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Masarone D, Kittleson MM, Pollesello P, Marini M, Iacoviello M, Oliva F, Caiazzo A, Petraio A, Pacileo G. Use of Levosimendan in Patients with Advanced Heart Failure: An Update. J Clin Med 2022; 11:jcm11216408. [PMID: 36362634 PMCID: PMC9659135 DOI: 10.3390/jcm11216408] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/04/2022] [Accepted: 10/26/2022] [Indexed: 11/25/2022] Open
Abstract
Levosimendan is an inodilator drug that, given its unique pharmacological actions and safety profile, represents a viable therapeutic option in patients with heart failure with reduced ejection fraction in the advanced stage of the disease (advHFrEF). Pulsed levosimendan infusion in patients with advHFrEF improves symptoms and clinical and hemodynamic status, prevents recurrent hospitalizations, and enables optimization of guidelines-directed medical therapy. Furthermore, considering its proprieties on right ventricular function and pulmonary circulation, levosimendan could be helpful for the prevention and treatment of the right ventricular dysfunction post-implanting a left ventricular assist device. However, to date, evidence on this issue is scarce and has yielded mixed results. Finally, preliminary experiences indicate that treatment with levosimendan at scheduled intervals may serve as a “bridge to transplant” strategy in patients with advHFrEF. In this review, we summarized the clinical pharmacology of levosimendan, the available evidence in the treatment of patients with advHFrEF, as well as a hypothesis for its use in patients with advanced heart failure with preserved ejection fraction.
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, 80131 Naples, Italy
- Correspondence: ; Tel.: +39-0817065163; Fax: +39-0817062674
| | - Michelle M. Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA 90048, USA
| | | | - Marco Marini
- Cardiology Division, Cardiovascular Department, Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona Umberto I-GM Lancisi-G Salesi, 60126 Ancona, Italy
| | - Massimo Iacoviello
- Intensive Cardiac Care Unit, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Fabrizio Oliva
- Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy
| | - Angelo Caiazzo
- Heart Transplant Unit, Department of Cardiac Surgery and Transplant, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Andrea Petraio
- Heart Transplant Unit, Department of Cardiac Surgery and Transplant, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, 80131 Naples, Italy
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Demirgan S, Akyol O, Temel Z, Şengelen A, Pekmez M, Ulaş O, Sevdi MS, Erkalp K, Selcan A. Intranasal levosimendan prevents cognitive dysfunction and apoptotic response induced by repeated isoflurane exposure in newborn rats. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2021; 394:1553-1567. [PMID: 33772342 DOI: 10.1007/s00210-021-02077-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 03/03/2021] [Indexed: 12/25/2022]
Abstract
Anesthetic-induced toxicity in early life may lead to risk of cognitive decline at later ages. Notably, multiple exposures to isoflurane (ISO) cause acute apoptotic cell death in the developing brain and long-term cognitive dysfunction. This study is the first to investigate whether levosimendan (LVS), known for its protective myocardial properties, can prevent anesthesia-induced apoptotic response in brain cells and learning and memory impairment. Postnatal day (P)7 Wistar albino pups were randomly assigned to groups consisting of an equal number of males and females in this laboratory investigation. We treated rats with LVS (0.8 mg/kg/day) intranasally 30 min before each ISO exposure (1.5%, 3 h) at P7+9+11. We selected DMSO as the drug vehicle. Also, the control group at P7+9+11 received 50% O2 for 3 h instead of ISO. Neuroprotective activity of LVS against ISO-induced cognitive dysfunction was evaluated by Morris water maze. Expression of apoptotic-related proteins was detected in the whole brain using western blot. LVS pretreatment significantly prevented anesthesia-induced deficit in spatial learning (at P28-32) and memory (at P33, P60, and P90). No sex-dependent difference occurred on any day of the training and probe trial. Intranasal LVS was also found to significantly prevent the ISO-induced apoptosis by reducing Bax and cleaved caspase-3, and by increasing Bcl-2 and Bcl-xL. Our findings support pretreatment with intranasal LVS application as a simple strategy in daily clinical practice in pediatric anesthesia to protect infants and children from the risk of general anesthesia-induced cell death and cognitive declines.
