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Rysz S, Fagerlund MJ, Lundberg J, Ringh M, Hollenberg J, Lindgren M, Jonsson M, Djärv T, Nordberg P. The Use of Levosimendan after Out-of-Hospital Cardiac Arrest and Its Association with Outcome-An Observational Study. J Clin Med 2022; 11:jcm11092621. [PMID: 35566747 PMCID: PMC9103888 DOI: 10.3390/jcm11092621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Levosimendan improves resuscitation rates and cardiac performance in animal cardiac arrest models. The aim of this study was to describe the use of levosimendan in out-of-hospital cardiac arrest (OHCA) patients and its association with outcome. Methods: A retrospective observational study of OHCA patients admitted to six intensive care units in Stockholm, Sweden, between 2010 and 2016. Patients treated with levosimendan within 24 h from admission were compared with those not treated with levosimendan. Propensity score matching and multivariable logistic regression analysis were used to assess the association between levosimendan treatment and 30-day mortality Results: Levosimendan treatment was initiated in 94/940 (10%) patients within 24 h. The proportion of men (81%, vs. 67%, p = 0.007), initial shockable rhythm (66% vs. 37%, p < 0.001), acute myocardial infarction, AMI (47% vs. 24%, p < 0.001) and need for vasoactive support (98% vs. 61%, p < 0.001) were higher among patients treated with levosimendan. After adjustment for age, sex, bystander cardiopulmonary resuscitation, witnessed status, initial rhythm and AMI, the odds ratio (OR) for 30-day mortality in the levosimendan group compared to the no-levosimendan group was 0.94 (95% Confidence interval [CI], 0.56−1.57, p = 0.82). Similar results were seen when using a propensity score analysis comparing patients with circulatory shock. Conclusions: In this observational study of OHCA patients, levosimendan was used in a limited patient group, most often in those with initial shockable rhythms, acute myocardial infarction and with a high need for vasopressors. In this limited patient cohort, levosimendan treatment was not associated with 30-day mortality. However, a better matching of patient factors and indications for use is required to derive conclusions on associations with outcome.
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Affiliation(s)
- Susanne Rysz
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76 Stockholm, Sweden; (S.R.); (M.J.F.)
- Department of Medicine Solna, Karolinska Institutet, 171 77 Stockholm, Sweden;
| | - Malin Jonsson Fagerlund
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76 Stockholm, Sweden; (S.R.); (M.J.F.)
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Johan Lundberg
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden;
- Department of Neuroradiology, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Mattias Ringh
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, 118 83 Stockholm, Sweden; (M.R.); (J.H.); (M.J.)
| | - Jacob Hollenberg
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, 118 83 Stockholm, Sweden; (M.R.); (J.H.); (M.J.)
| | - Marcus Lindgren
- Department of Medicine, Piteå Hospital, 941 50 Piteå, Sweden;
| | - Martin Jonsson
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, 118 83 Stockholm, Sweden; (M.R.); (J.H.); (M.J.)
| | - Therese Djärv
- Department of Medicine Solna, Karolinska Institutet, 171 77 Stockholm, Sweden;
- Function Emergency Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Per Nordberg
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76 Stockholm, Sweden; (S.R.); (M.J.F.)
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, 118 83 Stockholm, Sweden; (M.R.); (J.H.); (M.J.)
- Correspondence:
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Levosimendan increases brain tissue oxygen levels after cardiopulmonary resuscitation independent of cardiac function and cerebral perfusion. Sci Rep 2021; 11:14220. [PMID: 34244561 PMCID: PMC8270955 DOI: 10.1038/s41598-021-93621-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 06/28/2021] [Indexed: 11/11/2022] Open
Abstract
Prompt reperfusion is important to rescue ischemic tissue; however, the process itself presents a key pathomechanism that contributes to a poor outcome following cardiac arrest. Experimental data have suggested the use of levosimendan to limit ischemia–reperfusion injury by improving cerebral microcirculation. However, recent studies have questioned this effect. The present study aimed to investigate the influence on hemodynamic parameters, cerebral perfusion and oxygenation following cardiac arrest by ventricular fibrillation in juvenile male pigs. Following the return of spontaneous circulation (ROSC), animals were randomly assigned to levosimendan (12 µg/kg, followed by 0.3 µg/kg/min) or vehicle treatment for 6 h. Levosimendan-treated animals showed significantly higher brain PbtO2 levels. This effect was not accompanied by changes in cardiac output, preload and afterload, arterial blood pressure, or cerebral microcirculation indicating a local effect. Cerebral oxygenation is key to minimizing damage, and thus, current concepts are aimed at improving impaired cardiac output or cerebral perfusion. In the present study, we showed that NIRS does not reliably detect low PbtO2 levels and that levosimendan increases brain oxygen content. Thus, levosimendan may present a promising therapeutic approach to rescue brain tissue at risk following cardiac arrest or ischemic events such as stroke or traumatic brain injury.
