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Madonna R, Biondi F, Ghelardoni S, D'Alleva A, Quarta S, Massaro M. Pulmonary hypertension associated to left heart disease: Phenotypes and treatment. Eur J Intern Med 2024:S0953-6205(24)00326-1. [PMID: 39095300 DOI: 10.1016/j.ejim.2024.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 06/19/2024] [Accepted: 07/20/2024] [Indexed: 08/04/2024]
Abstract
Pulmonary hypertension associated to left heart disease (PH-LHD) refers to a clinical and haemodynamic condition of pulmonary hypertension associated with a heterogeneous group of diseases affecting any of the compartments that form the left ventricle and left atrium. PH-LHD is the most common cause of PH, accounting for 65-80 % of diagnoses. Based on the haemodynamic phase of the disease, PH-LDH is classified into three subgroups: postcapillary PH, isolated postcapillary PH and combined pre-postcapillary PH (CpcPH). Several signaling pathways involved in the regulation of vascular tone are dysfunctional in PH-LHD, including nitric oxide, MAP kinase and endothelin-1 pathways. These pathways are the same as those altered in PH group 1, however PH-LHD can heardly be treated by specific drugs that act on the pulmonary circulation. In this manuscript we provide a state of the art of the available clinical trials investigating the safety and efficacy of PAH-specific drugs, as well as drugs active in patients with heart failure and PH-LHD. We also discuss the different phenotypes of PH-LHD, as well as molecular targets and signaling pathways potentially involved in the pathophysiology of the disease. Finally we will mention some new emerging therapies that can be used to treat this form of PH.
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Affiliation(s)
- Rosalinda Madonna
- University Cardiology Division, Pisa University Hospital and University of Pisa, Via Paradisa, 2, Pisa 56124, Italy.
| | - Filippo Biondi
- University Cardiology Division, Pisa University Hospital and University of Pisa, Via Paradisa, 2, Pisa 56124, Italy
| | - Sandra Ghelardoni
- Department of Pathology, Laboratory of Biochemistry, University of Pisa, Italy
| | - Alberto D'Alleva
- Cardiac Intensive Care and Interventional Cardiology Unit, Santo Spirito Hospital, Pescara, Italy
| | - Stefano Quarta
- Institute of Clinical Physiology (IFC), National Research Council (CNR), Lecce 73100, Italy
| | - Marika Massaro
- Institute of Clinical Physiology (IFC), National Research Council (CNR), Lecce 73100, Italy
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Wang X, Zhao X, Wang X, Cao L, Lu B, Wang Z, Zhang W, Ti Y, Zhong M. Effect of levosimendan on ventricular remodelling in patients with left ventricular systolic dysfunction: a meta-analysis. ESC Heart Fail 2024; 11:1352-1376. [PMID: 38419326 PMCID: PMC11098670 DOI: 10.1002/ehf2.14714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 03/02/2024] Open
Abstract
Heart failure is the final stage of several cardiovascular diseases, and the key to effectively treating heart failure is to reverse or delay ventricular remodelling. Levosimendan is a novel inotropic and vasodilator agent used in heart failure, whereas the impact of levosimendan on ventricular remodelling is still unclear. This study aims to investigate the impact of levosimendan on ventricular remodelling in patients with left ventricular systolic dysfunction. Electronic databases were searched to identify eligible studies. A total of 66 randomized controlled trials involving 7968 patients were included. Meta-analysis results showed that levosimendan increased left ventricular ejection fraction [mean difference (MD) = 3.62, 95% confidence interval (CI) (2.88, 4.35), P < 0.00001] and stroke volume [MD = 6.59, 95% CI (3.22, 9.96), P = 0.0001] and significantly reduced left ventricular end-systolic volume [standard mean difference (SMD) = -0.52, 95% CI (-0.67, -0.37), P < 0.00001], left ventricular end-diastolic volume index [SMD = -1.24, 95% CI (-1.61, -0.86), P < 0.00001], and left ventricular end-systolic volume index [SMD = -1.06, 95% CI (-1.43, -0.70), P < 0.00001]. In terms of biomarkers, levosimendan significantly reduced the level of brain natriuretic peptide [SMD = -1.08, 95% CI (-1.60, -0.56), P < 0.0001], N-terminal pro-brain natriuretic peptide [SMD = -0.99, 95% CI (-1.41, -0.56), P < 0.00001], and interleukin-6 [SMD = -0.61, 95% CI (-0.86, -0.35), P < 0.00001]. Meanwhile, levosimendan may increase the incidence of hypotension [risk ratio (RR) = 1.24, 95% CI (1.12, 1.39), P < 0.0001], hypokalaemia [RR = 1.57, 95% CI (1.08, 2.28), P = 0.02], headache [RR = 1.89, 95% CI (1.50, 2.39), P < 0.00001], atrial fibrillation [RR = 1.31, 95% CI (1.12, 1.52), P = 0.0005], and premature ventricular complexes [RR = 1.86, 95% CI (1.27, 2.72), P = 0.001]. In addition, levosimendan reduced all-cause mortality [RR = 0.83, 95% CI (0.74, 0.94), P = 0.002]. In conclusion, our study found that levosimendan might reverse ventricular remodelling when applied in patients with left ventricular systolic dysfunction, especially in patients undergoing cardiac surgery, decompensated heart failure, and septic shock.
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Affiliation(s)
- Xia Wang
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Xiu‐Zhi Zhao
- Department of CardiologyPeople's Hospital of Lixia District of JinanJinanShandongChina
| | - Xi‐Wen Wang
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Lu‐Ying Cao
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Bin Lu
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Zhi‐Hao Wang
- Department of Geriatric MedicineShandong Key Laboratory of Cardiovascular Proteomics, Qilu Hospital, Cheeloo College of Medicine, Shandong UniversityJinanChina
| | - Wei Zhang
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Yun Ti
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Ming Zhong
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
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Sciaccaluga C, Procopio MC, Potena L, Masetti M, Bernazzali S, Maccherini M, Landra F, Righini FM, Cameli M, Valente S. Right ventricular dysfunction in left ventricular assist device candidates: is it time to change our prospective? Heart Fail Rev 2024; 29:559-569. [PMID: 38329583 PMCID: PMC10942886 DOI: 10.1007/s10741-024-10387-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 02/09/2024]
Abstract
The use of left ventricular assist devices (LVAD) has significantly increased in the last years, trying to offer a therapeutic alternative to heart transplantation, in light also to the significant heart donor shortage compared to the growing advanced heart failure population. Despite technological improvements in the devices, LVAD-related mortality is still fairly high, with right heart failure being one of the predominant predictors. Therefore, many efforts have been made toward a thorough right ventricular (RV) evaluation prior to LVAD implant, considering clinical, laboratory, echocardiographic, and invasive hemodynamic parameters. However, there is high heterogeneity regarding both which predictor is the strongest as well as the relative cut-off values, and a consensus has not been reached yet, increasing the risk of facing patients in which the distinction between good or poor RV function cannot be surely reached. In parallel, due to technological development and availability of mechanical circulatory support of the RV, LVADs are being considered even in patients with suboptimal RV function. The aim of our review is to analyze the current evidence regarding the role of RV function prior to LVAD and its evaluation, pointing out the extreme variability in parameters that are currently assessed and future prospective regarding new diagnostic tools. Finally, we attempt to gather the available information on the therapeutic strategies to use in the peri-operative phase, in order to reduce the incidence of RV failure, especially in patients in which the preoperative evaluation highlighted some conflicting results with regard to ventricular function.
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Affiliation(s)
- Carlotta Sciaccaluga
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy.
| | | | - Luciano Potena
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Masetti
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sonia Bernazzali
- Department of Cardiac Surgery, University of Siena, Siena, Italy
| | | | - Federico Landra
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Francesca Maria Righini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Serafina Valente
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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Awada C, Boucherat O, Provencher S, Bonnet S, Potus F. The future of group 2 pulmonary hypertension: Exploring clinical trials and therapeutic targets. Vascul Pharmacol 2023; 151:107180. [PMID: 37178949 DOI: 10.1016/j.vph.2023.107180] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Abstract
Pulmonary hypertension due to left heart disease (PH-LHD) or group 2 PH is the most common and lethal form of PH, occurring secondary to left ventricular systolic or diastolic heart failure (HF), left-sided valvular diseases, and congenital abnormalities. It is subdivided into isolated postcapillary PH (IpcPH) and combined pre- and post-capillary PH (CpcPH), with the latter sharing many similarities with group 1 PH. CpcPH is associated with worse outcomes and increased morbidity and mortality when compared to IpcPH. Although IpcPH can be improved by treatment of the underlying LHD, CpcPH is an incurable disease for which no specific treatment exists, likely due to the lack of understanding of its underlying mechanisms. Furthermore, drugs approved for PAH are not recommended for group 2 PH, as they are either ineffective or even deleterious. With this major unmet medical need, a better understanding of mechanisms and the identification of effective treatment strategies for this deadly condition are urgently needed. This review presents relevant background of the molecular mechanisms underlying PH-LHD that could translate into innovative therapeutic targets and explores novel targets currently being evaluated in clinical trials.
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Affiliation(s)
- Charifa Awada
- Pulmonary Hypertension Research Group, Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC, Canada
| | - Olivier Boucherat
- Pulmonary Hypertension Research Group, Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC, Canada
| | - Steeve Provencher
- Pulmonary Hypertension Research Group, Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC, Canada
| | - Sébastien Bonnet
- Pulmonary Hypertension Research Group, Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC, Canada
| | - François Potus
- Pulmonary Hypertension Research Group, Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, QC, Canada.
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Ltaief Z, Yerly P, Liaudet L. Pulmonary Hypertension in Left Heart Diseases: Pathophysiology, Hemodynamic Assessment and Therapeutic Management. Int J Mol Sci 2023; 24:9971. [PMID: 37373119 PMCID: PMC10298585 DOI: 10.3390/ijms24129971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
Pulmonary hypertension (PH) associated with left heart diseases (PH-LHD), also termed group 2 PH, represents the most common form of PH. It develops through the passive backward transmission of elevated left heart pressures in the setting of heart failure, either with preserved (HFpEF) or reduced (HFrEF) ejection fraction, which increases the pulsatile afterload of the right ventricle (RV) by reducing pulmonary artery (PA) compliance. In a subset of patients, progressive remodeling of the pulmonary circulation resulted in a pre-capillary phenotype of PH, with elevated pulmonary vascular resistance (PVR) further increasing the RV afterload, eventually leading to RV-PA uncoupling and RV failure. The primary therapeutic objective in PH-LHD is to reduce left-sided pressures through the appropriate use of diuretics and guideline-directed medical therapies for heart failure. When pulmonary vascular remodeling is established, targeted therapies aiming to reduce PVR are theoretically appealing. So far, such targeted therapies have mostly failed to show significant positive effects in patients with PH-LHD, in contrast to their proven efficacy in other forms of pre-capillary PH. Whether such therapies may benefit some specific subgroups of patients (HFrEF, HFpEF) with specific hemodynamic phenotypes (post- or pre-capillary PH) and various degrees of RV dysfunction still needs to be addressed.
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Affiliation(s)
- Zied Ltaief
- Service of Adult Intensive Care Medicine, University Hospital, 1011 Lausanne, Switzerland;
| | - Patrick Yerly
- Service of Cardiology, University Hospital, 1011 Lausanne, Switzerland;
| | - Lucas Liaudet
- Service of Adult Intensive Care Medicine, University Hospital, 1011 Lausanne, Switzerland;
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Barańska-Pawełczak K, Wojciechowska C, Jacheć W. Pregnancy in Patients with Pulmonary Arterial Hypertension in Light of New ESC Guidelines on Pulmonary Hypertension. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4625. [PMID: 36901635 PMCID: PMC10001459 DOI: 10.3390/ijerph20054625] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/23/2023] [Accepted: 03/01/2023] [Indexed: 06/18/2023]
Abstract
Pulmonary arterial hypertension (PAH) is defined as an elevated mean pulmonary artery pressure (mPAP) of >20 mmHg together with a pulmonary arterial wedge pressure (PAWP) of ≤15 mmHg and pulmonary vascular resistance (PVR) of>2 Wood units (WU). Although the total mortality of pregnant women with PAH has decreased significantly in recent years and is reported to be around 12% in some databases, total mortality is still at an unacceptably high percentage. Moreover, some subgroups, such as patients with Eisenmenger's syndrome, have a particularly high mortality rate of up to 36%. Pregnancy in patients with PAH is contraindicated; its appearance is an indication for a planned termination. Education of patients with PAH, including counseling on effective contraception, is essential. During pregnancy, blood volume, heart rate, and cardiac output increase, while PVR and systemic vascular resistance decrease. The hemostatic balance is shifted towards hypercoagulability. Among PAH-specific drugs, the use of inhaled or intravenous prostacyclins, phosphodiesterase inhibitors, and calcium channel blockers (in patients with preserved vasoreactivity) is acceptable. Endothelin receptor antagonists and riociguat are contraindicated. Childbirth can take place through either vaginal delivery or caesarean section; similarly, neuraxial and general anesthesia have proven indications. In a situation where all pharmacological options have been used in pregnant or postpartum patients in a serious condition, veno-arterial ECMO is a useful therapeutic option. For PAH patients who want to become mothers, an option that does not endanger their lives is adoption.
