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Tan R, Guo H, Yang Z, Yang H, Li Q, Zhu Q, Du Q. Efficacy and safety of levosimendan in patients with sepsis: a systematic review and network meta-analysis. Front Pharmacol 2024; 15:1358735. [PMID: 38523635 PMCID: PMC10957638 DOI: 10.3389/fphar.2024.1358735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/21/2024] [Indexed: 03/26/2024] Open
Abstract
Objective: We conducted a systematic review to assess the advantages and disadvantages of levosimendan in patients with sepsis compared with placebo, milrinone, and dobutamine and to explore the clinical efficacy of different concentrations of levosimendan. Methods: PubMed, Web of Science, Cochrane Library, Embase, CNKI, Wanfang data, VIP, and CBM databases were searched using such keywords as simendan, levosimendan, and sepsis. The search time was from the establishment of the database to July 2023. Two researchers were responsible for literature screening and data collection respectively. After the risk of bias in the included studies was evaluated, network meta-analysis was performed using R software gemtc and rjags package. Results: Thirty-two randomized controlled trials (RCTs) were included in the network meta-analysis. Meta-analysis results showed that while levosimendan significantly improved CI levels at either 0.1 µg/kg/min (mean difference [MD] [95%CrI] = 0.41 [-0.43, 1.4]) or 0.2 µg/kg/min (MD [95%CrI] =0.54 [0.12, 0.99]). Levosimendan, at either 0.075 µg/kg/min (MD [95% CrI] =0.033 [-0.75, 0.82]) or 0.2 µg/kg/min (MD [95% CrI] = -0.014 [-0.26, 0.23]), had no significant advantage in improving Lac levels. Levosimendan, at either 0.1 µg/kg/min (RR [95% CrI] = 0.99 [0.73, 1.3]) or 0.2 µg/kg/min (RR [95% CrI] = 1.0 [0.88, 1.2]), did not have a significant advantage in reducing mortality. Conclusion: The existing evidence suggests that levosimendan can significantly improve CI and lactate levels in patients with sepsis, and levosimendan at 0.1 µg/kg/min might be the optimal dose. Unfortunately, all interventions in this study failed to reduce the 28-day mortality. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023441220.
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Affiliation(s)
- Ruimin Tan
- School of Clinical Medical, North China University of Science and Technology, Tangshan, Hebei, China
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - He Guo
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
- School of Graduate, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Zinan Yang
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
- School of Graduate, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Huihui Yang
- School of Clinical Medical, North China University of Science and Technology, Tangshan, Hebei, China
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Qinghao Li
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
- School of Graduate, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Qiong Zhu
- Department of Orthopaedics, The People’s Hospital of Shizhu, Chongqing, China
| | - Quansheng Du
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
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Al-Tekreeti M, Addi Palle LR, Asif H, Amin MF, Anam H, Akurathi Y, Batool S, Ali N. Comparison of Postoperative Outcomes Between Intra-aortic Balloon Pump and Levosimendan in Patients Undergoing Coronary Artery Bypass Graft: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e43627. [PMID: 37719499 PMCID: PMC10504856 DOI: 10.7759/cureus.43627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/19/2023] Open
Abstract
This study was conducted to compare the postoperative outcomes between intra-aortic balloon pump (IABP) and levosimendan in patients undergoing coronary artery bypass graft (CABG) surgery. This meta-analysis was conducted following the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). For this meta-analysis, a literature search was performed on PubMed, Cochrane Central Register of Controlled Trials, and EMBASE from inception to July 15, 2023. Keywords used to search for relevant articles included "intra-aortic balloon," "levosimendan," and "cardiac surgery" along with their key terms and Medical Subject Headings (MeSH) terms. Outcomes assessed in this study included postoperative outcomes like all-cause mortality, postoperative arrhythmias, need for inotropic support, length of intensive care unit stay (ICU) in days, and duration of mechanical ventilation in hours. Other outcomes included two-hour, six-hour, and 24-hour postoperative central venous pressure (CVP), mean atrial pressure (MAP), and heart rate (HR). A total of eight studies were included in the pooled analysis. The pooled results found that the length of ICU stay and the duration of mechanical ventilation were significantly higher in patients receiving IABP. Additionally, the findings of this meta-analysis showed a higher need for inotropic support in patients receiving IABP compared to patients receiving levosimendan but the difference was statistically insignificant. However, no significant differences were found between the two groups in terms of mortality and arrhythmias. In conclusion, patients treated with levosimendan exhibited significant advantages, as they experienced shorter ICU stays and reduced duration of mechanical ventilation compared to the IABP group and less requirement for inotropic support.
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Affiliation(s)
- Marwah Al-Tekreeti
- Internal Medicine, Avalon University School of Medicine, Willemstad, CUW
| | - Lokeshwar Raaju Addi Palle
- Surgery, Kamala Children's Hospital, Chennai, IND
- General Surgery, Hackensack Meridian Health - Palisades Medical Center, North Bergen, USA
| | - Hamza Asif
- Pulmonology, Khyber Teaching Hospital, Peshawar, PAK
| | - Muhammad Fahad Amin
- Medicine, Ghurki Trust Teaching Hospital, Lahore, PAK
- Medicine, Jinnah Hospital, Lahore, PAK
| | - Hemalatha Anam
- Medicine, Apollo Institute of Medical Sciences and Research, Hyderabad, IND
| | | | - Saima Batool
- Internal Medicine, Hameed Latif Hospital, Lahore, PAK
| | - Neelum Ali
- Internal Medicine, University of Health Sciences, Lahore, PAK
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3
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Wannaz L, Boillat L, Perez MH, Di Bernardo S. Prophylactic use of levosimendan in preoperative setting for surgical repair of congenital heart disease in children. Front Pediatr 2023; 11:1205971. [PMID: 37539009 PMCID: PMC10394616 DOI: 10.3389/fped.2023.1205971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/04/2023] [Indexed: 08/05/2023] Open
Abstract
Introduction Low cardiac output syndrome (LCOS) is a significant cause of morbidity and the leading cause of mortality after pediatric cardiac surgery. Levosimendan has been shown safe and effective in pediatrics to treat LCOS. We aimed to review our local strategy with preoperative prophylactic Levosimendan infusion to minimize LCOS after heart surgery in identified high-risk patients. Methods Retrospective monocentric study. As there is no reliable cardiac output measurement in children, we recorded hemodynamic parameters as surrogates of cardiac output after extracorporeal circulation through an electronic patient survey system at different time points. Results Seventy-two children received Levosimendan before surgery between 2010 and 2019. As expected, most patients were newborns and infants with prolonged open-heart surgeries. Median cardiopulmonary bypass time was 182 [137-234] min, and aortic clamping time was 95 [64-126] min. The postoperative hemodynamic parameters, vasoactive-inotropic score, and urine output remained stable throughout the first 48 h. Only a tiny portion of the patients had combined surrogate markers of LCOS with a maximal median arterial lactate of 2.6 [1.9-3.5] mmol/L during the first six postoperative hours, which then progressively normalized. The median arterio-venous difference in oxygen saturation was 31 [23-38] % between 12 and 18 h post-surgery and gradually decreased. The median venous-to-arterial CO2 difference was the highest at 10 [7-12] mmHg between 12 and 18 h post-surgery. Nine patients (13%) required extracorporeal membrane oxygenation. No patient required dialysis or hemofiltration. Mortality was 0%. Conclusion Before congenital heart surgery, preoperative prophylactic administration of Levosimendan seems effective and safe for decreasing occurrence and duration of LCOS in high-risk children.