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Affiliation(s)
- Serdar Demirgan
- T.C. Health Ministry, Anesthesiology and Reanimation Clinic, University of Health Sciences, Bağcılar Training and Research Hospital, Istanbul, Turkey
- Department of Molecular Biology and Genetics, Institute of Graduate Studies in Sciences, Istanbul University, 34134, Vezneciler-Fatih/Istanbul, Turkey
| | - Onat Akyol
- T.C. Health Ministry, Anesthesiology and Reanimation Clinic, University of Health Sciences, Bağcılar Training and Research Hospital, Istanbul, Turkey
| | - Zeynep Temel
- Department of Neuroscience Institute of Health Sciences, Istanbul Medipol University, Istanbul, Turkey
| | - Aslıhan Şengelen
- Department of Molecular Biology and Genetics, Institute of Graduate Studies in Sciences, Istanbul University, 34134, Vezneciler-Fatih/Istanbul, Turkey.
| | - Murat Pekmez
- Department of Molecular Biology and Genetics, Faculty of Science, Istanbul University, Istanbul, Turkey
| | - Ozancan Ulaş
- Department of Molecular Biology and Genetics, Institute of Graduate Studies in Sciences, Istanbul University, 34134, Vezneciler-Fatih/Istanbul, Turkey
| | - Mehmet Salih Sevdi
- T.C. Health Ministry, Anesthesiology and Reanimation Clinic, University of Health Sciences, Bağcılar Training and Research Hospital, Istanbul, Turkey
| | - Kerem Erkalp
- T.C. Health Ministry, Anesthesiology and Reanimation Clinic, University of Health Sciences, Bağcılar Training and Research Hospital, Istanbul, Turkey
| | - Ayşin Selcan
- T.C. Health Ministry, Anesthesiology and Reanimation Clinic, University of Health Sciences, Bağcılar Training and Research Hospital, Istanbul, Turkey
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Jothinath K, Balakrishnan S, Raju V, Menon S, Osborn J. Clinical efficacy of levosimendan vs milrinone in preventing low cardiac output syndrome following pediatric cardiac surgery. Ann Card Anaesth 2021; 24:217-223. [PMID: 33884979 PMCID: PMC8253017 DOI: 10.4103/aca.aca_160_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Prophylactic milrinone is commonly used to prevent Low Cardiac Output Syndrome (LCOS) after pediatric cardiac surgery. This study compares the use of levosimendan with milrinone when used as the primary inotrope following pediatric cardiac surgery. Subjects and Methods: Forty infants undergoing corrective surgery for congenital heart disease were recruited during the study and randomized into two groups (group L and group M). During rewarming, a loading dose of levosimendan or milrinone was administered followed by a 24-hour infusion of the chosen inotrope. Echocardiographic variables were measured postoperatively. Statistical analysis was done with SPSS-20 computer package. Association between the variables was found by independent t test. P < 0.05 was considered statistically significant. Results: Mean age and weight of the patient in Group L was 8.55 ± 5.83 months and 6.05 ± 2.09 kgs, while that in group M was 6.85 ± 3.57 months and 5.26 ± 2.11 kgs. 4 patients (20%) treated with levosimendan had LCOS in comparison with 6 (30%) patients in those treated with milrinone. Echocardiographic parameters in both groups L and M were comparable (cardiac index 3.47 ± 0.76 vs 3.72 ± 1.05 L/min/m2, EF 66.10 ± 7.82% vs 59.34 ± 10.74%, stroke volume index 25.4 ± 6.3 vs 27.74 ± 10.35 mL/m2). The duration of ventilation, ICU stay and hospital stay were lesser in group L (12.75 ± 9.69, 35.95 ± 12.11, 119.10 ± 46.397 vs 23.60 ± 22.03, 51.20 ± 29.92, 140.20 ± 52.65 hours). Conclusions: The incidence of LCOS was lesser in those patients treated with levosimendan, when compared with those treated with milrinone. Cardiac index and stroke volume index were comparable between the two groups. Thus, levosimendan provides a non-inferior alternative to milrinone when used as the primary inotrope following pediatric cardiac surgery.