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Affiliation(s)
| | - Celina Wojciechowska
- Second Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
| | - Wojciech Jacheć
- Second Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
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Kaplangoray M, Aydın C. [Comparative assessment of the effects of dobutamine and levosimendan on right ventricular ejection fraction in patients with biventricular heart failure]. KARDIOLOGIIA 2023; 63:46-51. [PMID: 36880143 DOI: 10.18087/cardio.2023.2.n2157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/28/2022] [Indexed: 03/08/2023]
Abstract
Aim The primary objective of this study was to comparatively assess the effects of levosimendan and dobutamine on RVEF, right ventricular diastolic function, and hormonal balance in patients with biventricular heart failure. The secondary objective was to investigate the relationship between the RVEF and the peak systolic velocity (Sa), an indicator of right ventricular systolic function, as measured by tissue Doppler echocardiography from the tricuspid annulus, and by the tricuspid annular plane systolic excursion (TAPSE).Material and Methods The population of this cross-sectional, single-center, prospective study was comprised of 81 patients, who between December 2019 and January 2022, applied to the study health institution with diagnosis of ADHF. The study sample included 67 biventricular heart failure patients with left ventricular ejection fraction (LVEF) <35 % and RVEF <50 %, as measured by the ellipsoidal shell model, and who met the other study inclusion criteria. Of these 67 patients, 34 were treated with levosimendan, and 33 were treated with dobutamine. RVEF, LVEF, Sa, peak early (Ea) and peak late (Aa) annular velocities, Ea / Aa ratio, TAPSE, systolic pulmonary artery pressure (SPAP), n-terminal pro-brain natriuretic peptide (NT-pro BNP), and functional capacity (FC) were measured before treatment and at 48 hrs of treatment. The within group pre- and post-treatment differences (Δs) of these variables were compared.Results RVEF, SPAP, and BNP, and FC significantly improved in both treatment groups (p<0.05 for all). Sa (p<0.01), TAPSE (p<0.01), LVEF (p<0.01), and Ea / Aa (p<0.05) improved only in the levosimendan group. The pre- and post-treatment Δs for RVEF, LVEF, SPAP, Sa, TAPSE, FC, and Ea / Aa were higher in the levosimendan group than in the dobutamine group (p<0.05 for all).Conclusion Compared to dobutamine, levosimendan produced greater improvement in right ventricular systolic and diastolic function in patients with biventricular heart failure and in need of inotropic therapy support.
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Affiliation(s)
- Mustafa Kaplangoray
- University of Health Sciences - Mehmet Akif İnan Research and Training Hospital
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Lung Volume Reduction Surgery Reduces Pulmonary Arterial Hypertension Associated With Severe Lung Emphysema and Hypercapnia. ASAIO J 2023; 69:218-224. [PMID: 35417422 DOI: 10.1097/mat.0000000000001735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Lung volume reduction surgery (LVRS) represents a standard surgical approach for patients with severe pulmonary emphysema. One of the relevant risk factors for LVRS is the presence of pulmonary arterial hypertension (PAH). The aim of this study is to assess the postoperative changes in pulmonary arterial pressure (PAP) after LVRS for patients with severe pulmonary emphysema compared with preoperative measures. N = 61 consecutive patients with severe pulmonary emphysema and preoperative evidence for PAH (pulmonary arterial systolic pressure [PASP] ≥ 35 mmHg) were prospectively included into this study. In all patients, thoracoscopic LVRS was performed. PASP was assessed by echocardiography before surgery, early postoperatively, and 3 months after surgery. Data were prospectively recorded and analyzed retrospectively. Primary end points were the postoperative changes in PASP as well as the 90 day mortality rate. Secondary endpoints included: pulmonary function test, exercise capacity, quality of life, and dyspnea symptoms (Borg scale). Early after surgery, a significant reduction in PASP was observed at the day of discharge and at 3 month follow-up. In n = 34 patients, no tricuspid valve regurgitation was detectable anymore suggesting normal PAP. In n = 3 patients, venovenous extracorporeal lung support (VV ECLS) was already implemented preoperatively. In the remaining cases, VV ECLS was applied intraoperatively and continued postoperatively. Mean duration of postoperative ECLS support was 2 days. Four patients died due to acute right heart failure, two patients from sepsis with multiorgan failure, and one patient from acute pulmonary embolism. Ninety day mortality was 11.5 %. A significant improvement was postoperatively observed regarding the performance status, dyspnea scale, as well as quality of life. This study suggests a beneficial effect of LVRS on PAP, which may ultimately help to protect and stabilize right ventricular function. Further studies, implementing pre- and postoperative right heart catheterizations including invasive PAP evaluation, are necessary to support the findings in this study in greater detail.
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Masarone D, Kittleson M, Pollesello P, Tedford RJ, Pacileo G. Use of Levosimendan in Patients with Pulmonary Hypertension: What is the Current Evidence? Drugs 2023; 83:195-201. [PMID: 36652192 DOI: 10.1007/s40265-022-01833-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 01/19/2023]
Abstract
Pulmonary hypertension, defined as an increase in mean arterial pressure > 20 mmHg, is a chronic and progressive condition with high mortality and morbidity. Drug therapy of patients with pulmonary hypertension is based on the distinctive pathophysiologic aspect that characterizes the different groups. However, recently, levosimendan, a calcium-sensitizing agent with inotropic, pulmonary vasodilator, and cardioprotective properties, has been shown to be an effective and safe therapeutic strategy for patients with pulmonary arterial hypertension (in addition to specific drugs) and pulmonary hypertension associated with left heart disease (as possible treatment). This review provides a comprehensive overview of the current evidence on the use of levosimendan in patients with pulmonary hypertension.
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, Via Leonardo Bianchi 1, 80100, Naples, Italy.
| | - Michelle Kittleson
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Piero Pollesello
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, Via Leonardo Bianchi 1, 80100, Naples, Italy
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Baratto C, Caravita S, Soranna D, Dewachter C, Bondue A, Zambon A, Badano LP, Parati G, Vachiéry J. An updated meta-analysis of hemodynamics markers of prognosis in patients with pulmonary hypertension due to left heart disease. Pulm Circ 2022; 12:e12145. [PMID: 36568693 PMCID: PMC9768568 DOI: 10.1002/pul2.12145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/20/2022] [Accepted: 07/14/2022] [Indexed: 12/27/2022] Open
Abstract
Pulmonary hypertension (PH) is associated with a poor prognosis in left heart disease (LHD). We sought to provide an updated analysis on the association of hemodynamic variables, such as pulmonary vascular resistance (PVR), pulmonary artery compliance (PAC), and diastolic pressure gradient (DPG), with prognosis in PH-LHD, through a systematic literature review. Sixteen articles were identified, including 9600 patients with LHD, heterogeneous in terms of age, sex, and etiology of cardiac disease. In this large population, PVR (hazard ratio [HR], 1.07; 95% confidence interval [CI]: 1.05-1.0), DPG (HR, 1.02; 95% CI: 1.01-1.02) and PAC (HR, 0.76; 95% CI: 0.69-0.84) were associated with an increased risk of adverse outcome, albeit with a less solid performance of DPG. Similar results were found when hemodynamic variables were analyzed according to the thresholds commonly applied in clinical practice, or subdividing cohorts according to the underlying LHD. Furthermore, cumulative metanalysis indicated that these results are consistently stable since 2018. Thus, PVR, DPG and PAC have an established prognostic value in PH-LHD. These results are consistent through the years and unlikely to change with further studies.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCSOspedale San LucaMilanoItaly
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCSOspedale San LucaMilanoItaly
- Department of Management, Information and Production EngineeringUniversity of BergamoDalmine (BG)Italy
| | - Davide Soranna
- IRCCS Istituto Auxologico ItalianoBiostatistics UnitMilanItaly
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de BruxellesHôpital Académique ErasmeBruxellesBelgium
| | - Antoine Bondue
- Department of Cardiology, Cliniques Universitaires de BruxellesHôpital Académique ErasmeBruxellesBelgium
| | - Antonella Zambon
- IRCCS Istituto Auxologico ItalianoBiostatistics UnitMilanItaly
- Department of Statistic and Quantitative MethodsUniversity of Milano‐BicoccaMilanItaly
| | - Luigi P. Badano
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCSOspedale San LucaMilanoItaly
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanoItaly
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCSOspedale San LucaMilanoItaly
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanoItaly
| | - Jean‐Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de BruxellesHôpital Académique ErasmeBruxellesBelgium
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11
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The importance of pharmacokinetics, pharmacodynamic and repetitive use of levosimendan. Biomed Pharmacother 2022; 153:113391. [DOI: 10.1016/j.biopha.2022.113391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 12/15/2022] Open
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Hu Y, Wei Z, Zhang C, Lu C, Zeng Z. The effect of levosimendan on right ventricular function in patients with heart dysfunction: a systematic review and meta-analysis. Sci Rep 2021; 11:24097. [PMID: 34916560 PMCID: PMC8677770 DOI: 10.1038/s41598-021-03317-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 12/01/2021] [Indexed: 11/11/2022] Open
Abstract
Levosimendan exerts positive inotropic and vasodilatory effects. Currently, its effects on right heart function remain uncertain. This systematic review and meta-analysis is intended to illustrate the impacts of levosimendan on systolic function of the right heart in patients with heart dysfunction. We systematically searched electronic databases (PubMed, the Cochrane Library, Embase and Web of Science) up to November 30, 2020, and filtered eligible studies that reported the impacts of levosimendan on right heart function. Of these, only studies whose patients suffered from heart dysfunction or pulmonary hypertension were included. Additionally, patients were divided into two groups (given levosimendan or not) in the initial research. Then, RevMan5.3 was used to conduct further analysis. A total of 8 studies comprising 390 patients were included. The results showed that after 24 h of levosimendan, patients' right ventricular fractional area change [3.17, 95% CI (2.03, 4.32), P < 0.00001], tricuspid annular plane systolic excursion [1.26, 95% CI (0.35, 2.16), P = 0.007] and tricuspid annular peak systolic velocity [0.86, 95% CI (0.41, 1.32), P = 0.0002] were significantly increased compared to the control group. And there is an increasing trend of cardiac output in levosimendan group [1.06, 95% CI (- 0.16, 2.29), P = 0.09 ] .Furthermore, patients' systolic pulmonary arterial pressure [- 5.57, 95% CI (- 7.60, - 3.54), P < 0.00001] and mean pulmonary arterial pressure [- 1.01, 95% CI (- 1.64, - 0.37), P = 0.002] were both significantly decreased, whereas changes in pulmonary vascular resistance [- 55.88, 95% CI (- 206.57, 94.82), P = 0.47] were not significant. Our study shows that in patients with heart dysfunction, levosimendan improves systolic function of the right heart and decreases the pressure of the pulmonary artery.
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Affiliation(s)
- Yaoshi Hu
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, Guangxi, China
| | - Zhe Wei
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Chaoyong Zhang
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, Guangxi, China
| | - Chuanghong Lu
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, Guangxi, China
| | - Zhiyu Zeng
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China.
- Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, Guangxi, China.
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13
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Durur-Subasi I, Kose D, Yayla M, Sirin B, Karaman A, Calik I, Alper F. Does the cardiovascular drug levosimendan prevent iodinated contrast medium nephrotoxicity with glycerol aggravation in rats? Eur Radiol Exp 2021; 5:49. [PMID: 34786647 PMCID: PMC8595362 DOI: 10.1186/s41747-021-00249-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background We investigated whether levosimendan prevents contrast medium nephrotoxicity with glycerol aggravation in rats. Methods Forty-eight Wistar albino rats were assigned to eight groups (n = 6 × 8). No medication was administered to group I (controls); glycerol (intramuscular injection of 25% glycerol, 10 mL/kg) group II; intravenous iohexol 10 mL/kg to group III; glycerol and iohexol to group IV; iohexol and intraperitoneal levosimendan 0.25 mg/kg to group V; glycerol, iohexol, and levosimendan 0.25 mg/kg to group VI; iohexol and levosimendan 0.5 mg/kg to group VII; and glycerol, iohexol, and levosimendan 0.5 mg/kg to group VIII. One-day water withdrawal and glycerol injection prompted renal damage; iohexol encouraged nephrotoxicity; levosimendan was administered 30 min after glycerol injection and continued on days 2, 3, and 4. The experiment was completed on day 5. Serum blood urea nitrogen (BUN) and creatinine levels, superoxide dismutase (SOD) activity, glutathione (GSH), malondialdehyde (MDA) levels, tumour necrosis factor-α (TNF-α), nuclear factor kappa ß (NFK-ß), interleukin 6 (IL-6), and histopathological marks were assessed. One-way analysis of variance and Duncan’s multiple comparison tests were used. Results Levosimendan changed serum BUN (p = 0.012) and creatinine (p = 0.018), SOD (p = 0.026), GSH (p = 0.012), and MDA (p = 0.011). Levosimendan significantly downregulated TNF-α (p = 0.022), NFK-ß (p = 0.008), and IL-6 (p = 0.033). Histopathological marks of hyaline and haemorrhagic cast were improved in levosimendan-injected groups. Conclusion Levosimendan showed nephroprotective properties due to its vasodilator, oxidative distress decreasing and inflammatory cytokine preventing belongings.
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Affiliation(s)
- Irmak Durur-Subasi
- Department of Radiology, International Faculty of Medicine, Istanbul Medipol University, TEM Avrupa Otoyolu, Goztepe Cikisi No:1, Bagcilar, Istanbul, Turkey. .,Department of Radiology, Ataturk University Faculty of Medicine, Erzurum, Turkey.
| | - Duygu Kose
- Department of Pharmacology, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Muhammed Yayla
- Department of Pharmacology, Kafkas University Faculty of Medicine, Kars, Turkey
| | - Busra Sirin
- Department of Pharmacology, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Adem Karaman
- Department of Radiology, Ataturk University Faculty of Medicine, Erzurum, Turkey
| | - Ilknur Calik
- Department of Pathology, Faculty of Medicine, Fırat University, Elazig, Turkey
| | - Fatih Alper
- Department of Radiology, Ataturk University Faculty of Medicine, Erzurum, Turkey
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14
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Phoophiboon V, Pachinburavan M, Ruamsap N, Sanguanwong N, Jaimchariyatam N. Critical care management of pulmonary arterial hypertension in pregnancy: the pre-, peri- and post-partum stages. Acute Crit Care 2021; 36:286-293. [PMID: 34762794 PMCID: PMC8907465 DOI: 10.4266/acc.2021.00458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 08/31/2021] [Indexed: 11/30/2022] Open
Abstract
The mortality rate of pulmonary hypertension in pregnancy is 25%–56%. Pulmonary arterial hypertension is the highest incidence among this group, especially in young women. Despite clear recommendation of pregnancy avoidance, certain groups of patients are initially diagnosed during the gestational age step into the third trimester. While the presence of right ventricular failure in early gestation is usually trivial, it can be more severe in the late trimester. Current evidence shows no consensus in the management and serious precautions for each stage of the pre-, peri- and post-partum periods of this specific group. Pulmonary hypertension-targeted drugs, mode of delivery, type of anesthesia, and some avoidances should be planned among a multidisciplinary team to enhance maternal and fetal survival opportunities. Sudden circulatory collapse from cardiac decompensation during the peri- and post-partum phases is detrimental, and mechanical support such as extracorporeal membrane oxygenation should be considered for mitigating hemodynamics and extending cardiac recovery time. Our review aims to explain the pathophysiology of pulmonary arterial hypertension and summarize the current evidence for critical management and precautions in each stage of pregnancy.
