Failing heart—medical aspects
Home continuous positive inotropic infusion as a bridge to cardiac transplantation in patients with end-stage heart failure

https://doi.org/10.1016/S1053-2498(03)00203-1Get rights and content

Abstract

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.

Section snippets

Study population

We studied 21 consecutive patients who were maintained on continuous intravenous positive inotropic therapy at home while awaiting cardiac transplantation at UNOS status 1B between February 1999 and January 2002. All patients successfully weaned from positive inotropic therapy while receiving standard oral medical therapy for heart failure. Patients were discharged home from the hospital if they were clinically stable in New York Heart Association Class III or better while receiving stable

Clinical characteristics

We studied 12 men and 9 women with a mean age of 52 years (range, 30–63 years). The mean ejection fraction was 21% ± 2% (range, 10%–52%. The cause of left ventricular dysfunction was underlying ischemic heart disease in 9 patients and non-ischemic in 12 patients (idiopathic dilated cardiomyopathy in 8 patients, non-compaction cardiomyopathy in 1 subject, Adriamycin-induced cardiomyopathy in 1 subject, post-partum cardiomyopathy in 1 subject, and hypertrophic cardiomyopathy in 1 subject).

Discussion

In this series of 21 patients with end-stage heart disease, continuous, long-term positive inotropic therapy at home was associated with improved clinical status, improved renal function, decreased hospitalizations, sustained improvement in resting hemodynamics, decreased health care costs, and increased rate of survival until transplantation.

The use of ambulatory, continuous positive inotropic infusions for treating end-stage heart failure was first proposed soon after the introduction of

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    Supported in part by National Heart, Lung, and Blood Institute Grant HL K24-04024 (SDK).

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