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Levosimendan Ameliorates Post-Resuscitation Acute Intestinal Microcirculation Dysfunction Partly Independent of Its Effects on Systemic Circulation: A Pilot Study On Cardiac Arrest In A Rat Model. Shock 2021; 56:639-646. [PMID: 33710108 DOI: 10.1097/shk.0000000000001771] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Cardiac arrest (CA) is recognized as a life-threatening disease; however, the initial resuscitation success rate has increased due to advances in clinical treatment. Levosimendan has shown potential benefits in CA patients. However, its exact function on intestinal and systemic circulation in CA or post-cardiac arrest syndrome (PCAS) remained unclear. This study preliminarily investigated the link between dynamic changes in intestine and systemic hemodynamics post-resuscitation after levosimendan administration. METHODS Twenty-five rats were randomized into three groups: 1) sham control group (n = 5), 2) levosimendan group (n = 10), and 3) vehicle group (n = 10). Intestinal microcirculation was observed using a sidestream dark-field imaging device at baseline and each hour of the return of spontaneous circulation (≤6 h). Systemic hemodynamics, serum indicators of cardiac injury, and tissue perfusion/metabolism were measured by echo-cardiography, a biological signal acquisition system, and an enzyme-linked immunosorbent assay (ELISA), respectively. RESULTS Myocardial injury and global and intestinal perfusion/metabolism were significantly improved by levosimendan treatment. There was no statistically significant difference in the mean arterial pressure values between the vehicle and levosimendan groups (P > 0.05). The intestinal and systemic circulation measurements showed poor correlation (Pearson r-value of variable combinations in the levosimendan group was much less than 0.75; P < 0.01, levosimendan vs. vehicle group). CONCLUSIONS Levosimendan significantly reduced the cardiac injury and corrected the metabolic status in an experimental rat model of ventricular fibrillation (VF) induced CA and CPR. Levosimendan may ameliorate PCAS-induced intestinal microcirculation dysfunction, partly independent of its effects on macrocirculation.
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Wang CH, Chang WT, Tsai MS, Huang CH, Chen WJ. Synergistic Effects of Moderate Therapeutic Hypothermia and Levosimendan on Cardiac Function and Survival After Asphyxia-Induced Cardiac Arrest in Rats. J Am Heart Assoc 2020; 9:e016139. [PMID: 32476598 PMCID: PMC7429058 DOI: 10.1161/jaha.120.016139] [Citation(s) in RCA: 4] [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] [Indexed: 12/21/2022]
Abstract
Background This study investigated whether levosimendan, an inotropic calcium sensitizer, when combined with moderate therapeutic hypothermia, may exert synergistic benefits on post–cardiac arrest myocardial dysfunction and improve outcomes. Methods and Results After 9.5‐minute asphyxia‐induced cardiac arrest and resuscitation, 48 rats were randomized equally into 4 groups following return of spontaneous circulation (ROSC), including normothermia, hypothermia, normothermia–levosimendan, and hypothermia–levosimendan groups. For the normothermia group, the target temperature was 37°C while for the hypothermia group, the target temperature was 32°C, both of which were to be maintained for 4 hours after ROSC. Levosimendan was administered after ROSC with a loading dose of 10 μg/kg and then infused at 0.1 μg/kg per min for 4 hours. In the hypothermia–levosimendan group, left ventricular systolic function and cardiac output increased significantly, whereas the heart rate and systemic vascular resistance decreased significantly compared with the normothermia group. Also, the concentrations of interleukin 1β at 4 hours post‐ROSC and the production of NO between 1 hour and 4 hours post‐ROSC were reduced significantly in the hypothermia–levosimendan group compared with the normothermia group. The 72‐hour post‐ROSC survival and neurological recovery were also significantly better in the hypothermia–levosimendan group compared with the normothermia group (survival, 100% versus 50%, χ2 test, P=0.006). Conclusions Compared with normothermia, only combined moderate therapeutic hypothermia and levosimendan treatment could consistently improve post–cardiac arrest myocardial dysfunction and decrease the release of pro‐inflammatory molecules, thereby improving survival and neurological outcomes. These findings suggest synergistic benefits between moderate therapeutic hypothermia and levosimendan.