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Affiliation(s)
- Vorakamol Phoophiboon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Critical Care Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Monvasi Pachinburavan
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Critical Care Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Nicha Ruamsap
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Natthawan Sanguanwong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Sleep Disorder, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Nattapong Jaimchariyatam
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence Center for Sleep Disorder, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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15
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Varma PK, Srimurugan B, Jose RL, Krishna N, Valooran GJ, Jayant A. Perioperative right ventricular function and dysfunction in adult cardiac surgery-focused review (part 2-management of right ventricular failure). Indian J Thorac Cardiovasc Surg 2021; 38:157-166. [PMID: 34751203 PMCID: PMC8566189 DOI: 10.1007/s12055-021-01226-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/01/2021] [Accepted: 06/13/2021] [Indexed: 12/01/2022] Open
Abstract
The single most important factor in improving outcomes in right ventricular (RV) failure is anticipating and recognizing it. Once established, a vicious circle of systemic hypotension, and RV ischemia and dilation, occurs, leading to cardiogenic shock, multi-organ failure, and death. RV dysfunction and failure theoretically can occur in three settings-increase in the pre-load; increase in after load; and decrease in contractility. For patients deemed low risk for the development of RV failure, when it occurs, the correction of underlying cause is the most important and effective treatment strategy. Therapy of RV failure must focus on improving the RV coronary perfusion, lowering pulmonary vascular resistance, and optimizing the pre-load. Pre-load and after-load optimization, ventilator adjustments, and improving the contractility of RV by inotropes are the first line of therapy and should be initiated early to prevent multi-organ damage. Mechanical assist device implantation or circulatory support with extracorporeal membrane oxygenation (ECMO) may be needed in refractory cases.
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Affiliation(s)
- Praveen Kerala Varma
- Divisions of Cardio Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Balaji Srimurugan
- Divisions of Cardio Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Reshmi Liza Jose
- Divisions of Cardiac Anesthesiology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Neethu Krishna
- Divisions of Cardio Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | | | - Aveek Jayant
- Divisions of Cardio Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
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16
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Kost LV, Glaus TM, Diana A, Baron Toaldo M. Effect of a single dose of pimobendan on right ventricular and right atrial function in 11 healthy cats. J Vet Cardiol 2021; 37:52-61. [PMID: 34560344 DOI: 10.1016/j.jvc.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 07/30/2021] [Accepted: 08/12/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The objective of this study was to investigate the effect of pimobendan on echocardiographic parameters of right ventricular and atrial function in healthy cats. ANIMALS Eleven privately owned, healthy adult cats. MATERIAL AND METHODS Each cat underwent five echocardiographic examinations: the first and second examinations were performed 1 h apart on day 0. On day 1, the third examination served as baseline, whereas the fourth and fifth examinations were performed one and 6 h after administration of a single oral dose of pimobendan (1.25 mg/cat), respectively. Parameters of right ventricular and atrial morphology and function were collected and compared among time points. RESULTS Pimobendan administration produced a change in some echocardiographic variables. Specifically, heart rate, right ventricular fractional shortening and peak velocity of systolic lateral tricuspid annular motion increased (P = 0.032, P = 0.002 and P < 0.001, respectively), whereas right ventricular end-systolic internal diameter and right atrial maximum and minimum internal diameters decreased (P = 0.004, P = 0.025 and P = 0.01, respectively). Right ventricular fractional area change and tricuspid annular plane systolic excursion did not change. CONCLUSIONS This novel study showed that pimobendan had positive effects on right ventricular and right atrial function in healthy cats. Further studies are needed to determine whether pimobendan has similar effects in cats with cardiac diseases.
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Affiliation(s)
- L V Kost
- Division of Cardiology, Clinic for Small Animal Internal Medicine, Vetsuisse Faculty University of Zürich, Switzerland
| | - T M Glaus
- Division of Cardiology, Clinic for Small Animal Internal Medicine, Vetsuisse Faculty University of Zürich, Switzerland
| | - A Diana
- Department of Veterinary Medical Sciences, Alma Mater Studiorum, University of Bologna, Italy
| | - M Baron Toaldo
- Division of Cardiology, Clinic for Small Animal Internal Medicine, Vetsuisse Faculty University of Zürich, Switzerland; Department of Veterinary Medical Sciences, Alma Mater Studiorum, University of Bologna, Italy.
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17
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Conti N, Gatti M, Raschi E, Diemberger I, Potena L. Evidence and Current Use of Levosimendan in the Treatment of Heart Failure: Filling the Gap. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:3391-3409. [PMID: 34376973 PMCID: PMC8350150 DOI: 10.2147/dddt.s295214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/22/2021] [Indexed: 12/14/2022]
Abstract
Levosimendan is a distinctive inodilator combing calcium sensitization, phosphodiesterase inhibition and vasodilating properties through the opening of adenosine triphosphate-dependent potassium channels. It was first approved in Sweden in 2000 for the short-term treatment of acutely decompensated severe chronic heart failure when conventional therapy is not sufficient, and in cases where inotropic support is considered appropriate. After more than 20 years, clinical applications have considerably expanded across critical care and emergency medicine, and levosimendan is now under investigation in different cardiac settings (eg, septic shock, pulmonary hypertension) and for non-cardiac applications (eg, amyotrophic lateral sclerosis). This narrative review outlines key milestones in levosimendan history, by addressing regulatory issues, pharmacological peculiarities and clinical aspects (efficacy and safety) of a drug that did not receive great attention in the heart failure guidelines. A brief outlook to the ongoing clinical trials is also offered.
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Affiliation(s)
- Nicolina Conti
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Milo Gatti
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy.,SSD Clinical Pharmacology, IRCSS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Igor Diemberger
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum - University of Bologna, Bologna, Italy.,Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luciano Potena
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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18
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Myocardial Tissue Characterization in Heart Failure with Preserved Ejection Fraction: From Histopathology and Cardiac Magnetic Resonance Findings to Therapeutic Targets. Int J Mol Sci 2021; 22:ijms22147650. [PMID: 34299270 PMCID: PMC8304780 DOI: 10.3390/ijms22147650] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/13/2021] [Accepted: 07/16/2021] [Indexed: 12/12/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a complex clinical syndrome responsible for high mortality and morbidity rates. It has an ever growing social and economic impact and a deeper knowledge of molecular and pathophysiological basis is essential for the ideal management of HFpEF patients. The association between HFpEF and traditional cardiovascular risk factors is known. However, myocardial alterations, as well as pathophysiological mechanisms involved are not completely defined. Under the definition of HFpEF there is a wide spectrum of different myocardial structural alterations. Myocardial hypertrophy and fibrosis, coronary microvascular dysfunction, oxidative stress and inflammation are only some of the main pathological detectable processes. Furthermore, there is a lack of effective pharmacological targets to improve HFpEF patients' outcomes and risk factors control is the primary and unique approach to treat those patients. Myocardial tissue characterization, through invasive and non-invasive techniques, such as endomyocardial biopsy and cardiac magnetic resonance respectively, may represent the starting point to understand the genetic, molecular and pathophysiological mechanisms underlying this complex syndrome. The correlation between histopathological findings and imaging aspects may be the future challenge for the earlier and large-scale HFpEF diagnosis, in order to plan a specific and effective treatment able to modify the disease's natural course.
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19
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Lin Y, Fu S, Yao Y, Li Y, Zhao Y, Luo L. Heart failure with preserved ejection fraction based on aging and comorbidities. J Transl Med 2021; 19:291. [PMID: 34229717 PMCID: PMC8259336 DOI: 10.1186/s12967-021-02935-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/10/2021] [Indexed: 12/25/2022] Open
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) is a leading cause of hospitalizations and mortality when diagnosed at the age of ≥ 65 years. HFpEF represents multifactorial and multisystemic syndrome and has different pathophysiology and phenotypes. Its diagnosis is difficult to be established based on left ventricular ejection fraction and may benefit from individually tailored approaches, underlying age-related changes and frequent comorbidities. Compared with the rapid development in the treatment of heart failure with reduced ejection fraction, HFpEF presents a great challenge and needs to be addressed considering the failure of HF drugs to improve its outcomes. Further extensive studies on the relationships between HFpEF, aging, and comorbidities in carefully phenotyped HFpEF subgroups may help understand the biology, diagnosis, and treatment of HFpEF. The current review summarized the diagnostic and therapeutic development of HFpEF based on the complex relationships between aging, comorbidities, and HFpEF.
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Affiliation(s)
- Ying Lin
- Department of Cardiology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, 572013, China
| | - Shihui Fu
- Department of Cardiology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, 572013, China.
- Department of Geriatric Cardiology, Chinese People's Liberation Army General Hospital, Beijing, 100853, China.
| | - Yao Yao
- Centre for the Study of Ageing and Human Development and Geriatrics Division, Medical School of Duke University, Durham, NC, 27708, USA
- Centre for Healthy Ageing and Development Studies, National School of Development, Peking University, Beijing, 100871, China
| | - Yulong Li
- Department of Geriatric Cardiology, Chinese People's Liberation Army General Hospital, Beijing, 100853, China
| | - Yali Zhao
- Central Laboratory, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, 572013, China.
| | - Leiming Luo
- Department of Geriatric Cardiology, Chinese People's Liberation Army General Hospital, Beijing, 100853, China.
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20
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Kocabeyoglu SS, Kervan U, Sert DE, Karahan M, Aygun E, Beyazal OF, Unal EU, Akin Y, Demirkan B, Pac M. Optimization with levosimendan improves outcomes after left ventricular assist device implantation. Eur J Cardiothorac Surg 2021; 57:176-182. [PMID: 31155645 DOI: 10.1093/ejcts/ezz159] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 04/19/2019] [Accepted: 04/24/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The aim of this study was to examine the haemodynamic effects of preoperative levosimendan infusion in patients who underwent left ventricular assist device implantation and evaluate the prognoses. METHODS Between May 2013 and October 2018, 85 adult patients who underwent left ventricular assist device implantation were included; 44 and 41 patients suffered from dilated cardiomyopathy and ischaemic cardiomyopathy, respectively. Patients were divided into 2 groups: group A (58 patients) included those who received levosimendan infusion in addition to other inotropes and group B (27 patients) included those who received inotropic agents other than levosimendan. Levosimendan infusion was started at a dose of 0.1 µg⋅kg-1⋅min-1 for a maximum of 48 h without a bolus. The primary outcome was early right ventricular failure (RVF). The secondary outcomes were in-hospital mortality, need for right ventricular assist device, late RVF and recovery of end-organ functions. The safety end points of levosimendan included hypotension, atrial fibrillation, ventricular tachycardia or fibrillation and resuscitated cardiac arrest. RESULTS Patient characteristics were similar in both groups. No significant differences between groups were observed in the rates of early mortality, RVF, need for right ventricular assist device, cardiopulmonary bypass time and intensive care unit stay. Survival rates at 30 days, 1 year and 3 years and freedom from late RVF were similar between the groups. Administration of levosimendan was safe, generally well-tolerated and not interrupted because of side effects. CONCLUSIONS Levosimendan therapy was well-tolerated in patients who received permanent left ventricular assist devices. Combined preoperative therapy with inotropes and levosimendan significantly improves end-organ functions.
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Affiliation(s)
| | - Umit Kervan
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Dogan Emre Sert
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Mehmet Karahan
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Emre Aygun
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Osman Fehmi Beyazal
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Ertekin Utku Unal
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Yesim Akin
- Department of Cardiology, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Burcu Demirkan
- Department of Cardiology, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Mustafa Pac
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
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21
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Long YX, Cui DY, Kuang X, Hu S, Hu Y, Liu ZZ. Effect of Levosimendan on Ventricular Systolic and Diastolic Functions in Heart Failure Patients: A Meta-Analysis of Randomized Controlled Trials. J Cardiovasc Pharmacol 2021; 77:805-813. [PMID: 34001722 DOI: 10.1097/fjc.0000000000001010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/15/2021] [Indexed: 12/20/2022]
Abstract
ABSTRACT Levosimendan, a calcium sensitizer, exerts inotropic action through improving left ventricular ejection fraction. We noticed that only few clinical studies are published in which the effects of levosimendan on cardiac function are studied by echocardiography. When screening the literature (PubMed, Embase, and CENTRAL, from inception to August 2020), we found 29 randomized controlled trials on levosimendan containing echocardiographic data. We included those studies, describing a total of 574 heart failure patients, in our meta-analysis and extracted 14 ultrasonic parameters, pooling the effect estimates using a random-effect model. Our analysis of the diastolic parameters of the left ventricle shows that levosimendan reduce the early/late transmitral diastolic peak flow velocity ratio [standardized mean difference (SMD) -0.45 to 95% confidence interval (CI) (-0.87 to -0.03), P = 0.037] and E/e' (e': mitral annulus peak early diastolic wave velocity using tissue-doppler imaging) [SMD -0.59, 95% CI (-0.8 to -0.39), P < 0.001]. As it regards the systolic parameters of the right ventricle, levosimendan increased tricuspid annular plane systolic excursion [SMD 0.62, 95% CI (0.28 to 0.95), P < 0.001] and tricuspid annular peak systolic velocity [SMD 0.75, 95% CI (0.35 to 1.16), P < 0.001], and reduced systolic pulmonary artery pressure [SMD -1.02, 95% CI (-1.32, -0.73), P < 0.001]. As it regards the diastolic parameters of the right ventricle, levosimendan was associated with the decrease of Aa (peak late diastolic tricuspid annular velocity using tissue-doppler imaging) [SMD -0.38, 95% CI (-0.76 to 0), P = 0.047] and increase of Ea (peak early diastolic tricuspid annular velocity using tissue-doppler imaging) [SMD 1.03, 95% CI (0.63 to 1.42), P < 0.001] and Ea/Aa [SMD 0.86, 95% CI (0.18 to 1.54), P = 0.013]. We show that levosimendan is associated with an amelioration in the diastolic and systolic functions of both ventricles in heart failure patients.