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Affiliation(s)
- L. Wannaz
- Pediatric Cardiology, Women-Mother-Child Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - L. Boillat
- Pediatric Intensive Care Unit, Women-Mother-Child Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - M. H. Perez
- Pediatric Intensive Care Unit, Women-Mother-Child Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - S. Di Bernardo
- Pediatric Cardiology, Women-Mother-Child Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Zhao Z, Meng Z, Song G, Wang C, Shi S, Zhao J, Zhang H, Wang M, Niu G, Zhou Z, Wang J, Wu Y. The effects of levosimendan in patients undergoing transcatheter aortic valve replacement- a retrospective analysis. Front Pharmacol 2022; 13:969088. [PMID: 36408223 PMCID: PMC9669067 DOI: 10.3389/fphar.2022.969088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Aortic stenosis (AS) increases left ventricular afterload, leading to cardiac damage and heart failure (HF). Transcatheter aortic valve replacement (TAVR) is an effective therapy for AS. No inotropic agents including levosimendan have been evaluated in patients undergoing TAVR. Methods: A total of 285 patients underwent TAVR between 2014 and 2019; 210 were included in the matched analysis and 105 received 0.1 μg/kg body weight/min levosimendan immediately after the prosthesis had been successfully implanted. Medical history, laboratory tests, and echocardiography results were analyzed. Endpoints including 2-year all-cause mortality, stroke, or HF-related hospitalization, and a combination of the above were analyzed by Cox proportional hazard models. Results: The levosimendan group had no difference in 2-year mortality compared with the control group (hazard ratio [HR]: 0.603, 95% confidence interval [CI]: 0.197–1.844; p = 0.375). However, levosimendan reduced stroke or HF-related hospitalization (HR: 0.346; 95% CI: 0.135–0.884; p = 0.027) and the combined endpoint (HR: 0.459, 95% CI: 0.215–0.980; p = 0.044). After adjusting for multiple variants, levosimendan still reduced stroke or HF-related hospitalization (HR: 0.346, 95% CI: 0.134–0.944; p = 0.038). Conclusion: Prophylactic levosimendan administration immediately after valve implantation in patients undergoing TAVR can reduce stroke or HF-related hospitalization but does not lower all-cause mortality.
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Affiliation(s)
- Zhenyan Zhao
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhen Meng
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Guangyuan Song
- Interventional Center of Valvular Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Chunrong Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sheng Shi
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Zhao
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hongliang Zhang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Moyang Wang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Guannan Niu
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zheng Zhou
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jianhui Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Jianhui Wang, ; Yongjian Wu,
| | - Yongjian Wu
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Jianhui Wang, ; Yongjian Wu,
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Acute Ischaemic Mitral Valve Regurgitation. J Clin Med 2022; 11:jcm11195526. [PMID: 36233410 PMCID: PMC9571705 DOI: 10.3390/jcm11195526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/04/2022] [Accepted: 09/13/2022] [Indexed: 12/03/2022] Open
Abstract
Acute ischaemic mitral regurgitation (IMR) is an increasingly rare and challenging complication following acute myocardial infarction. Despite recent technical advances in both surgical and percutaneous interventions, a poor prognosis is often associated with this challenging patient cohort. In this review, we revisit the diagnosis and typical echocardiographic features, and evaluate current surgical and percutaneous treatment options for patients with acute IMR.
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Fakher M, Aboelghet M, Moharam A, Khaled M, Abdelaziz A. The Role of Perioperative Levosimendan in Patients with Reduced Ejection Fraction undergoing Cardiac surgery in Reducing Post-operative Hemodynamic Support. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Acute perioperative left ventricular dysfunction is a major complication affecting patients subjected to cardiac surgery and is associated with increased mortality. Levosimendan as a “calcium sensitizers” with inodilator effect improves myocardial contractility by sensitizing troponin C to calcium without increasing myocardial oxygen consumption and without impairing relaxation and diastolic function.
AIM: The aim of this study was to evaluate the effect of perioperative levosimendan compared to the conventional management used in the patient with poor left ventricular function undergoing cardiac surgery to reduce the need of post-operative pharmacological and mechanical circulatory support.
METHODS: It is prospective observational studies were patients undergoing cardiac surgery divided into two groups of 25 patients each. The first group received conventional management while the other group received levosimendan additionally duration and type of post-operative pharmacological support, duration of mechanical ventilation, durations of ICU and hospital stays, and major outcomes, and data about the need of mechanical support were collected.
RESULTS: In the levosimendan, fewer patients required vasoactive agents post-surgery (Noradrenaline) compared to the conventional group, yet the use of inotropic support (adrenaline) in the 2nd day and the need of mechanical circulatory support was equal in both groups. The mortality was equal in both groups.