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Affiliation(s)
- Kaushik Jothinath
- Department of Cardiac Anesthesiology, G Kuppuswamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
| | - Soundaravalli Balakrishnan
- Department of Cardiac Anesthesiology, G Kuppuswamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
| | - Vijayakumar Raju
- Department of Cardiac Surgery, G Kuppuswamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
| | - Shoba Menon
- Department of Cardiac Surgery, G Kuppuswamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
| | - Jenit Osborn
- Department of Community Medicine, PSG Institute of Medical Science and Research, Coimbatore, Tamil Nadu, India
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Wang H, Luo Q, Li Y, Zhang L, Wu X, Yan F. Effect of Prophylactic Levosimendan on All-Cause Mortality in Pediatric Patients Undergoing Cardiac Surgery-An Updated Systematic Review and Meta-Analysis. Front Pediatr 2020; 8:456. [PMID: 32923414 PMCID: PMC7456871 DOI: 10.3389/fped.2020.00456] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/30/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Levosimendan, a calcium sensitizer, enhances the myocardial function by generating more energy-efficient myocardial contractility than that achieved through adrenergic stimulation with catecholamines. We conducted this meta-analysis to primarily investigate the effects of levosimendan on all-cause mortality in pediatric patients undergoing cardiac surgery under cardiopulmonary bypass. Methods: The databases of Pubmed, Embase, and Cochrane Library were searched till 21st March 2020. The eligible criteria were participants with age<18 year and undergoing cardiac surgery for congenital heart disease (CHD), and studies of comparison between levosimendan and placebo or other inotropes. Stata version 12.0 was used to perform statistical analyses. Results: Six randomized controlled trials (RCTs) and 1 case-control trial (CCT) including 436 patients were included. The results showed that levosimendan did not significantly decrease all-cause mortality compared with control drugs (and placebo) in children undergoing cardiac surgery (P = 0.403). Perioperative prophylactic levosimendan administration strikingly decreased the low cardiac output syndrome (LCOS) incidence (P = 0.016) but did not significantly reduce acute kidney injury (AKI) incidence (P = 0.251) and shorten mechanical ventilation and ICU stay time compared with other inotropes and placebo by analyzing the included literatures [mechanical ventilation (or intubation) time: P = 0.188; ICU stay time: P = 0.620]. Conclusions: Compared with other inotropes and placebo, perioperative prophylactic administration of levosimendan did not decrease the rates of mortality and AKI and shorten the time of mechanical ventilation (or intubation) and ICU stay but demonstrated a significant reduction in LCOS incidence after corrective surgery in pediatric patients for CHD. Due to limited number of included studies, the current data were insufficient to make the conclusions.
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Affiliation(s)
- Hongbai Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qipeng Luo
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yinan Li
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liang Zhang
- Department of Anesthesiology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, China
| | - Xie Wu
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fuxia Yan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Giordano R, Cantinotti M, Mannacio VA, Palma G. First Experience With Levosimendan Therapy After Correction of Congenital Heart Disease. J Cardiothorac Vasc Anesth 2017; 31:e19-e21. [PMID: 28277244 DOI: 10.1053/j.jvca.2016.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Raffaele Giordano
- Department of Advanced Biomedical Science, Division of Adult and Pediatric Cardiac Surgery, University of Naples Federico II, Naples, Italy
| | | | - Vito Antonio Mannacio
- Department of Advanced Biomedical Science, Division of Adult and Pediatric Cardiac Surgery, University of Naples Federico II, Naples, Italy
| | - Gaetano Palma
- Department of Advanced Biomedical Science, Division of Adult and Pediatric Cardiac Surgery, University of Naples Federico II, Naples, Italy
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Joshi RK, Aggarwal N, Aggarwal M, Pandey R, Dinand V, Joshi R. Successful use of levosimendan as a primary inotrope in pediatric cardiac surgery: An observational study in 110 patients. Ann Pediatr Cardiol 2016; 9:9-15. [PMID: 27011685 PMCID: PMC4782480 DOI: 10.4103/0974-2069.171389] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Context: Levosimendan is a new generation inotrope with calcium sensitizing properties and proven benefits in adults. Aims: This study investigates the use of levosimendan as a first line inotrope in congenital heart surgery. Settings and Design: Prospective, observational study in a tertiary care center. Materials and Methods: One hundred and ten patients undergoing congenital cardiac surgery received levosimendan at a loading dose of 12 mcg/kg during rewarming on cardiopulmonary bypass followed by continuous infusion of 0.1 mcg/kg/min for 48 h. Hemodynamic parameters were recorded at the time of admission to Intensive Care Unit, and at 3 h, 6 h, 12 h, 24 h, and 48 h thereafter. Statistical Analysis: Categorical variables were compared using Chi-square test. Non-normally distributed quantitative variables were compared between groups using Kruskal-Wallis test. Results: At discharge from operating room (OR), 36 (32.7%) patients required levosimendan alone to maintain optimum cardiac output, 59 (53.6%) patients required the addition of low-dose adrenaline (<0.1 mcg/kg/min) and 15 (13.6%) patients required either increment in adrenaline to high-dose (≥0.1 mcg/kg/min) or starting another inotrope/vasoactive agent. Overall, there were five mortalities. Hypotension leading to discontinuation of levosimendan was not found in any patient. Arrhythmias were observed in three patients. Fifty-four patients were extubated in the OR. Conclusions: Levosimendan-based inotropic regime offers optimized cardiac output with a well-controlled heart rate and a low incidence of arrhythmias in patients undergoing all categories of congenital heart surgeries.