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Affiliation(s)
- Yu-Xiang Long
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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22
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Cosentino N, Niccoli G, Fracassi F, Rebuzzi A, Agostoni P, Marenzi G. Rationale, experimental data, and emerging clinical evidence on early and preventive use of levosimendan in patients with ventricular dysfunction. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 6:310-316. [PMID: 31688906 DOI: 10.1093/ehjcvp/pvz065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/18/2019] [Accepted: 11/01/2019] [Indexed: 12/13/2022]
Abstract
Acute ventricular dysfunction (AVD) is a complex condition with substantial morbidity and mortality, still featuring unique therapeutic challenges. Levosimendan is a calcium sensitizer and ATP-dependent potassium channel opener that was developed as an inodilating drug for the treatment of acute heart failure and cardiogenic shock. Differently from other more widely used inotropic agents, levosimendan has some exclusive characteristics, in terms of mechanisms of action, pharmacodynamic profile, and haemodynamic effects. This may have important clinical implications. In particular, in patients with AVD or in patients with pre-existing severe ventricular impairment undergoing planned myocardial stress, the administration of levosimendan before the onset of overt symptoms or before cardiovascular therapeutic procedures may have the potential to bridge the patient through the critical phase. In this review, we will focus on the rationale, the existing experimental data, and the emerging clinical experience supporting an early, even preventive use of levosimendan in severe ventricular dysfunction, beyond its recognized indications.
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Affiliation(s)
- Nicola Cosentino
- Centro Cardiologico Monzino, I.R.C.C.S, Via Parea 4, 20138 Milan, Italy
| | - Giampaolo Niccoli
- Department of Cardiovascular & Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli, I.R.C.C.S, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Fracassi
- Department of Cardiovascular & Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli, I.R.C.C.S, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Rebuzzi
- Department of Cardiovascular & Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli, I.R.C.C.S, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, I.R.C.C.S, Via Parea 4, 20138 Milan, Italy.,Department of Clinical Sciences and Community Health - Cardiovascular Section, Università degli Studi di Milano, Milan, Italy
| | - Giancarlo Marenzi
- Centro Cardiologico Monzino, I.R.C.C.S, Via Parea 4, 20138 Milan, Italy
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23
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Kumar D, Yadava OP, Ahlawat V, Kundu A, Yadav A, Prakash A. Pre-bypass levosimendan in ventricular dysfunction-effect on right ventricle. Asian Cardiovasc Thorac Ann 2020; 29:260-267. [PMID: 33143432 DOI: 10.1177/0218492320972891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Levosimendan is an effective calcium sensitizer with complementary mechanisms of action: calcium sensitization and opening of adenosine triphosphate-dependent potassium channels, both on the sarcolemma of the smooth muscle cells in the vasculature and on the mitochondria of cardiomyocytes. Levosimendan has a long-acting metabolite with a half-life of approximately 80 h. There have been a few small studies on this drug regarding right ventricular function. In view of this, we investigated the effect of levosimendan on right ventricular function in patients with coronary artery disease. METHODS This was a prospective, randomized, double-blind study on 50 patients with coronary artery disease and severe left ventricular dysfunction (left ventricular ejection fraction ≤35%) undergoing elective off-pump coronary artery bypass. RESULTS Levosimendan had an inotropic effect on right ventricular myocardium and a vasodilatory effect on blood vessels. It caused a decline in pulmonary vascular resistance (p < 0.018), right ventricular systolic pressure (p < 0.001), and pulmonary artery systolic pressure (p < 0.001), and improved right ventricular diastolic function as shown by the decrease in right ventricular Tei index (p < 0.001), right ventricular end-diastolic pressure, and the ratio of early diastolic tricuspid inflow to tricuspid lateral annular velocity (p < 0.006). However, we found no beneficial effects on intensive care unit or hospital stay (p = 0.164, p = 0.349, respectively) nor a mortality benefit. CONCLUSIONS Levosimendan has salutary effects on right ventricular function in patients with severe left ventricular dysfunction undergoing coronary artery bypass, in terms of improved hemodynamic parameters.
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Affiliation(s)
- Dhanesh Kumar
- Department of Cardiac Surgery, National Heart Institute, New Delhi, India
| | - Om Prakash Yadava
- Department of Cardiac Surgery, National Heart Institute, New Delhi, India
| | - Vikas Ahlawat
- Department of Cardiac Surgery, National Heart Institute, New Delhi, India
| | - Anirban Kundu
- Department of Cardiac Surgery, National Heart Institute, New Delhi, India
| | - Amita Yadav
- Department of Cardiac Surgery, National Heart Institute, New Delhi, India
| | - Arvind Prakash
- Department of Cardiac Surgery, National Heart Institute, New Delhi, India
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24
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Wintrich J, Kindermann I, Ukena C, Selejan S, Werner C, Maack C, Laufs U, Tschöpe C, Anker SD, Lam CSP, Voors AA, Böhm M. Therapeutic approaches in heart failure with preserved ejection fraction: past, present, and future. Clin Res Cardiol 2020; 109:1079-1098. [PMID: 32236720 PMCID: PMC7449942 DOI: 10.1007/s00392-020-01633-w] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/11/2020] [Indexed: 02/07/2023]
Abstract
In contrast to the wealth of proven therapies for heart failure with reduced ejection fraction (HFrEF), therapeutic efforts in the past have failed to improve outcomes in heart failure with preserved ejection fraction (HFpEF). Moreover, to this day, diagnosis of HFpEF remains controversial. However, there is growing appreciation that HFpEF represents a heterogeneous syndrome with various phenotypes and comorbidities which are hardly to differentiate solely by LVEF and might benefit from individually tailored approaches. These hypotheses are supported by the recently presented PARAGON-HF trial. Although treatment with LCZ696 did not result in a significantly lower rate of total hospitalizations for heart failure and death from cardiovascular causes among HFpEF patients, subanalyses suggest beneficial effects in female patients and those with an LVEF between 45 and 57%. In the future, prospective randomized trials should focus on dedicated, well-defined subgroups based on various information such as clinical characteristics, biomarker levels, and imaging modalities. These could clarify the role of LCZ696 in selected individuals. Furthermore, sodium-glucose cotransporter-2 inhibitors have just proven efficient in HFrEF patients and are currently also studied in large prospective clinical trials enrolling HFpEF patients. In addition, several novel disease-modifying drugs that pursue different strategies such as targeting cardiac inflammation and fibrosis have delivered preliminary optimistic results and are subject of further research. Moreover, innovative device therapies may enhance management of HFpEF, but need prospective adequately powered clinical trials to confirm safety and efficacy regarding clinical outcomes. This review highlights the past, present, and future therapeutic approaches in HFpEF.
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Affiliation(s)
- Jan Wintrich
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Kirrberger Straße, 66421, Homburg/Saar, Germany.
| | - Ingrid Kindermann
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Kirrberger Straße, 66421, Homburg/Saar, Germany
| | - Christian Ukena
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Kirrberger Straße, 66421, Homburg/Saar, Germany
| | - Simina Selejan
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Kirrberger Straße, 66421, Homburg/Saar, Germany
| | - Christian Werner
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Kirrberger Straße, 66421, Homburg/Saar, Germany
| | - Christoph Maack
- Comprehensive Heart Failure Center (CHFC), University Clinic Würzburg, Würzburg, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie im Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Carsten Tschöpe
- Department of Cardiology, Universitätsmedizin Berlin, Charite, Campus Rudolf Virchow Clinic (CVK), Augustenburger Platz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany
- Berlin-Brandenburg Institute of Health/Center for Regenerative Therapies (BIHCRT), Berlin, Germany
| | - Stefan D Anker
- Department of Cardiology, Universitätsmedizin Berlin, Charite, Campus Rudolf Virchow Clinic (CVK), Augustenburger Platz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany
- Berlin-Brandenburg Institute of Health/Center for Regenerative Therapies (BIHCRT), Berlin, Germany
| | - Carolyn S P Lam
- National Heart Centre, Singapore and Duke-National University of Singapore, Singapore, Singapore
- University Medical Centre Groningen, Groningen, The Netherlands
- The George Institute for Global Health, Sydney, Australia
| | - Adriaan A Voors
- University Medical Centre Groningen, Groningen, The Netherlands
| | - Michael Böhm
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Kirrberger Straße, 66421, Homburg/Saar, Germany
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25
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Papp Z, Agostoni P, Alvarez J, Bettex D, Bouchez S, Brito D, Černý V, Comin-Colet J, Crespo-Leiro MG, Delgado JF, Édes I, Eremenko AA, Farmakis D, Fedele F, Fonseca C, Fruhwald S, Girardis M, Guarracino F, Harjola VP, Heringlake M, Herpain A, Heunks LM, Husebye T, Ivancan V, Karason K, Kaul S, Kivikko M, Kubica J, Masip J, Matskeplishvili S, Mebazaa A, Nieminen MS, Oliva F, Papp JG, Parissis J, Parkhomenko A, Põder P, Pölzl G, Reinecke A, Ricksten SE, Riha H, Rudiger A, Sarapohja T, Schwinger RH, Toller W, Tritapepe L, Tschöpe C, Wikström G, von Lewinski D, Vrtovec B, Pollesello P. Levosimendan Efficacy and Safety: 20 years of SIMDAX in Clinical Use. Card Fail Rev 2020; 6:e19. [PMID: 32714567 PMCID: PMC7374352 DOI: 10.15420/cfr.2020.03] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/16/2020] [Indexed: 12/12/2022] Open
Abstract
Levosimendan was first approved for clinic use in 2000, when authorisation was granted by Swedish regulatory authorities for the haemodynamic stabilisation of patients with acutely decompensated chronic heart failure. In the ensuing 20 years, this distinctive inodilator, which enhances cardiac contractility through calcium sensitisation and promotes vasodilatation through the opening of adenosine triphosphate-dependent potassium channels on vascular smooth muscle cells, has been approved in more than 60 jurisdictions, including most of the countries of the European Union and Latin America. Areas of clinical application have expanded considerably and now include cardiogenic shock, takotsubo cardiomyopathy, advanced heart failure, right ventricular failure and pulmonary hypertension, cardiac surgery, critical care and emergency medicine. Levosimendan is currently in active clinical evaluation in the US. Levosimendan in IV formulation is being used as a research tool in the exploration of a wide range of cardiac and non-cardiac disease states. A levosimendan oral form is at present under evaluation in the management of amyotrophic lateral sclerosis. To mark the 20 years since the advent of levosimendan in clinical use, 51 experts from 23 European countries (Austria, Belgium, Croatia, Cyprus, Czech Republic, Estonia, Finland, France, Germany, Greece, Hungary, Italy, the Netherlands, Norway, Poland, Portugal, Russia, Slovenia, Spain, Sweden, Switzerland, UK and Ukraine) contributed to this essay, which evaluates one of the relatively few drugs to have been successfully introduced into the acute heart failure arena in recent times and charts a possible development trajectory for the next 20 years.