CONCLUSION: Perioperative levosimendan may reduce the need of vasoactive agents postoperatively, but it does not reduce the need of inotropic nor mechanical support.
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Shaker EH, Hussein K, Reyad EM. Levosimendan for patients with heart failure undergoing major oncological surgery: A randomised blinded pilot study. Indian J Anaesth 2019; 63:1001-1007. [PMID: 31879424 PMCID: PMC6921323 DOI: 10.4103/ija.ija_548_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 09/28/2019] [Accepted: 09/03/2019] [Indexed: 01/20/2023] Open
Abstract
Background and Aims: Cardiovascular diseases and cancer are among the leading causes of mortality worldwide. The aim of this study is to evaluate the efficacy and safety of preoperative administration of levosimendan in patients with chronic heart failure (CHF) scheduled for major abdominal oncologic surgery. Methods: This study included 60 patients with abdominal malignancy, ejection fraction (EF) <35% and CHF scheduled for surgery under isoflurane-fentanyl anaesthesia and were managed in the surgical intensive care unit perioperatively. They were randomised to receive levosimendan infusion (n = 30) at a dose of 0.1 μg/kg/min or placebo (n = 30) for 24 hours before surgery. Results: The risk of hypotension (RR: 0.40, 95% CI: 0.19-0.83) or decompensated heart failure (RR: 0.31, 95% CI: 0.12-0.76) was significantly lower in the levosimendan group. The ejection fraction, cardiac index and stroke volume index were significantly higher in the levosimendan group after surgery (P < 0.001). Duration of postoperative ventilation and hospital stay were significantly shorter in the levosimendan group (P < 0.001) while the frequency of dysrhythmia, deterioration of renal function and sepsis was comparable. Conclusion: In patients with low EF <35% and CHF, administration of levosimendan for 24 hours before major abdominal oncologic surgeries may reduce the risk of hypotension and decompensated heart failure and may improve cardiac function.
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Affiliation(s)
- Ehab H Shaker
- Department of Anaesthesia and Pain Management, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Khaled Hussein
- Department of Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ehab M Reyad
- Department of Clinical Pathology, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
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Santillo E, Migale M, Massini C, Incalzi RA. Levosimendan for Perioperative Cardioprotection: Myth or Reality? Curr Cardiol Rev 2018; 14:142-152. [PMID: 29564979 PMCID: PMC6131406 DOI: 10.2174/1573403x14666180322104015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 02/23/2018] [Accepted: 03/06/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Levosimendan is a calcium sensitizer drug causing increased contractility in the myocardium and vasodilation in the vascular system. It is mainly used for the therapy of acute decompensated heart failure. Several studies on animals and humans provided evidence of the cardioprotective properties of levosimendan including preconditioning and anti-apoptotic. In view of these favorable effects, levosimendan has been tested in patients undergoing cardiac surgery for the prevention or treatment of low cardiac output syndrome. However, initial positive results from small studies have not been confirmed in three recent large trials. AIM To summarize levosimendan mechanisms of action and clinical use and to review available evidence on its perioperative use in a cardiac surgery setting. METHODS We searched two electronic medical databases for randomized controlled trials studying levosimendan in cardiac surgery patients, ranging from January 2000 to August 2017. Metaanalyses, consensus documents and retrospective studies were also reviewed. RESULTS In the selected interval of time, 54 studies on the use of levosimendan in heart surgery have been performed. Early small size studies and meta-analyses have suggested that perioperative levosimendan infusion could diminish mortality and other adverse outcomes (i.e. intensive care unit stay and need for inotropic support). Instead, three recent large randomized controlled trials (LEVO-CTS, CHEETAH and LICORN) showed no significant survival benefits from levosimendan. However, in LEVO-CTS trial, prophylactic levosimendan administration significantly reduced the incidence of low cardiac output syndrome. CONCLUSIONS Based on most recent randomized controlled trials, levosimendan, although effective for the treatment of acute heart failure, can't be recommended as standard therapy for the management of heart surgery patients. Further studies are needed to clarify whether selected subgroups of heart surgery patients may benefit from perioperative levosimendan infusion.
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Affiliation(s)
- Elpidio Santillo
- Geriatric-Rehabilitative Department, Italian National Research Center on Aging (INRCA), Fermo, Italy
| | - Monica Migale
- Geriatric-Rehabilitative Department, Italian National Research Center on Aging (INRCA), Fermo, Italy
| | - Carlo Massini
- Cardiac, Thoracic and Vascular Surgery Ward, Salus Hospital-GVM Care & Research, Reggio Emilia, Italy
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Levosimendan versus placebo in cardiac surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2018; 27:677-685. [DOI: 10.1093/icvts/ivy133] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 03/25/2018] [Indexed: 11/14/2022] Open
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10
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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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Caruba T, Hourton D, Sabatier B, Rousseau D, Tibi A, Hoffart-Jourdain C, Souag A, Freitas N, Yjjou M, Almeida C, Gomes N, Aucouturier P, Djadi-Prat J, Menasché P, Chatellier G, Cholley B. Rationale and design of the multicenter randomized trial investigating the effects of levosimendan pretreatment in patients with low ejection fraction (≤40 %) undergoing CABG with cardiopulmonary bypass (LICORN study). J Cardiothorac Surg 2016; 11:127. [PMID: 27496105 PMCID: PMC4974786 DOI: 10.1186/s13019-016-0530-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 07/28/2016] [Indexed: 12/04/2022] Open
Abstract
Background Patients with a left ventricular ejection fraction (LVEF) of less than 40 % are at high risk of developing postoperative low cardiac output syndrome (LCOS). Despite actual treatments (inotropic agents and/or mechanical assist devices), the mortality rate of such patients remains very high (13 to 24 %). The LICORN trial aims at assessing the efficacy of a preoperative infusion of levosimendan in reducing postoperative LCOS in patients with poor LVEF undergoing coronary artery bypass grafting (CABG). Methods/Design LICORN study is a multicenter, randomized double-blind, placebo-controlled trial in parallel groups. 340 patients with LVEF ≤40 %, undergoing CABG will be recruited from 13 French hospitals. The study drug will be started after anaesthesia induction and infused over 24 h (0.1 μg/kg/min). The primary outcome (postoperative LCOS) is evaluated using a composite criterion composed of: 1) need for inotropic agents beyond 24 h following discontinuation of the study drug; 2) need for post-operative mechanical assist devices or failure to wean from these techniques when inserted pre-operatively; 3) need for renal replacement therapy. Secondary outcomes include: 1) mortality at Day 28 and Day 180; 2) each item of the composite criterion of the primary outcome; 3) the number of “ventilator-free” days and “out of intensive care unit” days at Day 28. Discussion The usefulness of levosimendan in the perioperative period has not yet been documented with a high level of evidence. The LICORN study is the first randomized controlled trial evaluating the clinical value of preoperative levosimendan in high risk cardiac surgical patients undergoing CABG. Trial registration number NCT02184819 (ClinicalTrials.gov).