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Affiliation(s)
- Reena Khantwal Joshi
- Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Neeraj Aggarwal
- Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Mridul Aggarwal
- Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Rakesh Pandey
- Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Veronique Dinand
- Department of Research, Sir Ganga Ram Hospital, New Delhi, India
| | - Raja Joshi
- Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi, India
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Varvarousi G, Xanthos T, Sarafidou P, Katsioula E, Georgiadou M, Eforakopoulou M, Pavlou H. Role of levosimendan in the management of subarachnoid hemorrhage. Am J Emerg Med 2016; 34:298-306. [DOI: 10.1016/j.ajem.2015.11.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 09/27/2015] [Accepted: 11/12/2015] [Indexed: 11/16/2022] Open
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Hillestad V, Kramer F, Golz S, Knorr A, Andersson KB, Christensen G. Long-term levosimendan treatment improves systolic function and myocardial relaxation in mice with cardiomyocyte-specific disruption of the Serca2 gene. J Appl Physiol (1985) 2013; 115:1572-80. [PMID: 24072410 DOI: 10.1152/japplphysiol.01044.2012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In human heart failure (HF), reduced cardiac function has, at least partly, been ascribed to altered calcium homeostasis in cardiomyocytes. The effects of the calcium sensitizer levosimendan on diastolic dysfunction caused by reduced removal of calcium from cytosol in early diastole are not well known. In this study, we investigated the effect of long-term levosimendan treatment in a murine model of HF where the sarco(endo)plasmatic reticulum ATPase (Serca) gene is specifically disrupted in the cardiomyocytes, leading to reduced removal of cytosolic calcium. After induction of Serca2 gene disruption, these mice develop marked diastolic dysfunction as well as impaired contractility. SERCA2 knockout (SERCA2KO) mice were treated with levosimendan or vehicle from the time of KO induction. At the 7-wk end point, cardiac function was assessed by echocardiography and pressure measurements. Vehicle-treated SERCA2KO mice showed significantly diminished left-ventricular (LV) contractility, as shown by decreased ejection fraction, stroke volume, and cardiac output. LV pressure measurements revealed a marked increase in the time constant (τ) of isovolumetric pressure decay, showing impaired relaxation. Levosimendan treatment significantly improved all three systolic parameters. Moreover, a significant reduction in τ toward normalization indicated improved relaxation. Gene-expression analysis, however, revealed an increase in genes related to production of the ECM in animals treated with levosimendan. In conclusion, long-term levosimendan treatment improves both contractility and relaxation in a heart-failure model with marked diastolic dysfunction due to reduced calcium transients. However, altered gene expression related to fibrosis was observed.
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Affiliation(s)
- Vigdis Hillestad
- Institute for Experimental Medical Research, Oslo University Hospital Ullevål and University of Oslo, Oslo, Norway
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Levosimendan infusion in newborns after corrective surgery for congenital heart disease: randomized controlled trial. Intensive Care Med 2012; 38:1198-204. [PMID: 22527079 DOI: 10.1007/s00134-012-2564-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Accepted: 03/20/2012] [Indexed: 12/21/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of levosimendan in neonates with congenital heart disease undergoing cardiac surgery with cardiopulmonary bypass (CPB). METHODS Neonates undergoing risk-adjusted classification for congenital heart surgery (RACHS) 3 and 4 procedures were randomized to receive either a 72 h continuous infusion of 0.1 μg/kg/min levosimendan or standard post-CPB inotrope infusion. RESULTS Sixty-three patients (32 cases and 31 controls) were recruited. There were no differences between groups regarding demographic and baseline clinical data. No side effects were observed. There were no significant differences in mortality (1 vs. 3 patients, p = 0.35), length of mechanical ventilation (5.9 ± 5 vs. 6.9 ± 8 days, p = 0.54), and pediatric cardiac intensive care unit (PCICU) stay (11 ± 8 vs. 14 ± 14 days, p = 0.26). Low cardiac output syndrome occurred in 37 % of levosimendan patients and in 61 % of controls (p = 0.059, OR 0.38, 95 % CI 0.14-1.0). Postoperative heart rate, with a significant difference at 6 (p = 0.008), 12 (p = 0.037), and 24 h (p = 0.046), and lactate levels, with a significant difference at PCICU admission (p = 0.015) and after 6 h (p = 0.048), were lower in the levosimendan group. Inotropic score was significantly lower in the levosimendan group at PCICU admission, after 6 h and after 12 h, (p < 0.0001). According to multivariate analysis, a lower lactate level 6 h after PCICU admission was independently associated with levosimendan administration after correction for CPB time and the need for deep hypothermic circulatory arrest. CONCLUSIONS Levosimendan infused in neonates undergoing cardiac surgery was well tolerated with a potential benefit of levosimendan on postoperative hemodynamic and metabolic parameters of RACHS 3-4 neonates.
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Fernández M, Vicario JL, Reyes E, Carrillo L, Badía D. Organocatalytic enantioselective synthesis of 2,3-dihydropyridazines. Chem Commun (Camb) 2012; 48:2092-4. [DOI: 10.1039/c2cc17370k] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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