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Affiliation(s)
- Zoltán Papp
- Department of Cardiology, Faculty of Medicine, University of Debrecen Debrecen, Hungary
| | - Piergiuseppe Agostoni
- Department of Clinical Sciences and Community Health, Centro Cardiologico Monzino, IRCCS Milan, Italy
| | - Julian Alvarez
- Department of Surgery, School of Medicine, University of Santiago de Compostela Santiago de Compostela, Spain
| | - Dominique Bettex
- Institute of Anaesthesiology, University Hospital of Zurich Zurich, Switzerland
| | - Stefan Bouchez
- Department of Anaesthesiology, University Hospital Ghent, Belgium
| | - Dulce Brito
- Cardiology Department, Centro Hospitalar Universitario Lisboa Norte, CCUI, Faculdade de Medicina, Universidade de Lisboa Lisbon, Portugal
| | - Vladimir Černý
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University Usti nad Labem, Czech Republic
| | - Josep Comin-Colet
- Heart Diseases Institute, Hospital Universitari de Bellvitge Barcelona, Spain
| | - Marisa G Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), CIBERCV, Instituto de Investigacion Biomedica A Coruña (INIBIC), Universidad de a Coruña (UDC) La Coruña, Spain
| | - Juan F Delgado
- Heart Failure and Transplant Program, Cardiology Department, University Hospital 12 Octubre Madrid, Spain
| | - Istvan Édes
- Department of Cardiology, Faculty of Medicine, University of Debrecen Debrecen, Hungary
| | - Alexander A Eremenko
- Department of Cardiac Intensive Care, Petrovskii National Research Centre of Surgery, Sechenov University Moscow, Russia
| | - Dimitrios Farmakis
- Department of Cardiology, Medical School, University of Cyprus Nicosia, Cyprus
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, La Sapienza University of Rome Rome, Italy
| | - Cândida Fonseca
- Heart Failure Clinic, São Francisco Xavier Hospital, CHLO Lisbon, Portugal
| | - Sonja Fruhwald
- Department of Anaesthesiology and Intensive Care Medicine, Division of Anaesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz Graz, Austria
| | - Massimo Girardis
- Struttura Complessa di Anestesia 1, Policlinico di Modena Modena, Italy
| | - Fabio Guarracino
- Dipartimento di Anestesia e Terapie Intensive, Azienda Ospedaliero-Universitaria Pisana Pisa, Italy
| | - Veli-Pekka Harjola
- Emergency Medicine, Meilahti Central University Hospital, University of Helsinki Helsinki, Finland
| | - Matthias Heringlake
- Department of Anaesthesiology and Intensive Care Medicine, University of Lübeck Lübeck, Germany
| | - Antoine Herpain
- Department of Intensive Care, Hôpital Erasme Brussels, Belgium
| | - Leo Ma Heunks
- Department of Intensive Care Medicine, Amsterdam UMC Amsterdam, the Netherlands
| | - Tryggve Husebye
- Department of Cardiology, Oslo University Hospital Ullevaal Oslo, Norway
| | - Višnja Ivancan
- Department of Anaesthesiology, Reanimatology and Intensive Care, University Hospital Centre Zagreb, Croatia
| | - Kristjan Karason
- Departments of Cardiology and Transplantation, Sahlgrenska University Hospital Gothenburg, Sweden
| | - Sundeep Kaul
- Intensive Care Unit, National Health Service Leeds, UK
| | - Matti Kivikko
- Global Medical Affairs, R&D, Orion Pharma Espoo, Finland
| | - Janek Kubica
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University Torun, Poland
| | - Josep Masip
- Intensive Care Department, Consorci Sanitari Integral, University of Barcelona Barcelona, Spain
| | | | - Alexandre Mebazaa
- Department of Anaesthesiology and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals Paris, France
| | | | - Fabrizio Oliva
- Department of Cardiology, Niguarda Ca'Granda Hospital Milan, Italy
| | - Julius-Gyula Papp
- MTA-SZTE Research Group of Cardiovascular Pharmacology, Hungarian Academy of Sciences, University of Szeged Szeged, Hungary
| | - John Parissis
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Athens, Greece
| | - Alexander Parkhomenko
- Emergency Cardiology Department, National Scientific Centre MD Strazhesko Institute of Cardiology Kiev, Ukraine
| | - Pentti Põder
- Department of Cardiology, North Estonia Medical Centre Tallinn, Estonia
| | - Gerhard Pölzl
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck Innsbruck, Austria
| | - Alexander Reinecke
- Klinik für Innere Medizin III, Kardiologie, Universitätsklinikum Schleswig-Holstein Kiel, Germany
| | - Sven-Erik Ricksten
- Department of Anaesthesiology and Intensive Care, Sahlgrenska University Hospital Gothenburg, Sweden
| | - Hynek Riha
- Cardiothoracic Anaesthesiology and Intensive Care, Department of Anaesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine Prague, Czech Republic
| | - Alain Rudiger
- Department of Medicine, Spittal Limmattal Schlieren, Switzerland
| | | | - Robert Hg Schwinger
- Medizinische Klinik II, Klinikum Weiden, Teaching Hospital of University of Regensburg Weiden, Germany
| | - Wolfgang Toller
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz Graz, Austria
| | - Luigi Tritapepe
- Anaesthesia and Intensive Care Division, San Camillo-Forlanini Hospital Rome, Italy
| | - Carsten Tschöpe
- Department of Cardiology, Campus Virchow Klinikum, Charité - University Medicine Berlin Berlin, Germany
| | - Gerhard Wikström
- Institute of Medical Sciences, Uppsala University Uppsala, Sweden
| | - Dirk von Lewinski
- Department of Cardiology, Myokardiale Energetik und Metabolismus Research Unit, Medical University of Graz Graz, Austria
| | - Bojan Vrtovec
- Advanced Heart Failure and Transplantation Centre, Department of Cardiology, University Clinical Centre Ljubljana, Slovenia
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26
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Papp Z, Agostoni P, Alvarez J, Bettex D, Bouchez S, Brito D, Černý V, Comin-Colet J, Crespo-Leiro MG, Delgado JF, Édes I, Eremenko AA, Farmakis D, Fedele F, Fonseca C, Fruhwald S, Girardis M, Guarracino F, Harjola VP, Heringlake M, Herpain A, Heunks LMA, Husebye T, Ivancan V, Karason K, Kaul S, Kivikko M, Kubica J, Masip J, Matskeplishvili S, Mebazaa A, Nieminen MS, Oliva F, Papp JG, Parissis J, Parkhomenko A, Põder P, Pölzl G, Reinecke A, Ricksten SE, Riha H, Rudiger A, Sarapohja T, Schwinger RHG, Toller W, Tritapepe L, Tschöpe C, Wikström G, von Lewinski D, Vrtovec B, Pollesello P. Levosimendan Efficacy and Safety: 20 Years of SIMDAX in Clinical Use. J Cardiovasc Pharmacol 2020; 76:4-22. [PMID: 32639325 PMCID: PMC7340234 DOI: 10.1097/fjc.0000000000000859] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022]
Abstract
Levosimendan was first approved for clinical use in 2000, when authorization was granted by Swedish regulatory authorities for the hemodynamic stabilization of patients with acutely decompensated chronic heart failure (HF). In the ensuing 20 years, this distinctive inodilator, which enhances cardiac contractility through calcium sensitization and promotes vasodilatation through the opening of adenosine triphosphate-dependent potassium channels on vascular smooth muscle cells, has been approved in more than 60 jurisdictions, including most of the countries of the European Union and Latin America. Areas of clinical application have expanded considerably and now include cardiogenic shock, takotsubo cardiomyopathy, advanced HF, right ventricular failure, pulmonary hypertension, cardiac surgery, critical care, and emergency medicine. Levosimendan is currently in active clinical evaluation in the United States. Levosimendan in IV formulation is being used as a research tool in the exploration of a wide range of cardiac and noncardiac disease states. A levosimendan oral form is at present under evaluation in the management of amyotrophic lateral sclerosis. To mark the 20 years since the advent of levosimendan in clinical use, 51 experts from 23 European countries (Austria, Belgium, Croatia, Cyprus, Czech Republic, Estonia, Finland, France, Germany, Greece, Hungary, Italy, the Netherlands, Norway, Poland, Portugal, Russia, Slovenia, Spain, Sweden, Switzerland, the United Kingdom, and Ukraine) contributed to this essay, which evaluates one of the relatively few drugs to have been successfully introduced into the acute HF arena in recent times and charts a possible development trajectory for the next 20 years.
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Affiliation(s)
- Zoltán Papp
- Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Piergiuseppe Agostoni
- Department of Clinical Sciences and Community Health, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Julian Alvarez
- Department of Surgery, School of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Dominique Bettex
- Institute of Anaesthesiology, University Hospital of Zurich, Zurich, Switzerland
| | - Stefan Bouchez
- Department of Anaesthesiology, University Hospital, Ghent, Belgium
| | - Dulce Brito
- Cardiology Department, Centro Hospitalar Universitario Lisboa Norte, CCUI, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Vladimir Černý
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, Usti nad Labem, Czech Republic
| | - Josep Comin-Colet
- Heart Diseases Institute, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Marisa G. Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), CIBERCV, Instituto de Investigacion Biomedica A Coruña (INIBIC), Universidad de a Coruña (UDC), La Coruña, Spain
| | - Juan F. Delgado
- Heart Failure and Transplant Program, Cardiology Department, University Hospital 12 Octubre, Madrid, Spain
| | - István Édes
- Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Alexander A. Eremenko
- Department of Cardiac Intensive Care, Petrovskii National Research Centre of Surgery, Sechenov University, Moscow, Russia
| | - Dimitrios Farmakis
- Department of Cardiology, Medical School, University of Cyprus, Nicosia, Cyprus
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, La Sapienza University of Rome, Rome, Italy
| | - Cândida Fonseca
- Heart Failure Clinic, São Francisco Xavier Hospital, CHLO, Lisbon, Portugal
| | - Sonja Fruhwald
- Department of Anaesthesiology and Intensive Care Medicine, Division of Anaesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Massimo Girardis
- Struttura Complessa di Anestesia 1, Policlinico di Modena, Modena, Italy
| | - Fabio Guarracino
- Dipartimento di Anestesia e Terapie Intensive, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Veli-Pekka Harjola
- Emergency Medicine, Meilahti Central University Hospital, University of Helsinki, Helsinki, Finland
| | - Matthias Heringlake
- Department of Anaesthesiology and Intensive Care Medicine, University of Lübeck, Lübeck, Germany
| | - Antoine Herpain
- Department of Intensive Care, Hôpital Erasme, Brussels, Belgium
| | - Leo M. A. Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Amsterdam, the Netherlands
| | - Tryggve Husebye
- Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway
| | - Višnja Ivancan
- Department of Anaesthesiology, Reanimatology and Intensive Care, University Hospital Centre, Zagreb, Croatia
| | - Kristjan Karason
- Departments of Cardiology and Transplantation, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sundeep Kaul
- Intensive Care Unit, National Health Service, Leeds, United Kingdom
| | - Matti Kivikko
- Global Medical Affairs, R&D, Orion Pharma, Espoo, Finland
| | - Janek Kubica
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Torun, Poland
| | - Josep Masip
- Intensive Care Department, Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain
| | | | - Alexandre Mebazaa
- Department of Anaesthesiology and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, Paris, France
| | | | - Fabrizio Oliva
- Department of Cardiology, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Julius G. Papp
- MTA-SZTE Research Group of Cardiovascular Pharmacology, Hungarian Academy of Sciences, University of Szeged, Szeged, Hungary
| | - John Parissis
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexander Parkhomenko
- Emergency Cardiology Department, National Scientific Centre MD Strazhesko Institute of Cardiology, Kiev, Ukraine
| | - Pentti Põder
- Department of Cardiology, North Estonia Medical Centre, Tallinn, Estonia
| | - Gerhard Pölzl
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alexander Reinecke
- Klinik für Innere Medizin III, Kardiologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Sven-Erik Ricksten
- Department of Anaesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hynek Riha
- Department of Anaesthesiology and Intensive Care Medicine, Cardiothoracic Anaesthesiology and Intensive Care, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Alain Rudiger
- Department of Medicine, Spittal Limmattal, Schlieren, Switzerland
| | | | - Robert H. G. Schwinger
- Medizinische Klinik II, Klinikum Weiden, Teaching Hospital of University of Regensburg, Weiden, Germany
| | - Wolfgang Toller
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Luigi Tritapepe
- Anaesthesia and Intensive Care Division, San Camillo-Forlanini Hospital, Rome, Italy
| | - Carsten Tschöpe
- Department of Cardiology, Campus Virchow Klinikum, Charité—University Medicine Berlin, Berlin, Germany
| | - Gerhard Wikström
- Institute of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Dirk von Lewinski
- Department of Cardiology, Myokardiale Energetik und Metabolismus Research Unit, Medical University of Graz, Graz, Austria
| | - Bojan Vrtovec
- Department of Cardiology, Advanced Heart Failure and Transplantation Centre, University Clinical Centre, Ljubljana, Slovenia
| | - Piero Pollesello
- Critical Care Proprietary Products, Orion Pharma, Espoo, Finland.
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27
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Fredholm M, Jörgensen K, Houltz E, Ricksten S. Levosimendan or milrinone for right ventricular inotropic treatment?-A secondary analysis of a randomized trial. Acta Anaesthesiol Scand 2020; 64:193-201. [PMID: 31556095 DOI: 10.1111/aas.13486] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/18/2019] [Accepted: 09/18/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND The aim of the present study was to compare the effects of milrinone and levosimendan on right ventricular (RV) inotropy and lusitropy in patients after aortic valve replacement (AVR) for aortic stenosis, a procedure in which an abnormal postoperative RV function may be seen. METHODS In a prospective, blinded trial, 31 patients were randomized to receive either milrinone (0.4 and 0.8 µg/kg/min, n = 16) or levosimendan (0.1 and 0.2 µg/kg/min, n = 15) after AVR for aortic stenosis. RV performance, afterload (pulmonary arterial elastance), RV strain, systolic (SR-S) and early diastolic (SR-E) strain rate were measured by pulmonary artery thermodilution catheterization and transoesophageal two-dimensional speckle tracking echocardiography. To circumvent the indirect effects of inodilator-induced hemodynamic changes on RV systolic and diastolic deformation, pulmonary arterial elastance, central venous pressure and heart rate were maintained constant by atrial pacing, plasma volume expansion with colloids and phenylephrine-induced vasoconstriction during treatment with the inotropes. RESULTS A dose-dependent increase in stroke volume index and cardiac index by approximately 20% were seen with both agents at the highest doses, with no difference between groups (P = .792 and 0.744, respectively). In both groups, RV strain and SR-S dose-dependently increased by 20% and 15%-19%, respectively, at the highest doses (P = .742 and 0.259, respectively) with no difference between groups. SR-E improved by both agents 20%-24% at the highest dose with no difference between groups (P = .714). CONCLUSIONS The direct RV inotropic and lusitropic effects of levosimendan and milrinone were comparable at clinically relevant infusion rates.
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Affiliation(s)
- Martin Fredholm
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy University of Gothenburg Sahlgrenska University Hospital Gothenburg Sweden
| | - Kirsten Jörgensen
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy University of Gothenburg Sahlgrenska University Hospital Gothenburg Sweden
| | - Erik Houltz
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy University of Gothenburg Sahlgrenska University Hospital Gothenburg Sweden
| | - Sven‐Erik Ricksten
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy University of Gothenburg Sahlgrenska University Hospital Gothenburg Sweden
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Abstract
Levosimendan is an inodilator that promotes cardiac contractility primarily through calcium sensitization of cardiac troponin C and vasodilatation via opening of adenosine triphosphate–sensitive potassium (KATP) channels in vascular smooth muscle cells; the drug also exerts organ-protective effects through a similar effect on mitochondrial KATP channels. This pharmacological profile identifies levosimendan as a drug that may have applications in a wide range of critical illness situations encountered in intensive care unit medicine: hemodynamic support in cardiogenic or septic shock; weaning from mechanical ventilation or from extracorporeal membrane oxygenation; and in the context of cardiorenal syndrome. This review, authored by experts from 9 European countries (Austria, Belgium, Czech republic, Finland, France, Germany, Italy, Sweden, and Switzerland), examines the clinical and experimental data for levosimendan in these situations and concludes that, in most instances, the evidence is encouraging, which is not the case with other cardioactive and vasoactive drugs routinely used in the intensive care unit. The size of the available studies is, however, limited and the data are in need of verification in larger controlled trials. Some proposals are offered for the aims and designs of these additional studies.