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Affiliation(s)
- Thibaut Caruba
- Department of Pharmacy, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Delphine Hourton
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Brigitte Sabatier
- Department of Pharmacy, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.,INSERM Centre de Recherche des Cordeliers UMR S 872 eq 22 Université Paris Descartes, Paris, France
| | - Dominique Rousseau
- Department of Pharmacy, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Annick Tibi
- Agence Générale des Equipements et des Produits de Santé (AGEPS), AP-HP, Paris, France
| | - Cécile Hoffart-Jourdain
- Département de la Recherche Clinique et du Développement (DRCD), Hôpital Saint-Louis, (AP-HP), Paris, France
| | - Akim Souag
- Département de la Recherche Clinique et du Développement (DRCD), Hôpital Saint-Louis, (AP-HP), Paris, France
| | - Nelly Freitas
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Mounia Yjjou
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Carla Almeida
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Nathalie Gomes
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Pascaline Aucouturier
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Juliette Djadi-Prat
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Philippe Menasché
- Department of Cardiovascular Surgery, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Gilles Chatellier
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Bernard Cholley
- Department of Anaesthesiology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, 20 rue Leblanc, 75015, Paris, France. .,Université Paris Descartes, Sorbonne Paris Cité, Paris, France.
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Levosimendan beyond inotropy and acute heart failure: Evidence of pleiotropic effects on the heart and other organs: An expert panel position paper. Int J Cardiol 2016; 222:303-312. [PMID: 27498374 DOI: 10.1016/j.ijcard.2016.07.202] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/28/2016] [Indexed: 02/04/2023]
Abstract
Levosimendan is a positive inotrope with vasodilating properties (inodilator) indicated for decompensated heart failure (HF) patients with low cardiac output. Accumulated evidence supports several pleiotropic effects of levosimendan beyond inotropy, the heart and decompensated HF. Those effects are not readily explained by cardiac function enhancement and seem to be related to additional properties of the drug such as anti-inflammatory, anti-oxidative and anti-apoptotic ones. Mechanistic and proof-of-concept studies are still required to clarify the underlying mechanisms involved, while properly designed clinical trials are warranted to translate preclinical or early-phase clinical data into more robust clinical evidence. The present position paper, derived by a panel of 35 experts in the field of cardiology, cardiac anesthesiology, intensive care medicine, cardiac physiology, and cardiovascular pharmacology from 22 European countries, compiles the existing evidence on the pleiotropic effects of levosimendan, identifies potential novel areas of clinical application and defines the corresponding gaps in evidence and the required research efforts to address those gaps.
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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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Levosimendan as an adjunctive therapy to MitraClip implantation in patients with severe mitral regurgitation and left ventricular dysfunction. Int J Cardiol 2016; 202:517-8. [DOI: 10.1016/j.ijcard.2015.09.056] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/21/2015] [Indexed: 02/07/2023]
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15
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Preoperative and perioperative use of levosimendan in cardiac surgery: European expert opinion. Int J Cardiol 2015; 184:323-336. [DOI: 10.1016/j.ijcard.2015.02.022] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 02/09/2015] [Accepted: 02/21/2015] [Indexed: 01/07/2023]
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16
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Treskatsch S, Balzer F, Geyer T, Spies CD, Kastrup M, Grubitzsch H, Wernecke KD, Erb JM, Braun JP, Sander M. Early levosimendan administration is associated with decreased mortality after cardiac surgery. J Crit Care 2015; 30:859.e1-6. [PMID: 25837801 DOI: 10.1016/j.jcrc.2015.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/04/2015] [Accepted: 03/07/2015] [Indexed: 12/29/2022]
Abstract
PURPOSE The aim of this study was to assess the effects on postoperative outcome of levosimendan with respect to timing of its administration in cardiac surgery patients. MATERIALS AND METHODS Levosimendan administration was triggered by a severely reduced left ventricular systolic function (left ventricular ejection fraction, <35%) and/or signs of a low cardiac output syndrome. A total of 159 patients were retrospectively assigned depending on an early (perioperatively up to the first hour after intensive care unit [ICU] admission) vs late (later than the first hour after ICU admission) start of treatment. RESULTS Patients receiving levosimendan after the first hour of ICU admission (n = 89) had a significantly increased inhospital (P = .004) and 1-year (P = .027) mortality. Duration of mechanical ventilation (P = .002), incidence of renal dysfunction (P = .002), and need of renal replacement therapy (P = .032) were significantly increased in the late start group. A late start of levosimendan treatment was associated with an odds ratio of 2.258 (95% confidence interval, 1.139-4.550; P = .021) for inhospital mortality and an adjusted hazard ratio of 1.827 (95% confidence interval, 1.155-2.890; P = .010) for 1-year survival. CONCLUSIONS Findings of this retrospective analysis favor an "early," that is, intraoperatively up to the first hour after ICU admission, start of perioperative levosimendan treatment to maximize its ability to reduce mortality and morbidity.
