We identified 11 studies that meet eligibility requirements and which were published between 2001 and 2016 and included 23,056 patients. Only one randomized clinical trial was identified, with the remaining studies comprising observational cohort studies. The primary outcome, all-cause mortality, trended towards a benefit with milrinone but did not meet pre-specified significance (OR 1.13, 95% CI 1.00-1.29, p=0.06). While LOS-ICU (mean difference -0.72, 95% CI -1.10- -0.34, p=0.0002) was shorter with dobutamine, there was no difference in LOS-H (mean difference -1.22, 95% CI -4.68 - 2.24, p=0.49). Significant arrhythmias, specifically symptomatic and/or requiring antiarrhythmic therapy, were no different between the groups (OR 1.78, 95% CI 0.85-3.76, p=0.13). CONCLUSIONS: Currently available data comparing milrinone to dobutamine in patients requiring inotropic support is limited. Dobutamine may be associated with a shorter LOS in the ICU, with a worrisome signal of increased risk of allcause mortality. Randomized data are needed to guide inotrope selection in patients with LCOS and/or CS.

Predicting Acute Kidney Injury following Transcatheter Aortic Valve Replacement.

PURPOSE: Acute kidney injury occurs in up to a quarter of patients following transcatheter aortic valve replacement (TAVR) and has been associated with increased short and long-term mortality rates. A variety of patient characteristics predictive of post-TAVR acute kidney injury (AKI) have been identified, however discrepancies among studies exist almost uniformly. We investigated the hypothesis that the change in glomerular filtration rate (ΔGFR) in response to contrast administered during pre-TAVR coronary angiography is predictive of ΔGFR post-TAVR. METHODS: The study comprised 195 patients who underwent TAVR at a single center between August 2008 and June 2015 and were prospectively included in the CAPITAL TAVR registry. Multiple linear regression analysis was conducted to estimate the effect of independent variables on the change in renal function post-TAVR. RESULTS: There was no relationship identified between the ΔGFR post-angiogram and the ΔGFR post-TAVR (r=0.043, P=0.582). Multiple linear regression analysis revealed that a significant amount of the change in renal function post-TAVR can be explained by the patient's baseline creatinine (beta coefficient, -0.310, P.