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Li H, Duan Y, Chen B, Zhao Y, Su W, Wang S, Wu J, Lu L. New pharmacological treatments for heart failure with reduced ejection fraction (HFrEF): A Bayesian network meta-analysis. Medicine (Baltimore) 2020; 99:e18341. [PMID: 32000355 PMCID: PMC7004768 DOI: 10.1097/md.0000000000018341] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Heart failure with reduced ejection fraction (HFrEF) has contributed to an increasing number of deaths and readmissions over the past few decades. Despite the appearance of standard treatments, including diuretics, β-receptor blockers and angiotensin-converting enzyme inhibitor (ACEI), there are still a large number of patients who have progressive deterioration of heart function and, inevitably, end-stage heart failure. In recent years, new medications for treating chronic heart failure have been clinically applied, but there is controversy surrounding drug selection and whether patients with HFrEF benefit from these medications. Therefore, we aimed to compare and rank different new pharmacological treatments in patients with HFrEF. METHODS We performed a network meta-analysis to identify both direct and indirect evidence from relevant studies. We searched MEDLINE, EMBASE, and PsycINFO through the OVID database and CENTRAL through the Cochrane Library for clinical randomized controlled trials investigating new pharmacological treatments in patients with HFrEF published up to September 30, 2018. We included trials of ivabradine, levosimendan, omega-3, tolvaptan, recombinant human B-type natriuretic peptide (rhBNP), isosorbide dinitrate and hydralazine (ISDN/HYD) and angiotensin-neprilysin inhibition (LCZ696). We extracted the relevant information from these trials with a predefined data extraction sheet and assessed the risk of bias with the Cochrane risk of bias tool. Based on these items, more than half of the entries were judged as having an overall low to moderate risk of bias; the remaining studies had a high or unclear risk of bias. The outcomes investigated were left ventricle ejection fraction (LVEF %), heart rate (HR) and serum level of B-type natriuretic peptide (BNP). We performed a random-effects network meta-analysis within a Bayesian framework. RESULTS We deemed 32 trials to be eligible that included 3810 patients and 32 treatments. Overall, 32 (94.1%) trials had a low to moderate risk of bias, while 2 (5.9%) trials had a high risk of bias. The quality of the included studies was rated as low in regard to allocation concealment and blinding and high in regard to other domains according to the Cochrane tools. As for increasing LVEF%, levosimendan was better than placebo (-3.77 (-4.96, -2.43)) and was the best intervention for improving ventricle contraction. As for controlling HR, n3-PUFA was better than placebo (4.01 (-0.44, 8.48)) and was the best choice for regulating HR. As for decreasing BNP, omega-3 was better than placebo (941.99 (-47.48, 1952.89) and was the best therapy for improving ventricle wall tension. CONCLUSIONS Our study confirmed the effectiveness of the included new pharmacological treatments for optimizing the structural performance and improving the cardiac function in the management of patients with HFrEF and recommended several interventions for clinical practice.
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Affiliation(s)
- Heng Li
- Cardiology Department of Tung Wah, Affiliated Hospital of Sun-Yat-Sen University
| | - Yuting Duan
- Clinical Research Center, South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine
| | - Benfa Chen
- Cardiology Department of Tung Wah, Affiliated Hospital of Sun-Yat-Sen University
| | - Yu Zhao
- Cardiology Department of Tung Wah, Affiliated Hospital of Sun-Yat-Sen University
| | - Weiping Su
- Cardiology Department of Tung Wah, Affiliated Hospital of Sun-Yat-Sen University
| | - Shanhua Wang
- Cardiology Department of Tung Wah, Affiliated Hospital of Sun-Yat-Sen University
| | - Jiaming Wu
- Zhongshan Affiliated Hospital, Guangzhou University of Chinese Medicine, China
| | - Liming Lu
- Clinical Research Center, South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine
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Cholley B, Levy B, Fellahi JL, Longrois D, Amour J, Ouattara A, Mebazaa A. Levosimendan in the light of the results of the recent randomized controlled trials: an expert opinion paper. Crit Care 2019; 23:385. [PMID: 31783891 PMCID: PMC6883606 DOI: 10.1186/s13054-019-2674-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 11/14/2019] [Indexed: 12/28/2022] Open
Abstract
Despite interesting and unique pharmacological properties, levosimendan has not proven a clear superiority to placebo in the patient populations that have been enrolled in the various recent multicenter randomized controlled trials. However, the pharmacodynamic effects of levosimendan are still considered potentially very useful in a number of specific situations.Patients with decompensated heart failure requiring inotropic support and receiving beta-blockers represent the most widely accepted indication. Repeated infusions of levosimendan are increasingly used to facilitate weaning from dobutamine and avoid prolonged hospitalizations in patients with end-stage heart failure, awaiting heart transplantation or left ventricular assist device implantation. New trials are under way to confirm or refute the potential usefulness of levosimendan to facilitate weaning from veno-arterial ECMO, to treat cardiogenic shock due to left or right ventricular failure because the current evidence is mostly retrospective and requires confirmation with better-designed studies. Takotsubo syndrome may represent an ideal target for this non-adrenergic inotrope, but this statement also relies on expert opinion. There is no benefit from levosimendan in patients with septic shock. The two large trials evaluating the prophylactic administration of levosimendan (pharmacological preconditioning) in cardiac surgical patients with poor left ventricular ejection fraction could not show a significant reduction in their composite endpoints reflecting low cardiac output syndrome with respect to placebo. However, the subgroup of those who underwent isolated CABG appeared to have a reduction in mortality. A new study will be required to confirm this exploratory finding.Levosimendan remains a potentially useful inodilator agent in a number of specific situations due to its unique pharmacological properties. More studies are needed to provide a higher level of proof regarding these indications.
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Affiliation(s)
- Bernard Cholley
- Department of Anesthesiology and Critical Care MedicineP, Hôpital Européen Georges Pompidou, AP-HP, 20 rue Leblanc, 75015, Paris, France.
- Université Paris Descartes - Université de Paris, Paris, France.
- INSERM UMR_S1140, Paris, France.
| | - Bruno Levy
- CHRU Nancy, Réanimation Médicale Brabois, Vandoeuvre-les Nancy, France
| | - Jean-Luc Fellahi
- Department of Anesthesiology and Critical Care, Hôpital Cardiologique Louis Pradel, Lyon, France
- INSERM U1060, University Claude Bernard, Lyon, France
| | - Dan Longrois
- Department of Anesthesiology and Critical Care, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Julien Amour
- Department of Anesthesiology and Critical Care Medicine, Hôpital de La Pitié Salpêtrière, AP-HP, Paris, France
- University Pierre & Marie Curie, Paris, France
| | - Alexandre Ouattara
- Department of Anesthesiology and Critical Care, Magellan Medico-Surgical Center, Bordeaux, France
- University of Bordeaux, Bordeaux, France
- INSERM, UMR 1034, Biology of Cardiovascular Diseases, Bordeaux, France
| | - Alexandre Mebazaa
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- Department of Anesthesia, Burn and Critical Care, Hôpitaux Universitaires Saint Louis Lariboisière, AP-HP, Paris, France
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31
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Hepburn-Brown M, Darvall J, Hammerschlag G. Acute pulmonary embolism: a concise review of diagnosis and management. Intern Med J 2019; 49:15-27. [PMID: 30324770 DOI: 10.1111/imj.14145] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 09/27/2018] [Accepted: 10/01/2018] [Indexed: 12/14/2022]
Abstract
An acute pulmonary embolism (aPE) is characterised by occlusion of one or more pulmonary arteries. Physiological disturbance may be minimal, but often cardiac output decreases as the right ventricle attempts to overcome increased afterload. Additionally, ventilation-perfusion mismatches can develop in affected vascular beds, reducing systemic oxygenation. Incidence is reported at 50-75 per 100 000 in Australia and New Zealand, with 30-day mortality rates ranging from 0.5% to over 20%. Incidence is likely to increase with the ageing population, increased survival of patients with comorbidities that are considered risk factors and improving sensitivity of imaging techniques. Use of clinical prediction scores, such as the Wells score, has assisted in clinical decision-making and decreased unnecessary radiological investigations. However, imaging (i.e. computed tomography pulmonary angiography or ventilation-perfusion scans) is still necessary for objective diagnosis. Anti-coagulation remains the foundation of PE management. Haemodynamically unstable patients require thrombolysis unless absolutely contraindicated, while stable patients with right ventricular dysfunction or ischaemia should be aggressively anti-coagulated. Stable patients with no right ventricular dysfunction can be discharged home early with anti-coagulation and review. However, treatment should be case dependent with full consideration of the patient's clinical state. Direct oral anti-coagulants have become an alternative to vitamin K antagonists and are facilitating shorter hospital admissions. Additionally, duration of anti-coagulation must be decided by considering any provoking factors, bleeding risk and comorbid state. Patients with truly unprovoked or idiopathic PE often require indefinite treatment, while in provoked cases it is typically 3 months with some patients requiring longer periods of 6-12 months.
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Affiliation(s)
- Morgan Hepburn-Brown
- Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Jai Darvall
- Department of Intensive Care and Anaesthesia/Pain Management, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Gary Hammerschlag
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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32
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Levosimendan: What Have We Learned So Far? CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00346-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Cameli M, Incampo E, Navarri R, Mandoli GE, Sciaccaluga C, Righini FM, Palmerini E, Sisti N, Mondillo S, Lunghetti S. Effects of levosimendan in heart failure: The role of echocardiography. Echocardiography 2019; 36:1566-1572. [DOI: 10.1111/echo.14419] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/01/2019] [Accepted: 06/06/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
- Matteo Cameli
- Department of Cardiovascular Diseases University of Siena Siena Italy
| | - Eufemia Incampo
- Department of Cardiovascular Diseases University of Siena Siena Italy
| | - Romina Navarri
- Department of Cardiovascular Diseases University of Siena Siena Italy
| | | | | | | | | | - Nicolò Sisti
- Department of Cardiovascular Diseases University of Siena Siena Italy
| | - Sergio Mondillo
- Department of Cardiovascular Diseases University of Siena Siena Italy
| | - Stefano Lunghetti
- Department of Cardiovascular Diseases University of Siena Siena Italy
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Chizinga M, Fares WH. Chronic Right Heart Failure: Expanding Prevalence and Challenges in Outpatient Management. Heart Fail Clin 2018; 14:413-423. [PMID: 29966638 DOI: 10.1016/j.hfc.2018.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Right heart failure is caused by right heart dysfunction resulting in suboptimal stroke volume to supply the pulmonary circulation. Therapeutic developments mean that patients with acute right heart failure survive to hospital discharge and live with chronic right heart failure. Chronic right heart failure management aims to reduce afterload, optimize preload, and support contractility, with the best evidence available in vascular targeted therapy for pulmonary arterial hypertension. However, the management of chronic right heart failure relies on adapting therapies for left ventricular heart failure to the right. We review right heart failure management in the ambulatory setting and its challenges.
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Affiliation(s)
- Mwelwa Chizinga
- Department of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Wassim H Fares
- Department of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, CT, USA.
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35
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Kırış T, Avcı E. Short-term effects of levosimendan on strain/strain rate markers in patients with nonischemic dilated cardiomyopathy. JOURNAL OF CLINICAL ULTRASOUND : JCU 2018; 46:527-532. [PMID: 30229927 DOI: 10.1002/jcu.22627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 05/05/2018] [Accepted: 06/21/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To investigate whether repetitive measurements of speckle tracking echocardiography (STE)-derived strain (S) and strain rate (SR) could reveal changes in left ventricular function in patients with nonischemic dilated cardiomyopathy treated with levosimendan. METHODS We included 22 consecutive patients (age 53 ±12 years) with an ejection fraction (EF) below 35% and New York Heart Association (NYHA) class III-IV symptoms that required intravenous inotropic support despite optimal medical therapy. The absence of any occlusive coronary artery disease was identified via previous coronary angiography in all patients. Echocardiographic variables, including strain/strain rate, and NYHA functional class, were evaluated before and after levosimendan infusion at the 72nd hour and one month. RESULTS The strain and strain rate values for both left and right ventricles were observed to be increased NYHA functional class and left ventricular EF (P <.05). CONCLUSION STE can successfully completed conventional echocardiography in the evaluation of patients with decompensated heart failure who were treated with levosimendan.
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Affiliation(s)
- Tuncay Kırış
- Department of Cardiology, Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
| | - Eyüp Avcı
- Cardiology Department, Balikesir University Faculty of Medicine, Balikesir, Turkey
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36
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Abstract
Pulmonary hypertension is a multifactorial disease with a high morbidity and
mortality. Right ventricular function is the most important predictor of
morbidity and mortality in patients suffering from pulmonary hypertension, but
currently there are no approved treatments directly supporting the failing right
ventricle. Levosimendan is a calcium sensitizing agent with inotropic, pulmonary
vasodilatory, and cardioprotective properties. Given its pharmacodynamic
profile, levosimendan could be a potential novel agent for the treatment of
right ventricular failure caused by pulmonary hypertension. The aim of this
review is to provide an overview of the current knowledge on the effects of
levosimendan in pulmonary hypertension and right heart failure.
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Affiliation(s)
- Mona Sahlholdt Hansen
- Department of Cardiology, Institute of Clinical Medicine, Aarhus University Hospital, Denmark
| | - Asger Andersen
- Department of Cardiology, Institute of Clinical Medicine, Aarhus University Hospital, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Institute of Clinical Medicine, Aarhus University Hospital, Denmark
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Albulushi A, Giannopoulos A, Kafkas N, Dragasis S, Pavlides G, Chatzizisis YS. Acute right ventricular myocardial infarction. Expert Rev Cardiovasc Ther 2018; 16:455-464. [PMID: 29902098 DOI: 10.1080/14779072.2018.1489234] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Acute right ventricular myocardial infarction (RVMI) is observed in 30-50% of patients presenting with inferior wall myocardial infarction (MI) and, occasionally, with anterior wall MI. The clinical consequences vary from no hemodynamic compromise to severe hypotension and cardiogenic shock depending on the extent of RV ischemia. Areas covered: The pathophysiological mechanisms, diagnostic steps, and novel therapeutic approaches of acute RVMI are described. Expert commentary: Diagnosis of acute RVMI is based on physical examination, cardiac biomarkers, electrocardiography, and coronary angiography, whereas noninvasive imaging modalities (echocardiography, cardiac magnetic resonance imaging) play a complementary role. Early revascularization, percutaneous or pharmacological, represents key step in the management of RMVI. Maintenance of reasonable heart rate and atrioventricular synchrony is essential to sustain adequate cardiac output in these patients. When conventional treatment is not successful, mechanical circulatory support, including right ventricle assist devices, percutaneous cardiopulmonary support, and intra-aortic balloon pump, might be considered. The prognosis associated with RVMI is worse in the short term, compared to non-RVMI, but those patients who survive hospitalization have a relatively good long-term prognosis.