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Affiliation(s)
- Chih-Hung Wang
- Department of Emergency Medicine National Taiwan University Hospital Taipei Taiwan.,Department of Emergency Medicine College of Medicine National Taiwan University Taipei Taiwan
| | - Wei-Tien Chang
- Department of Emergency Medicine National Taiwan University Hospital Taipei Taiwan.,Department of Emergency Medicine College of Medicine National Taiwan University Taipei Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine National Taiwan University Hospital Taipei Taiwan.,Department of Emergency Medicine College of Medicine National Taiwan University Taipei Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine National Taiwan University Hospital Taipei Taiwan.,Department of Emergency Medicine College of Medicine National Taiwan University Taipei Taiwan
| | - Wen-Jone Chen
- Department of Emergency Medicine National Taiwan University Hospital Taipei Taiwan.,Department of Emergency Medicine College of Medicine National Taiwan University Taipei Taiwan.,Division of Cardiology Department of Internal Medicine National Taiwan University Hospital and National Taiwan University College of Medicine Taipei Taiwan
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Levosimendan enhances memory through antioxidant effect in rat model: behavioral and molecular study. Behav Pharmacol 2018; 29:344-350. [DOI: 10.1097/fbp.0000000000000362] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Séguéla PE, Tafer N, Thambo JB, Mauriat P. [Use of levosimendan in children]. Arch Pediatr 2016; 23:848-56. [PMID: 27369103 DOI: 10.1016/j.arcped.2016.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 03/09/2016] [Accepted: 05/10/2016] [Indexed: 11/17/2022]
Abstract
Levosimendan is a calcium-sensitizing drug with positive inotropic properties. As an inodilator, this molecule also has a vasodilation effect. While its efficacy has been demonstrated in the adult in the context of cardiac surgery, its pediatric use is still not widespread. Many studies have shown its safety of use in children, including in the newborn. Across the world, a growing number of teams use levosimendan to treat both acute and chronic heart failure. Through a review of the literature, we describe its pharmacodynamic effects, its current applications, and its perspectives of use in children.
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Affiliation(s)
- P-E Séguéla
- Service de cardiologie pédiatrique et congénitale, hôpital Haut-Lévèque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac cedex, France; Service de réanimation chirurgicale des cardiopathies congénitales, hôpital Haut-Lévèque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac, France.
| | - N Tafer
- Service de réanimation chirurgicale des cardiopathies congénitales, hôpital Haut-Lévèque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac, France
| | - J-B Thambo
- Service de cardiologie pédiatrique et congénitale, hôpital Haut-Lévèque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac cedex, France
| | - P Mauriat
- Service de réanimation chirurgicale des cardiopathies congénitales, hôpital Haut-Lévèque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac, France
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Guerrero-Orriach JL, Ariza-Villanueva D, Florez-Vela A, Garrido-Sánchez L, Moreno-Cortés MI, Galán-Ortega M, Ramírez-Fernández A, Alcaide Torres J, Fernandez CS, Navarro Arce I, Melero-Tejedor JM, Rubio-Navarro M, Cruz-Mañas J. Cardiac, renal, and neurological benefits of preoperative levosimendan administration in patients with right ventricular dysfunction and pulmonary hypertension undergoing cardiac surgery: evaluation with two biomarkers neutrophil gelatinase-associated lipocalin and neuronal enolase. Ther Clin Risk Manag 2016; 12:623-30. [PMID: 27143905 PMCID: PMC4844253 DOI: 10.2147/tcrm.s102772] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE To evaluate if the preoperative administration of levosimendan in patients with right ventricular (RV) dysfunction, pulmonary hypertension, and high perioperative risk would improve cardiac function and would also have a protective effect on renal and neurological functions, assessed using two biomarkers neutrophil gelatinase-associated lipocalin (N-GAL) and neuronal enolase. METHODS This is an observational study. Twenty-seven high-risk cardiac patients with RV dysfunction and pulmonary hypertension, scheduled for cardiac valve surgery, were prospectively followed after preoperative administration of levosimendan. Levosimendan was administered preoperatively on the day before surgery. All patients were considered high risk of cardiac and perioperative renal complications. Cardiac function was assessed by echocardiography, renal function by urinary N-GAL levels, and the acute kidney injury scale. Neuronal damage was assessed by neuron-specific enolase levels. RESULTS After surgery, no significant variations were found in mean and SE levels of N-GAL (14.31 [28.34] ng/mL vs 13.41 [38.24] ng/mL), neuron-specific enolase (5.40 [0.41] ng/mL vs 4.32 [0.61] ng/mL), or mean ± SD creatinine (1.06±0.24 mg/dL vs 1.25±0.37 mg/dL at 48 hours). RV dilatation decreased from 4.23±0.7 mm to 3.45±0.6 mm and pulmonary artery pressure from 58±18 mmHg to 42±19 mmHg at 48 hours. CONCLUSION Preoperative administration of levosimendan has shown a protective role against cardiac, renal, and neurological damage in patients with a high risk of multiple organ dysfunctions undergoing cardiac surgery.