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Affiliation(s)
- Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
| | - Felix Balzer
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
| | - Torsten Geyer
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
| | - Claudia D Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
| | - Marc Kastrup
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
| | - Herko Grubitzsch
- Department of Cardiovascular Surgery, Campus Charité Mitte, Charité-Universitätsmedizin, Berlin, Germany.
| | | | - Joachim M Erb
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital of Basel, Basel, Switzerland.
| | - Jan P Braun
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Helios Klinikum Hildesheim GmbH, Hildesheim, Germany.
| | - Michael Sander
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
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Shah B, Sharma P, Brahmbhatt A, Shah R, Rathod B, Shastri N, Patel J, Malhotra A. Study of levosimendan during off-pump coronary artery bypass grafting in patients with LV dysfunction: a double-blind randomized study. Indian J Pharmacol 2014; 46:29-34. [PMID: 24550581 PMCID: PMC3912803 DOI: 10.4103/0253-7613.125161] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 08/05/2013] [Accepted: 10/06/2013] [Indexed: 12/03/2022] Open
Abstract
Objectives: Levosimendan is a calcium sensitizer drug which has been used in cardiac surgery for the prevention of postoperative low cardiac output syndrome (LCOS) and in difficult weaning from cardiopulmonary bypass (CPB). This study aims to evaluate perioperative hemodynamic effects of levosimendan pretreatment in patients for off-pump coronary artery bypass graft (OPCABG) surgery with low left ventricular ejection fractions (LVEF < 30%). Materials and Methods: Fifty patients undergoing OPCABG surgery with low LVEF (<30%) were enrolled in the study. Patients were randomly divided in two groups: Levosimendan pretreatment (Group L) and placebo pretreatment (Group C) of 25 each. Group L, patients received levosimendan infusion 200 μg/kg over 24 h and in Group C Patients received placebo. The clinical parameters measured before and after the drug administration up to 48 h were heart rate (HR; for the hour after drug infusion), cardiac index (CI), and pulmonary capillary wedge pressure (PCWP). The requirement of inotropes, intraaortic balloon pump (IABP), CPB, intensive care unit (ICU) stay, and hospital stay were also measured. Results: The patients in group L exhibited higher CI and PCWP during operative in early postoperative period as compared to control group C. Group L also had a less requirement for inotropes, CPB support and IABP with shorter ICU stay as well as hospital stay. Conclusion: Levosimendan pretreatment (24 h infusion) in patient for OPCABG with poor LVEF shows better outcomes and hemodynamics in terms of inotropes, CPB and IABP requirements. It also reduces ICU stay.
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Affiliation(s)
- B Shah
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - P Sharma
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - A Brahmbhatt
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - R Shah
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - B Rathod
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - Naman Shastri
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - J Patel
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - A Malhotra
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
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18
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Jia Z, Guo M, Zhang YQ, Liang HQ, Zhang LY, Song Y. Efficacy of intravenous levosimendan in patients with heart failure complicated by acute myocardial infarction. Cardiology 2014; 128:195-201. [PMID: 24751462 DOI: 10.1159/000357864] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 12/10/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To evaluate the efficacy of a short-term intravenous infusion of levosimendan in patients with heart failure due to acute myocardial infarction (AMI). METHODS This was a randomized, single-center, single-blind study that included 160 patients. Patients were randomly divided into 2 groups: 1 received levosimendan (n = 80) and the other received placebo (n = 80). The study included multiple primary end points (death, myocardial ischemia or worsening heart at the 6 month follow-up) and used a composite outcome. RESULTS The primary end point rate in the levosimendan group was lower than that in placebo group (43.7 vs. 62.5%, HR 0.636, 95% CI 0.413-0.981, p = 0.041). Moreover, the mortality rate at 6 months was similar between the 2 groups (17.5 vs. 22.5%, HR 0.786, 95% CI 0.382-1.543, p = 0.458). There was a higher incidence of myocardial ischemia in the levosimendan group at 14 days than in the placebo group (11.2 vs. 7.5%, HR 1.510, p = 0.435), but between 15 and 180 days, it was significantly lower in the levosimendan group than in the placebo group (3.8 vs. 13.8%, HR 0.261, p = 0.036). CONCLUSION Short-term intravenous infusion of levosimendan appears to be more effective than placebo for treating patients with heart failure complicated by AMI.
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Affiliation(s)
- Zhi Jia
- TEDA International Cardiovascular Hospital, Cardiovascular Clinical College of Tianjin Medical University, TEDA, Tianjin, China
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19
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Pierrakos C, Velissaris D, Franchi F, Muzzi L, Karanikolas M, Scolletta S. Levosimendan in critical illness: a literature review. J Clin Med Res 2014; 6:75-85. [PMID: 24578748 PMCID: PMC3935527 DOI: 10.14740/jocmr1702w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2013] [Indexed: 01/30/2023] Open
Abstract
Levosimendan, the active enantiomer of simendan, is a calcium sensitizer developed for treatment of decompensated heart failure, exerts its effects independently of the beta adrenergic receptor and seems beneficial in cases of severe, intractable heart failure. Levosimendan is usually administered as 24-h infusion, with or without a loading dose, but dosing needs adjustment in patients with severe liver or renal dysfunction. Despite several promising reports, the role of levosimendan in critical illness has not been thoroughly evaluated. Available evidence suggests that levosimendan is a safe treatment option in critically ill patients and may reduce mortality from cardiac failure. However, data from well-designed randomized controlled trials in critically ill patients are needed to validate or refute these preliminary conclusions. This literature review is an attempt to synthesize available evidence on the role and possible benefits of levosimendan in critically ill patients with severe heart failure.
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Affiliation(s)
- Charalampos Pierrakos
- Department of Intensive Care, Universite Catholique de Louvain, Mont-Godinne University Hospital, Yvoir 5530, Belgium
| | - Dimitrios Velissaris
- Department of Internal Medicine, University of Patras School of Medicine, Patras, Greece
| | - Federico Franchi
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Luigi Muzzi
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Menelaos Karanikolas
- Department of Anesthesiology, Washington University School of Medicine, Campus Box 8054, 660 S. Euclid Avenue, St. Louis, MO, USA
| | - Sabino Scolletta
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
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Abstract
Background Levosimendan is a new calcium sensitizing drug with vasodilatory and inotropic properties, which is used for the treatment of postoperative low cardiac output syndrome and difficult weaning from cardiopulmonary bypass. Objective To evaluate the hemodynamic effects of levosimendan during and after coronary artery bypass grafting on cardiopulmonary bypass and mitral valve repair in patients with low left ventricular ejection fractions (<30%). Methods 40 patients were enrolled in this double-blind prospective randomized controlled trial. They received either levosimendan or a placebo preoperatively ( n = 20) for 24 h. Clinical parameters were measured before and after administration. Any adverse events during and after drug administration and postoperative complications were evaluated. Results Patients treated with levosimendan exhibited a higher cardiac index and mean arterial pressure intraoperative and in the early postoperative period, compared to the control group. Patients treated with levosimendan required less ventilatory support ( p < 0.0001) and had shorter intensive care unit ( p < 0.0001) and hospital stay ( p < 0.0001). Conclusions Preoperative treatment with levosimendan in patients undergoing coronary artery bypass grafting and mitral valve repair resulted in improved hemodynamics and a stable postoperative course.