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Affiliation(s)
- Arif Albulushi
- a Cardiovascular Division , University of Nebraska Medical Center , Omaha , NE , USA
| | - Andreas Giannopoulos
- b Cardiac Imaging, Department of Nuclear Medicine , University Hospital Zurich , Zurich , Switzerland
| | - Nikolaos Kafkas
- c Cardiology Department , General Hospital KAT , Athens , Greece
| | | | - Gregory Pavlides
- a Cardiovascular Division , University of Nebraska Medical Center , Omaha , NE , USA
| | - Yiannis S Chatzizisis
- a Cardiovascular Division , University of Nebraska Medical Center , Omaha , NE , USA
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Foschi M, Di Mauro M, Tancredi F, Capparuccia C, Petroni R, Leonzio L, Romano S, Gallina S, Penco M, Cibelli M, Calafiore A. The Dark Side of the Moon: The Right Ventricle. J Cardiovasc Dev Dis 2017; 4:jcdd4040018. [PMID: 29367547 PMCID: PMC5753119 DOI: 10.3390/jcdd4040018] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/16/2017] [Accepted: 10/19/2017] [Indexed: 01/28/2023] Open
Abstract
The aim of this review article is to summarize current knowledge of the pathophysiology underlying right ventricular failure (RVF), focusing, in particular, on right ventricular assessment and prognosis. The right ventricle (RV) can tolerate volume overload well, but is not able to sustain pressure overload. Right ventricular hypertrophy (RVH), as a response to increased afterload, can be adaptive or maladaptive. The easiest and most common way to assess the RV is by two-dimensional (2D) trans-thoracic echocardiography measuring surrogate indexes, such as tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tissue Doppler velocity of the lateral aspect of the tricuspid valvular plane. However, both volumes and function are better estimated by 3D echocardiography and cardiac magnetic resonance (CMR). The prognostic role of the RV in heart failure (HF), pulmonary hypertension (PH), acute myocardial infarction (AMI), and cardiac surgery has been overlooked for many years. However, several recent studies have placed much greater importance on the RV in prognostic assessments. In conclusion, RV dimensions and function should be routinely assessed in cardiovascular disease, as RVF has a significant impact on disease prognosis. In the presence of RVF, different therapeutic approaches, either pharmacological or surgical, may be beneficial.
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Affiliation(s)
| | - Michele Di Mauro
- Chair of Cardiology, University of L'Aquila, 67100 L'Aquila, Italy.
| | - Fabrizio Tancredi
- Department of Heart Disease, SS Annunziata Hospital, 66100 Chieti, Italy.
| | - Carlo Capparuccia
- Department of Heart Disease, SS Annunziata Hospital, 66100 Chieti, Italy.
| | - Renata Petroni
- Chair of Cardiology, University of L'Aquila, 67100 L'Aquila, Italy.
| | - Luigi Leonzio
- Department of Heart Disease, SS Annunziata Hospital, 66100 Chieti, Italy.
| | - Silvio Romano
- Chair of Cardiology, University of L'Aquila, 67100 L'Aquila, Italy.
| | - Sabina Gallina
- Cardiology, University "Gabriele D'Annunzio"of Chieti-Pescara, 66100 Chieti, Italy.
| | - Maria Penco
- Chair of Cardiology, University of L'Aquila, 67100 L'Aquila, Italy.
| | - Mario Cibelli
- Department of Cardiothoracic Anaesthesia, University Hospitals Birmingham, Birmingham B15 2TH, UK.
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Giannini C, Petronio AS, Fiorelli F, Liga R, Spontoni P, De Carlo M, Marraccini E, Pieroni A, Guarracino F. Effects of levosimendan in patients with severe functional mitral regurgitation undergoing MitraClip implantation. J Cardiovasc Med (Hagerstown) 2017; 18:679-686. [DOI: 10.2459/jcm.0000000000000537] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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40
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Qiu J, Jia L, Hao Y, Huang S, Ma Y, Li X, Wang M, Mao Y. Efficacy and safety of levosimendan in patients with acute right heart failure: A meta-analysis. Life Sci 2017; 184:30-36. [PMID: 28689804 DOI: 10.1016/j.lfs.2017.07.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/22/2017] [Accepted: 07/01/2017] [Indexed: 01/13/2023]
Abstract
AIMS Right heart failure (RHF), which is caused by a variety of heart and lung diseases, has a high morbidity and mortality rate. Levosimendan is a cardiac inotropic drug and vasodilator. The effect of levosimendan on RHF remains unclear. We sought to evaluate the efficacy and safety of levosimendan in patients with acute RHF. MATERIALS AND METHODS We systematically searched PubMed, Cochrane Library, EMBASE, and ClinicalTrials.gov to identify studies reporting the efficacy and safety of levosimendan for the treatment of RHF. KEY FINDINGS Ten trials, including 359 participants from 6 RCTs and 4 self-controlled trials, were evaluated. In the 6 RCTs, we found that patients treated with levosimendan for 24h showed a significant increase in tricuspid annular plane systolic excursion [1.53; 95% CI (0.54, 2.53); P=0.002] and ejection fraction [3.59; 95% CI (1.21, 5.98); P=0.003] as well as a significant reduction in systolic pulmonary artery pressure [-6.15; 95% CI (-9.29, -3.02); P=0.0001] and pulmonary vascular resistance [-39.48; 95% CI (-65.59, -13.38); P=0.003], whereas changes in mean pulmonary pressure were nonsignificant. Adverse events did not significantly differ between the two groups. SIGNIFICANCE Our study shows that levosimendan exhibits short-term efficacy for treating RHF in patients with a variety of heart and lung diseases. Additional strict multicentre RCTs with long follow-up times and large sample sizes are required to further validate the efficacy and safety of this treatment.
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Affiliation(s)
- Jiayong Qiu
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Lei Jia
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Yingying Hao
- Department of Infectious Diseases, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Shenshen Huang
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Yaqing Ma
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Xiaofang Li
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Min Wang
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Yimin Mao
- Department of Respiratory Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China.
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Pölzl G, Altenberger J, Baholli L, Beltrán P, Borbély A, Comin-Colet J, Delgado JF, Fedele F, Fontana A, Fruhwald F, Giamouzis G, Giannakoulas G, Garcia-González MJ, Gustafsson F, Kaikkonen K, Kivikko M, Kubica J, von Lewinski D, Löfman I, Malfatto G, Manito N, Martínez-Sellés M, Masip J, Merkely B, Morandi F, Mølgaard H, Oliva F, Pantev E, Papp Z, Perna GP, Pfister R, Piazza V, Bover R, Rangel-Sousa D, Recio-Mayoral A, Reinecke A, Rieth A, Sarapohja T, Schmidt G, Seidel M, Störk S, Vrtovec B, Wikström G, Yerly P, Pollesello P. Repetitive use of levosimendan in advanced heart failure: need for stronger evidence in a field in dire need of a useful therapy. Int J Cardiol 2017; 243:389-395. [PMID: 28571618 DOI: 10.1016/j.ijcard.2017.05.081] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 05/15/2017] [Accepted: 05/20/2017] [Indexed: 10/19/2022]
Abstract
Patients in the latest stages of heart failure are severely compromised, with poor quality of life and frequent hospitalizations. Heart transplantation and left ventricular assist device implantation are viable options only for a minority, and intermittent or continuous infusions of positive inotropes may be needed as a bridge therapy or as a symptomatic approach. In these settings, levosimendan has potential advantages over conventional inotropes (catecholamines and phosphodiesterase inhibitors), such as sustained effects after initial infusion, synergy with beta-blockers, and no increase in oxygen consumption. Levosimendan has been suggested as a treatment that reduces re-hospitalization and improves quality of life. However, previous clinical studies of intermittent infusions of levosimendan were not powered to show statistical significance on key outcome parameters. A panel of 45 expert clinicians from 12 European countries met in Rome on November 24-25, 2016 to review the literature and envision an appropriately designed clinical trial addressing these needs. In the earlier FIGHT trial (daily subcutaneous injection of liraglutide in heart failure patients with reduced ejection fraction) a composite Global Rank Score was used as primary end-point where death, re-hospitalization, and change in N-terminal-prohormone-brain natriuretic peptide level were considered in a hierarchical order. In the present study, we tested the same end-point post hoc in the PERSIST and LEVOREP trials on oral and repeated i.v. levosimendan, respectively, and demonstrated superiority of levosimendan treatment vs placebo. The use of the same composite end-point in a properly powered study on repetitive levosimendan in advanced heart failure is strongly advocated.
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Affiliation(s)
| | | | | | | | - Attila Borbély
- Division of Clinical Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | | | | | | | | | | | - Gregory Giamouzis
- University of Thessaly, Larissa University Hospital, Larissa, Greece
| | | | | | | | | | | | - Jacek Kubica
- Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | - Ida Löfman
- Karolinska Univ Sjukhus Huddinge, Huddinge, Sweden
| | | | | | | | | | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | | | | | | | - Zoltán Papp
- Division of Clinical Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Gian Piero Perna
- Dipartimento di Scienze Cardiologiche Medico-Chirurgiche, Ospedali Riuniti, Ancona, Italy
| | - Roman Pfister
- Klinik III fuer Innere Medizin, Herzzentrum der Universität zu Köln, Germany
| | - Vito Piazza
- Azienda ospedaliera San Camillo-Forlanini, Rome, Italy
| | | | | | | | | | | | | | | | - Mirko Seidel
- Klinik für innere Medizin, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center, University and University Hospital, Würzburg, Germany
| | | | - Gerhard Wikström
- Institute of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Patrik Yerly
- Centre Hospitalier Universitaire Vaudois CHUV, Lausanne, Switzerland
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Fruhwald S, Pollesello P, Fruhwald F. Advanced heart failure: an appraisal of the potential of levosimendan in this end-stage scenario and some related ethical considerations. Expert Rev Cardiovasc Ther 2016; 14:1335-1347. [PMID: 27778514 DOI: 10.1080/14779072.2016.1247694] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The later stages of heart failure are characterized by a steady decline in quality of life. Clinical priorities should be to maintain functional capacity and quality of life. In the absence of sufficient organs for transplantation, options include left ventricular assist devices and inotropic support. Areas covered: We examined data published in the last two decades on the use of inotropes and inodilators in advanced heart failure. Expert commentary: In the literature, use of conventional inotropes, including adrenergic agonists and phosphodiesterase inhibitors, appears to be suboptimal for achieving the clinical priorities of late-stage heart failure. Evidence suggests instead that the calcium-sensitizing inodilator levosimendan, administered intermittently, delivers improvements in functional capacity and quality of life and does so with no adverse impact on life expectancy. At a terminal or near-terminal stage of heart failure, the therapeutic philosophy should shift towards meeting patients' existential priorities rather than traditional heart failure-centric targets.
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Affiliation(s)
- Sonja Fruhwald
- a Department of Anesthesiology and Intensive Care Medicine, Division of Anesthesiology for Cardiovascular Surgery and Intensive Care Medicine , Medical University of Graz , Graz , Austria
| | - Piero Pollesello
- b Critical Care Proprietary Products , Orion Pharma , Espoo , Finland
| | - Friedrich Fruhwald
- c Department of Internal Medicine, Division of Cardiology , Medical University of Graz , Graz , Austria
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Onody P, Aranyi P, Turoczi Z, Stangl R, Fulop A, Dudas E, Lotz G, Szijarto A. Levosimendan Administration in Limb Ischemia: Multicomponent Signaling Serving Kidney Protection. PLoS One 2016; 11:e0163675. [PMID: 27684548 PMCID: PMC5042425 DOI: 10.1371/journal.pone.0163675] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/11/2016] [Indexed: 11/19/2022] Open
Abstract
Aims and Objectives Acute renal failure is a severe complication of lower extremity major arterial reconstructions, which could even be fatal. Levosimendan is a dual-acting positive inotropic and vasodilatory agent, which is suspected to have protective effects against cardiac ischemia. However, there is no data available on lower limb or remote organ ischemic injuries therefore the aim of the study was to investigate the effect of levosimendan on lower limb ischemia-reperfusion injury and the corollary renal dysfunction. Methods Male Wistar rats underwent 180 min bilateral lower limb ischemia followed by 4 or 24 hours of reperfusion. Intravenous Levosimendan was administered continuously (0.2μg/bwkg/min) throughout the whole course of ischemia and the first 3h of reperfusion. Results were compared with sham-operated and ischemia-reperfusion groups. Hemodynamic monitoring was performed by invasive arterial blood pressure measurement. Kidney and lower limb muscle microcirculation was registered by a laser Doppler flowmeter. After 4h and 24h of reperfusion, serum, urine and histological samples were collected. Results Systemic hemodynamic parameters and microcirculation of kidney and the lower limb significantly improved in the Levosimendan treated group. Muscle viability was significantly preserved 4 and 24 hours after reperfusion. At the same time, renal functional laboratory tests and kidney histology demonstrated significantly less expressive kidney injury in Levosimendan groups. TNF-α levels were significantly less elevated in the Levosimendan group 4 hours after reperfusion. Conclusion The results claim a protective role for Levosimendan administration during major vascular surgeries to prevent renal complications.
