Can volume overload and mild tricuspid regurgitation on post-operative day 3 be a typical part of the post-operative course after minimally invasive mitral valve repair, prompting the use of milrinone (amrinone) and furosemide (Lasix)?

From the Guidelines

Volume overload on post-operative day 3 after minimally invasive mitral valve repair can be a typical part of the post-operative course, and the ICU doctor's plan to start milrinone and Lasix is a reasonable approach to manage this condition. The combination of surgical stress, cardiopulmonary bypass, and post-operative inflammatory response often leads to fluid retention despite minimal oral intake, as noted in the management of perioperative heart failure in cardiac surgery 1. Milrinone, an inotrope and vasodilator, can improve cardiac output and reduce pulmonary pressures, while Lasix (furosemide) will help with diuresis to reduce the volume overload.

The mild tricuspid regurgitation observed on echo may be related to right ventricular dysfunction secondary to the volume overload or could be a pre-existing condition exacerbated by the current hemodynamic state. According to the 2014 AHA/ACC guideline for the management of patients with valvular heart disease, tricuspid valve repair may be considered for patients with moderate functional TR and pulmonary artery hypertension at the time of left-sided valve surgery 1. However, in this scenario, the primary focus should be on managing the volume overload and assessing the patient's response to diuresis and inotropic support.

Typically, Lasix would be started at 20-40mg IV, potentially as a continuous infusion (0.1-0.4 mg/kg/hr) for more controlled diuresis, while milrinone is usually initiated at 0.375-0.75 mcg/kg/min without a loading dose in this setting. Close monitoring of renal function, electrolytes (particularly potassium), and hemodynamic parameters is essential during this treatment. The patient should improve within 24-48 hours with appropriate diuresis, and the medications can be weaned as the patient stabilizes.

Some key points to consider in the management of this patient include:

• Close monitoring of volume status and cardiac function
• Adjusting the dose of milrinone and Lasix based on the patient's response
• Monitoring for potential complications such as renal dysfunction or electrolyte imbalances
• Considering the patient's overall clinical condition and adjusting the treatment plan accordingly.

From the Research

Post-Operative Course After Minimally Invasive Mitral Valve Repair

• The patient's condition on post-op day 3, with possible volume overload despite minimal fluid intake, may be a typical part of the post-operative course after minimally invasive mitral valve repair 2, 3.
• The use of milrinone and Lasix, as suggested by the ICU doctor, is a common approach to manage volume overload and pulmonary hypertension in patients after cardiac surgery 4.
• The visualization of possible mild tricuspid regurgitation on echo is not uncommon in patients with mitral valve disease, as functional tricuspid regurgitation (FTR) occurs in approximately 30% of patients with mitral valve disease 5.

Management of Volume Overload and Tricuspid Regurgitation

• The management of volume overload and tricuspid regurgitation after minimally invasive mitral valve repair typically involves a combination of diuretics, such as Lasix, and inotropic agents, such as milrinone 4.
• The decision to start milrinone and Lasix should be based on the patient's individual clinical assessment, including echocardiographic findings and hemodynamic parameters 4.
• The presence of mild tricuspid regurgitation may not necessarily require immediate surgical intervention, but rather close monitoring and individualized management based on the patient's risk assessment 5.

Clinical Considerations

• The patient's clinical course should be closely monitored, with regular echocardiographic assessments to evaluate the severity of tricuspid regurgitation and the effectiveness of the treatment strategy 5.
• The use of milrinone and Lasix should be titrated to achieve optimal clinical outcomes, while minimizing potential side effects and complications 4.
• The patient's volume status and hemodynamic parameters should be carefully managed to prevent complications, such as pulmonary edema or cardiac dysfunction 2, 3.