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21
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Hajj-Chahine J. eComment. Levosimendan in adult patients undergoing cardiac surgery. Interact Cardiovasc Thorac Surg 2013; 17:715. [PMID: 24065758 DOI: 10.1093/icvts/ivt328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jamil Hajj-Chahine
- Department of Cardio-Thoracic Surgery, University Hospital of Poitiers, Poitiers, France
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22
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Lomivorotov VV, Boboshko VA, Efremov SM, Kornilov IA, Chernyavskiy AM, Lomivorotov VN, Knazkova LG, Karaskov AM. Levosimendan Versus an Intra-Aortic Balloon Pump in High-Risk Cardiac Patients. J Cardiothorac Vasc Anesth 2012; 26:596-603. [DOI: 10.1053/j.jvca.2011.09.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Indexed: 11/11/2022]
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23
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Resumen del documento de consenso «Guías de práctica clínica para el manejo del síndrome de bajo gasto cardiaco en el postoperatorio de cirugía cardiaca». Med Intensiva 2012; 36:277-87. [DOI: 10.1016/j.medin.2012.01.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 12/17/2011] [Accepted: 01/07/2012] [Indexed: 11/18/2022]
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24
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Pérez Vela J, Martín Benítez J, Carrasco González M, De la Cal López M, Hinojosa Pérez R, Sagredo Meneses V, del Nogal Saez F. Guías de práctica clínica para el manejo del síndrome de bajo gasto cardíaco en el postoperatorio de cirugía cardíaca. Med Intensiva 2012; 36:e1-44. [DOI: 10.1016/j.medin.2012.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 01/07/2012] [Indexed: 01/04/2023]
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25
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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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26
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Elahi MM, Lam J, Asopa S, Matata BM. Levosimendan Versus an Intra-aortic Balloon Pump in Adult Cardiac Surgery Patients With Low Cardiac Output. J Cardiothorac Vasc Anesth 2011; 25:1154-62. [DOI: 10.1053/j.jvca.2011.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Indexed: 11/11/2022]
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Leppikangas H, Järvelä K, Sisto T, Maaranen P, Virtanen M, Lehto P, Karlsson S, Kööbi T, Lindgren L. Preoperative levosimendan infusion in combined aortic valve and coronary bypass surgery. Br J Anaesth 2011; 106:298-304. [PMID: 21258075 DOI: 10.1093/bja/aeq402] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cardiopulmonary bypass may have detrimental effects on intestinal function and decrease the concentrations of the active, long-acting metabolites of levosimendan, an inodilator used to improve cardiac function. The aim of this study was to evaluate the haemodynamic effects of preoperative levosimendan in patients undergoing high-risk cardiac surgery. METHODS Twenty-four patients were randomized to receive levosimendan (12 µg bolus followed by an infusion of 0.2 µg kg(-1) min(-1)) or a placebo 24 h before surgery. The inclusion criteria were left ventricular ejection fraction (LVEF) <50% or LV hypertrophy indicated by a wall thickness of >12 mm. Haemodynamics were recorded every hour for 24 h (pulmonary artery catheter) and daily until postoperative day 4 (whole-body impedance cardiography). Doppler echocardiography with tissue Doppler imaging was used to assess systolic and diastolic cardiac function. RESULTS The cardiac index (CI) and stroke volume index (SI) were higher in the levosimendan group (LG) for the 4 day postoperative period (P<0.05); on the fourth postoperative day, the CI was 3.0 litre m(-2) min(-1) in the LG compared with 2.4 litre m(-2) min(-1) in the control group (CG) and the SI was 30 vs 25 ml m(-2), respectively. The LVEF measured at baseline and on the fourth postoperative morning decreased in the CG, but was maintained in the LG. CONCLUSIONS Levosimendan improved haemodynamics compared with a placebo in patients undergoing high-risk cardiac surgery. The concentrations of levosimendan's metabolites were higher compared with earlier studies using perioperative dosing.
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Affiliation(s)
- H Leppikangas
- Department of Anaesthesia, Tampere University Hospital, PO Box 2000, Tampere 33521, Finland.