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Affiliation(s)
- Peter Onody
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Peter Aranyi
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Zsolt Turoczi
- 2 Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Rita Stangl
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Andras Fulop
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Emese Dudas
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Gabor Lotz
- 2 Department of Pathology, Semmelweis University, Budapest, Hungary
| | - Attila Szijarto
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
- * E-mail:
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Guerrero-Orriach JL, Ariza-Villanueva D, Florez-Vela A, Garrido-Sánchez L, Moreno-Cortés MI, Galán-Ortega M, Ramírez-Fernández A, Alcaide Torres J, Fernandez CS, Navarro Arce I, Melero-Tejedor JM, Rubio-Navarro M, Cruz-Mañas J. Cardiac, renal, and neurological benefits of preoperative levosimendan administration in patients with right ventricular dysfunction and pulmonary hypertension undergoing cardiac surgery: evaluation with two biomarkers neutrophil gelatinase-associated lipocalin and neuronal enolase. Ther Clin Risk Manag 2016; 12:623-30. [PMID: 27143905 PMCID: PMC4844253 DOI: 10.2147/tcrm.s102772] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE To evaluate if the preoperative administration of levosimendan in patients with right ventricular (RV) dysfunction, pulmonary hypertension, and high perioperative risk would improve cardiac function and would also have a protective effect on renal and neurological functions, assessed using two biomarkers neutrophil gelatinase-associated lipocalin (N-GAL) and neuronal enolase. METHODS This is an observational study. Twenty-seven high-risk cardiac patients with RV dysfunction and pulmonary hypertension, scheduled for cardiac valve surgery, were prospectively followed after preoperative administration of levosimendan. Levosimendan was administered preoperatively on the day before surgery. All patients were considered high risk of cardiac and perioperative renal complications. Cardiac function was assessed by echocardiography, renal function by urinary N-GAL levels, and the acute kidney injury scale. Neuronal damage was assessed by neuron-specific enolase levels. RESULTS After surgery, no significant variations were found in mean and SE levels of N-GAL (14.31 [28.34] ng/mL vs 13.41 [38.24] ng/mL), neuron-specific enolase (5.40 [0.41] ng/mL vs 4.32 [0.61] ng/mL), or mean ± SD creatinine (1.06±0.24 mg/dL vs 1.25±0.37 mg/dL at 48 hours). RV dilatation decreased from 4.23±0.7 mm to 3.45±0.6 mm and pulmonary artery pressure from 58±18 mmHg to 42±19 mmHg at 48 hours. CONCLUSION Preoperative administration of levosimendan has shown a protective role against cardiac, renal, and neurological damage in patients with a high risk of multiple organ dysfunctions undergoing cardiac surgery.
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Affiliation(s)
| | - Daniel Ariza-Villanueva
- Department of Cardio-Anaesthesiology, University Hospital Virgen de la Victoria, Málaga, Spain
| | - Ana Florez-Vela
- Department of Cardio-Anaesthesiology, University Hospital Virgen de la Victoria, Málaga, Spain
| | - Lourdes Garrido-Sánchez
- CIBER Fisiología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Málaga, Spain
- Department of Nutrition and Endocrinology, Instituto de Investigaciones Biomédicas de Málaga (IBIMA), University Hospital Virgen de la Victoria, Málaga, Spain
| | | | - Manuel Galán-Ortega
- Department of Cardio-Anaesthesiology, University Hospital Virgen de la Victoria, Málaga, Spain
| | | | - Juan Alcaide Torres
- Department of Nutrition and Endocrinology, Instituto de Investigaciones Biomédicas de Málaga (IBIMA), University Hospital Virgen de la Victoria, Málaga, Spain
| | - Concepción Santiago Fernandez
- Department of Nutrition and Endocrinology, Instituto de Investigaciones Biomédicas de Málaga (IBIMA), University Hospital Virgen de la Victoria, Málaga, Spain
| | - Isabel Navarro Arce
- Department of Cardio-Anaesthesiology, University Hospital Virgen de la Victoria, Málaga, Spain
| | | | - Manuel Rubio-Navarro
- Department of Cardio-Anaesthesiology, University Hospital Virgen de la Victoria, Málaga, Spain
| | - José Cruz-Mañas
- Department of Cardio-Anaesthesiology, University Hospital Virgen de la Victoria, Málaga, Spain
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Tolppanen H, Logeart D. Nouveaux médicaments dans l’insuffisance cardiaque aiguë. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-015-1167-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Alvarez Escudero J, Calvo Vecino JM, Veiras S, García R, González A. Clinical Practice Guideline (CPG). Recommendations on strategy for reducing risk of heart failure patients requiring noncardiac surgery: reducing risk of heart failure patients in noncardiac surgery. ACTA ACUST UNITED AC 2015; 62:359-419. [PMID: 26164471 DOI: 10.1016/j.redar.2015.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/04/2015] [Indexed: 12/29/2022]
Affiliation(s)
- J Alvarez Escudero
- Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain
| | - J M Calvo Vecino
- Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain; Associated Professor and Head of the Department of Anesthesiology, Infanta Leonor University Hospital, Complutense University of Madrid, Madrid, Spain.
| | - S Veiras
- Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain
| | - R García
- Department of Anesthesiology, Puerta del Mar University Hospital. Cadiz, Spain
| | - A González
- Department of Anesthesiology, Puerta de Hierro University Hospital. Madrid, Spain
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Nieminen MS, Dickstein K, Fonseca C, Serrano JM, Parissis J, Fedele F, Wikström G, Agostoni P, Atar S, Baholli L, Brito D, Colet JC, Édes I, Gómez Mesa JE, Gorjup V, Garza EH, González Juanatey JR, Karanovic N, Karavidas A, Katsytadze I, Kivikko M, Matskeplishvili S, Merkely B, Morandi F, Novoa A, Oliva F, Ostadal P, Pereira-Barretto A, Pollesello P, Rudiger A, Schwinger RHG, Wieser M, Yavelov I, Zymliński R. The patient perspective: Quality of life in advanced heart failure with frequent hospitalisations. Int J Cardiol 2015; 191:256-64. [PMID: 25981363 DOI: 10.1016/j.ijcard.2015.04.235] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 04/30/2015] [Indexed: 12/27/2022]
Abstract
End of life is an unfortunate but inevitable phase of the heart failure patients' journey. It is often preceded by a stage in the progression of heart failure defined as advanced heart failure, and characterised by poor quality of life and frequent hospitalisations. In clinical practice, the efficacy of treatments for advanced heart failure is often assessed by parameters such as clinical status, haemodynamics, neurohormonal status, and echo/MRI indices. From the patients' perspective, however, quality-of-life-related parameters, such as functional capacity, exercise performance, psychological status, and frequency of re-hospitalisations, are more significant. The effects of therapies and interventions on these parameters are, however, underrepresented in clinical trials targeted to assess advanced heart failure treatment efficacy, and data are overall scarce. This is possibly due to a non-universal definition of the quality-of-life-related endpoints, and to the difficult standardisation of the data collection. These uncertainties also lead to difficulties in handling trade-off decisions between quality of life and survival by patients, families and healthcare providers. A panel of 34 experts in the field of cardiology and intensive cardiac care from 21 countries around the world convened for reviewing the existing data on quality-of-life in patients with advanced heart failure, discussing and reaching a consensus on the validity and significance of quality-of-life assessment methods. Gaps in routine care and research, which should be addressed, were identified. Finally, published data on the effects of current i.v. vasoactive therapies such as inotropes, inodilators, and vasodilators on quality-of-life in advanced heart failure patients were analysed.
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Affiliation(s)
| | | | - Cândida Fonseca
- S. Francisco Xavier Hospital, CHLO, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Portugal
| | - Jose Magaña Serrano
- División de Educación en Salud, UMAE Hospital de Cardiología Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico
| | - John Parissis
- Second University Cardiology Clinic, Attiko Teaching Hospital, Athens, Greece
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology and Geriatric Science, University of Rome, Italy
| | | | | | - Shaul Atar
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel
| | - Loant Baholli
- Department of Intensive Care, Klinikum Dortmund, Germany
| | - Dulce Brito
- Cardiology Department, Hospital Universitario de Santa Maria, Lisbon, Portugal
| | | | - István Édes
- Department of Cardiology, University of Debrecen, Hungary
| | | | - Vojka Gorjup
- Department of Intensive Internal Medicine, University Medical Center Ljubljana, Slovenia
| | - Eduardo Herrera Garza
- Heart Failure, Heart Transplant Department, Centro Médico Zambrano Hellion, Heart Failure Clinic Unidad Médica de Alta Especialidad, Hospital de Cardiología No. 34, IMSS Monterrey Nuevo León, Mexico
| | | | - Nenad Karanovic
- Clinical Department of Anaesthesiology and Intensive Care, University Hospital of Split, Croatia
| | - Apostolos Karavidas
- Heart Failure Clinic & Echo Lab, Gennimatas General Hospital of Athens, Greece
| | - Igor Katsytadze
- Cardiology Intensive Care Unit, O. Bogomolets National Medical University, Kiev, Ukraine
| | | | | | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Fabrizio Morandi
- Department of Cardiovascular Science, University of Insubria, Circolo Hospital and Macchi Foundation, Varese, Italy
| | | | - Fabrizio Oliva
- Department of Cardiology, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Petr Ostadal
- Department of Cardiology, Cardiovascular Center, Na Homolce Hospital, Prague, Czech Republic
| | | | | | - Alain Rudiger
- Institute of Anaesthesiology, University Hospital Zurich, Switzerland
| | - Robert H G Schwinger
- Department of Internal Medicine, Kliniken Nordoberpfalz, Weiden, Germany; Teaching Hospital of the University of Regensburg, Germany
| | - Manfred Wieser
- Department of Internal Medicine 1, University Hospital Krems, Karl Landsteiner University of Health Sciences, Austria
| | - Igor Yavelov
- Scientific Research Institute of Physico-Chemical Medicine of the Federal Medico-Biological Agency of the Russian Federation, Moscow, Russia
| | - Robert Zymliński
- Department of Cardiology, Cardiology Intensive Care Unit, The 4th Military Hospital, Wroclaw, Poland
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Palmerini E, Söderberg S, Mondillo S, Favilli R, Lunghetti S. Effects of levosimendan on heart failure in normotensive patients: does loading dose matter? ACUTE CARDIAC CARE 2015; 17:14-9. [PMID: 25806830 DOI: 10.3109/17482941.2015.1005102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Levosimendan is a calcium sensitizer and K(+)-ATP channel opener with inotropic and vasodilatatory effects irrespective of myocardial oxygen consumption, used for treatment of heart failure (HF). A loading dose is usually given by infusion for 12 h; however, profound lowering of blood pressure often disrupts or prolongs the infusion. The aim of this study was to assess clinical, biochemical and myocardial differences between different regimes of levosimendan therapy, with or without loading dose, and compared to standard therapy in heart failure. METHODS Fifty-seven patients (mean age ± SD: 60.9 ± 9.3 years, 45 males) with HF, New York Heart Association (NYHA) III-IV, reduced left ventricular ejection fraction (LVEF) were included. Twenty patients (NB group) were given levosimendan without loading dose, 14 patients (B group) were given levosimendan with loading dose, and 23 patients (C group) were given standard therapy. Clinical, biochemical and echocardiographic characteristics at baseline and one week after treatment were evaluated. RESULTS Groups were similar at baseline. After one week NHYA class (P < 0.001), NT pro-BNP (P < 0.001), LVEF (P = 0.045), E/A (P = 0.048) E/e' (P < 0.001), and PAPs (P < 0.001) decreased. DT (P = 0.011) and TAPSE (P = 0.035) increased in all groups. CONCLUSIONS Levosimendan, as well as standard therapy, improves myocardial function and symptoms of HF, irrespective of the loading dose administration. Treatment options for patients with end-stage heart failure refractory to conventional medical therapy are limited. Inotropic drugs play an important role in heart failure (HF).
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Affiliation(s)
- Elisabetta Palmerini
- Department of Cardiovascular Diseases, Siena University Hospital , Siena , Italy
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Abstract
Right ventricular (RV) failure occurs when the RV fails to maintain enough blood flow through the pulmonary circulation to achieve adequate left ventricular filling. This can occur suddenly in a previously healthy heart due to massive pulmonary embolism or right-sided myocardial infarction, but many cases encountered in the intensive care unit involve worsening of compensated RV failure in the setting of chronic heart and lung disease. Management of RV failure is directed at optimizing right-sided filling pressures and reducing afterload. Due to a lower level of vascular tone, vasoactive medications have less salient effects on reducing vascular resistance in the pulmonary than in the systemic circulation. Successful management requires reversal of any conditions that heighten pulmonary vascular tone and the use of selective pulmonary vasodilators at doses that do not induce systemic hypotension or worsening of oxygenation. Systemic systolic arterial pressure should be kept close to RV systolic pressure to maintain RV perfusion. When these efforts fail, the judicious use of inotropic agents may help improve RV contractility enough to maintain cardiac output. Extracorporeal life support is increasingly being used to support patients with acute RV failure who fail to respond to medical management while the underlying cause of their RV failure is addressed.
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Malfatto G, Della Rosa F, Rella V, Villani A, Branzi G, Blengino S, Giglio A, Facchini M, Parati G. Prognostic value of noninvasive hemodynamic evaluation of the acute effect of levosimendan in advanced heart failure. J Cardiovasc Med (Hagerstown) 2014; 15:322-30. [PMID: 24699010 DOI: 10.2459/01.jcm.0000435614.40439.21] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIMS Optimization of inotropic treatment in worsening heart failure sometimes requires invasive hemodynamic assessment in selected patients. Impedance cardiography (ICG) may be useful for a noninvasive hemodynamic evaluation. METHODS ICG was performed in 40 patients (69 ± 8 years; left ventricular ejection fraction 27.5 ± 5.6%; New York Heart Association 3.18 ± 0.34; Interagency Registry for Mechanically Assisted Circulatory Support 5.48 ± 0.96, before and after infusion of Levosimendan (0.1–0.2 µg/kg per min for up to 24 h). Echocardiogram, ICG [measuring cardiac index (CI), total peripheral resistances (TPRs) and thoracic fluid content (TFC)] and plasma levels of brain natriuretic peptide (BNP) were obtained; in nine patients, right heart catheterization was also carried out. RESULTS When right catheterization and ICG were performed simultaneously, a significant relationship was observed between values of CI and TPR, and between TFC and pulmonary wedge pressure. ICG detected the Levosimendan-induced recovery of the hemodynamic status, associated with improved systolic and diastolic function and reduction in BNP levels. One-year mortality was 4.4%. At multivariate analysis, independent predictors of mortality were: no improvement in the severity of mitral regurgitation, a persistent restrictive filling pattern (E/E’ > 15), a reduction of BNP levels below 30% and a change below 10% in CI, TPR and TFC. When combined, absence of hemodynamic improvement at ICG could predict 1-year mortality with better sensitivity (86%) and specificity (85%) than the combination of echocardiographic and BNP criteria only (sensitivity 80% and specificity 36%). CONCLUSION Noninvasive hemodynamic evaluation of heart failure patients during infusion of inodilator drugs is reliable and may help in their prognostic stratification.
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