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Brogly N, Guasch E, Puertas L, Alsina E, López T, Gilsanz F. Défaillance cardiaque aiguë associée à une cardiomyopathie dilatée en post-partum précoce : traitement par ballon de contrepulsion aortique et lévosimendan. ACTA ACUST UNITED AC 2010; 29:807-10. [DOI: 10.1016/j.annfar.2010.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 08/27/2010] [Indexed: 10/19/2022]
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29
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Carl M, Alms A, Braun J, Dongas A, Erb J, Goetz A, Goepfert M, Gogarten W, Grosse J, Heller A, Heringlake M, Kastrup M, Kroener A, Loer S, Marggraf G, Markewitz A, Reuter D, Schmitt D, Schirmer U, Wiesenack C, Zwissler B, Spies C. S3-Leitlinie zur intensivmedizinischen Versorgung herzchirurgischer Patienten. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2010. [DOI: 10.1007/s00398-010-0790-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Omerovic E, Råmunddal T, Albertsson P, Holmberg M, Hallgren P, Boren J, Grip L, Matejka G. Levosimendan neither improves nor worsens mortality in patients with cardiogenic shock due to ST-elevation myocardial infarction. Vasc Health Risk Manag 2010; 6:657-63. [PMID: 20859537 PMCID: PMC2941779 DOI: 10.2147/vhrm.s8856] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Indexed: 01/13/2023] Open
Abstract
Background: The aim of this study was to evaluate the effect of levosimendan on mortality in cardiogenic shock (CS) after ST elevation myocardial infarction (STEMI). Methods and results: Data were obtained prospectively from the SCAAR (Swedish Coronary Angiography and Angioplasty Register) and the RIKS-HIA (Register of Information and Knowledge about Swedish Heart Intensive Care Admissions) about 94 consecutive patients with CS due to STEMI. Patients were classified into levosimendan-mandatory and levosimendan-contraindicated cohorts. Inotropic support with levosimendan was mandatory in all patients between January 2004 and December 2005 (n = 46). After the SURVIVE and REVIVE II studies were presented, levosimendan was considered contraindicated and was not used in consecutive patients between December 2005 and December 2006 (n = 48). The cohorts were similar with respect to pre-treatment characteristics and concomitant medications. There was no difference in the incidence of new-onset atrial fibrillation, in-hospital cardiac arrest and length of stay at the coronary care unit. There was no difference in adjusted mortality at 30 days and at one year. Conclusion: The use of levosimendan neither improves nor worsens mortality in patients with CS due to STEMI. Well-designed randomized clinical trials are needed to define the role of inotropic therapy in the treatment of CS.
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Affiliation(s)
- Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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31
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Carl M, Alms A, Braun J, Dongas A, Erb J, Goetz A, Goepfert M, Gogarten W, Grosse J, Heller AR, Heringlake M, Kastrup M, Kroener A, Loer SA, Marggraf G, Markewitz A, Reuter D, Schmitt DV, Schirmer U, Wiesenack C, Zwissler B, Spies C. S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2010; 8:Doc12. [PMID: 20577643 PMCID: PMC2890209 DOI: 10.3205/000101] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Indexed: 01/20/2023]
Abstract
Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery (Deutsche Gesellschaft für Thorax-, Herz- und Gefässchirurgie, DGTHG) and the German Society for Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin, DGAI) made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess the available monitoring methods with regard to indication, procedures, predication, limits, contraindications and risks for use. The differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilatators, inodilatators and calcium sensitizers and the use of intra-aortic balloon pumps will also be addressed. The guideline has been developed following the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the Scientific Medical Societies in Germany (AWMF).
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Affiliation(s)
- M. Carl
- Department of Anesthesiology and Intensive Care, Charité University Medicine Berlin, Charité Campus Mitte and Campus Virchow Klinikum, Berlin, Germany
| | - A. Alms
- Department of Anaesthesia and Intensive Care Medicine, University of Rostock, Germany
| | - J. Braun
- Department of Anesthesiology and Intensive Care, Charité University Medicine Berlin, Charité Campus Mitte and Campus Virchow Klinikum, Berlin, Germany
| | - A. Dongas
- Department of Anesthesiology, Heart and Diabetic Center NRW, Ruhr University of Bochum, Bad Oeynhausen, Germany
| | - J. Erb
- Department of Anesthesiology and Intensive Care, Charité University Medicine Berlin, Charité Campus Mitte and Campus Virchow Klinikum, Berlin, Germany
| | - A. Goetz
- Department of Anaesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - M. Goepfert
- Department of Anaesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - W. Gogarten
- Department of Anaesthesiology and Intensive Care, University of Muenster, Germany
| | - J. Grosse
- Department of Anesthesiology and Intensive Care, Charité University Medicine Berlin, Charité Campus Mitte and Campus Virchow Klinikum, Berlin, Germany
| | - A. R. Heller
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - M. Heringlake
- Department of Anesthesiology, University of Luebeck, Germany
| | - M. Kastrup
- Department of Anesthesiology and Intensive Care, Charité University Medicine Berlin, Charité Campus Mitte and Campus Virchow Klinikum, Berlin, Germany
| | - A. Kroener
- Department of Cardiothoracic Surgery, University of Cologne, Germany
| | - S. A. Loer
- Department of Anesthesiology, VU University Hospital Center, Amsterdam, The Netherlands
| | - G. Marggraf
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center, Essen, Germany
| | - A. Markewitz
- Department of Cardiovascular Surgery, German Armed Forces Central Hospital, Koblenz, Germany
| | - D. Reuter
- Department of Anaesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - D. V. Schmitt
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Germany
| | - U. Schirmer
- Department of Anesthesiology, Heart and Diabetic Center NRW, Ruhr University of Bochum, Bad Oeynhausen, Germany
| | - C. Wiesenack
- Department of Anaesthesia, University Hospital of Regensburg, Germany
| | - B. Zwissler
- Clinic of Anesthesiology, Ludwig Maximilian University, Munich, Germany
| | - C. Spies
- Department of Anesthesiology and Intensive Care, Charité University Medicine Berlin, Charité Campus Mitte and Campus Virchow Klinikum, Berlin, Germany
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Omerovic E, Waagstein F, Swedberg K. Is levosimendan better than dobutamine in acute heart failure in patients on beta-blockade treatment? What is the evidence? Eur J Heart Fail 2010; 12:313-4. [DOI: 10.1093/eurjhf/hfq035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Elmir Omerovic
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy; University of Gothenburg; Göteborg Sweden
| | - Finn Waagstein
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy; University of Gothenburg; Göteborg Sweden
| | - Karl Swedberg
- Department of Emergency and Cardiovascular Medicine, Sahlgrenska Academy; University of Gothenburg; Göteborg Sweden
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Landoni G, Mizzi A, Biondi-Zoccai G, Bruno G, Bignami E, Corno L, Zambon M, Gerli C, Zangrillo A. Reducing Mortality in Cardiac Surgery With Levosimendan: A Meta-analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2010; 24:51-7. [PMID: 19700350 DOI: 10.1053/j.jvca.2009.05.031] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Indexed: 02/08/2023]
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Greif M, Zwermann L, Reithmann C, Weis M. Levosimendan as rescue therapy in severe cardiogenic shock after ST-elevation myocardial infarction. ACTA ACUST UNITED AC 2009; 10:185-90. [DOI: 10.1080/17482940801935774] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Zhang Y, Mazgalev TN. Cardiac Vagal Stimulation Eliminates Detrimental Tachycardia Effects of Dobutamine Used for Inotropic Support. Ann Thorac Surg 2009; 88:117-22. [DOI: 10.1016/j.athoracsur.2009.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Revised: 04/01/2009] [Accepted: 04/03/2009] [Indexed: 11/24/2022]
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Osthaus WA, Boethig D, Winterhalter M, Huber D, Goerler H, Sasse M, Sümpelmann R. First experiences with intraoperative Levosimendan in pediatric cardiac surgery. Eur J Pediatr 2009; 168:735-40. [PMID: 18813947 DOI: 10.1007/s00431-008-0834-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2008] [Revised: 08/29/2008] [Accepted: 09/03/2008] [Indexed: 11/29/2022]
Abstract
Levosimendan is a calcium-sensitizing agent with effective inotropic properties. It has been shown to improve cardiac function, hemodynamic performance, and survival in adults with severe heart failure. However, the effect of Levosimendan in pediatric cardiac surgery has not yet been investigated. Thus, we report on our experience with the intraoperative application of Levosimendan in seven infants (body weight range 2.6-6.3 kg) with severe myocardial dysfunction after complex congenital heart surgery. During the administration of Levosimendan, the heart rate, mean arterial blood pressure, and central venous pressure did not change. The mean arterial lactate level significantly decreased 24 and 48 h after the first infusion compared to baseline. Central venous oxygen saturation increased significantly 24 and 48 h after the onset of Levosimendan infusion. We found intraoperatively administered Levosimendan to be well tolerated in the seven infants with severe myocardial dysfunction after complex congenital heart surgery. Levosimendan is a new rescue drug which has beneficial effects, even in pediatric cardiac surgery.
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Affiliation(s)
- Wilhelm Alexander Osthaus
- Klinik für Anästhesiologie und Intensivmedizin, OE 8050, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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Kurt IH. Use of levosimendan in patients with ischemic heart disease following mechanical reperfusion. Surg Today 2009; 39:381-6. [PMID: 19408074 DOI: 10.1007/s00595-008-3869-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Accepted: 10/29/2008] [Indexed: 11/30/2022]
Abstract
Cardiac failure is among the most significant conditions associated with acute coronary syndrome. In ischemic heart disease, serious hemodynamic problems are reported in patients with left ventricular dysfunction during the acute phase despite mechanical revascularization. Several positive inotropic agents in addition to intra-aortic balloon pump (IABP) are required to support patients with impaired left ventricular pump function during this phase. Intravenous inotropic agents, beta-mimetics, and phosphodiesterase inhibitors lead to increases in the incidence of arrhythmia and myocardial O(2) consumption owing to their effect of increasing intracellular calcium amount, although they produce rapid hemodynamic improvements in cardiac failure. This causes severe problems particularly in cardiac failure of ischemic origin. Recently, levosimendan, a calcium-sensitizing agent with cardioprotective properties, is being used alone or in combination with IABP in cases with severe left ventricular systolic dysfunction during mechanical revascularization procedures (percutaneous coronary interventions, coronary bypass surgery). This review includes studies with levosimendan in cases not recovering due to myocardial stunning in the acute phase despite mechanical approaches applied.
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Affiliation(s)
- Ibrahim Halil Kurt
- Department of Cardiology, Adana Numune Education and Research Hospital, Adana, Turkey
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Rehberg S, Enkhbaatar P, Traber DL. Role of the Calcium Sensitizer, Levosimendan, in Perioperative Intensive Care Medicine. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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De Hert SG, Lorsomradee S, vanden Eede H, Cromheecke S, Van der Linden PJ. RETRACTED: A Randomized Trial Evaluating Different Modalities of Levosimendan Administration in Cardiac Surgery Patients With Myocardial Dysfunction. J Cardiothorac Vasc Anesth 2008; 22:699-705. [DOI: 10.1053/j.jvca.2008.02.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2007] [Indexed: 11/11/2022]
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Levin RL, Degrange MA, Porcile R, Salvagio F, Blanco N, Botbol AL, Tanus E, del Mazo CD. Superioridad del sensibilizante al calcio levosimendán comparado con dobutamina en el síndrome de bajo gasto cardiaco postoperatorio. Rev Esp Cardiol 2008. [DOI: 10.1157/13119990] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2008. [DOI: 10.1002/pds.1486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Vanek T, Kolesar M, Nejedly M, Jirmar R. Rescue peri-operative management of the patient with giant electrical storm and severe left ventricular dysfunction: support by levosimendan and intraaortic balloon counterpulsation. Interact Cardiovasc Thorac Surg 2008; 7:648-50. [PMID: 18397933 DOI: 10.1510/icvts.2008.176883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We present a case of a 62-year-old male patient (coronary heart disease, and stenosis of aortic valve) with severe left ventricular dysfunction (left ventricular ejection fraction 20%, left ventricular end-diastolic diameter 80 mm, end-diastolic volume 329 ml) who developed giant electrical storm (on the whole 115 episodes of pulseless ventricular tachycardia treated by antiarrhythmics and electrical discharges) with low-elevation of cardiac biomarkers. The patient was referred to emergent cardiac surgery (double coronary bypass grafting, aortic valve replacement, and implantation of left ventricular epicardial electrode). Levosimendan and intraaortic balloon counterpulsation were used for successful weaning from the cardiopulmonary bypass; no other arrhythmia appeared in the post-bypass period. Postoperatively no arrhythmic events were detected, and repeated echocardiographic examinations of the patient in good general condition showed gradual improvement of left ventricular ejection fraction (30-35%), likewise in other parameters (left ventricular end-diastolic diameter 72 mm, end-diastolic volume 285 ml).
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Affiliation(s)
- Tomas Vanek
- Department of Cardiac Surgery, 3rd Faculty of Medicine, Charles University Prague and University Hospital Kralovske Vinohrady, FNKV, Srobarova 50, 100 34 Prague 10, Czech Republic.
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The Calcium Sensitizer Levosimendan Gives Superior Results to Dobutamine in Postoperative Low Cardiac Output Syndrome. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s1885-5857(08)60160-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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