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Affiliation(s)
| | - Daniel Ariza-Villanueva
- Department of Cardio-Anaesthesiology, University Hospital Virgen de la Victoria, Málaga, Spain
| | - Ana Florez-Vela
- Department of Cardio-Anaesthesiology, University Hospital Virgen de la Victoria, Málaga, Spain
| | - Lourdes Garrido-Sánchez
- CIBER Fisiología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Málaga, Spain
- Department of Nutrition and Endocrinology, Instituto de Investigaciones Biomédicas de Málaga (IBIMA), University Hospital Virgen de la Victoria, Málaga, Spain
| | | | - Manuel Galán-Ortega
- Department of Cardio-Anaesthesiology, University Hospital Virgen de la Victoria, Málaga, Spain
| | | | - Juan Alcaide Torres
- Department of Nutrition and Endocrinology, Instituto de Investigaciones Biomédicas de Málaga (IBIMA), University Hospital Virgen de la Victoria, Málaga, Spain
| | - Concepción Santiago Fernandez
- Department of Nutrition and Endocrinology, Instituto de Investigaciones Biomédicas de Málaga (IBIMA), University Hospital Virgen de la Victoria, Málaga, Spain
| | - Isabel Navarro Arce
- Department of Cardio-Anaesthesiology, University Hospital Virgen de la Victoria, Málaga, Spain
| | | | - Manuel Rubio-Navarro
- Department of Cardio-Anaesthesiology, University Hospital Virgen de la Victoria, Málaga, Spain
| | - José Cruz-Mañas
- Department of Cardio-Anaesthesiology, University Hospital Virgen de la Victoria, Málaga, Spain
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Picard J, Meek T. Lipid emulsion for intoxication by local anaesthetic: sunken sink? Anaesthesia 2016; 71:879-82. [PMID: 26854285 DOI: 10.1111/anae.13395] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- J Picard
- Department of Anaesthesia, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK.
| | - T Meek
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
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Levijoki J, Kivikko M, Pollesello P, Sallinen J, Hyttilä-Hopponen M, Kuoppamäki M, Haasio K, Gröhn O, Miettinen R, Puoliväli J, Tähtivaara L, Yrjänheikki J, Haapalinna A. Levosimendan alone and in combination with valsartan prevents stroke in Dahl salt-sensitive rats. Eur J Pharmacol 2015; 750:132-40. [PMID: 25641751 DOI: 10.1016/j.ejphar.2015.01.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 01/20/2015] [Accepted: 01/21/2015] [Indexed: 11/16/2022]
Abstract
The effects of levosimendan on cerebrovascular lesions and mortality were investigated in models of primary and secondary stroke. We aimed to determine whether the effects of levosimendan are comparable to and/or cumulative with those of valsartan, and to investigate whether levosimendan-induced vasodilation has a role in its effects on stroke. In a primary stroke Dahl/Rapp rat model, mortality rates were 70% and 5% for vehicle and levosimendan, respectively. Both stroke incidence (85% vs. 10%, P<0.001) and stroke-associated behavioral deficits (7-point neuroscore: 4.59 vs. 5.96, P<0.001) were worse for vehicle compared to levosimendan. In a secondary stroke model in which levosimendan treatment was started after cerebrovascular incidences were already detected, mean survival times were 15 days with vehicle, 20 days with levosimendan (P=0.025, vs. vehicle), 22 days with valsartan (P=0.001, vs. vehicle), and 31 days with levosimendan plus valsartan (P<0.001, vs. vehicle). The respective survivals were 0%, 16%, 20% and 59%, and the respective incidences of severe lesions were 50%, 67%, 50% and 11%. In this rat model, levosimendan increased blood volume of the cerebral vessels, with significant effects in the microvessels of the cortex (∆R=3.5±0.15 vs. 2.7±0.17ml for vehicle; P=0.001) and hemisphere (∆R=3.2±0.23 vs. 2.6±0.14ml for vehicle; P=0.018). Overall, levosimendan significantly reduced stroke-induced mortality and morbidity, both alone and with valsartan, with apparent cumulative effects, an activity in which the vasodilatory effects of levosimendan have a role.
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Affiliation(s)
- Jouko Levijoki
- Critical Care Proprietary Products, Orion Pharma, Orionintie 1, P.O. Box 65, FI-02101 Espoo, Finland
| | - Matti Kivikko
- Critical Care Proprietary Products, Orion Pharma, Orionintie 1, P.O. Box 65, FI-02101 Espoo, Finland
| | - Piero Pollesello
- Critical Care Proprietary Products, Orion Pharma, Orionintie 1, P.O. Box 65, FI-02101 Espoo, Finland.
| | - Jukka Sallinen
- Critical Care Proprietary Products, Orion Pharma, Orionintie 1, P.O. Box 65, FI-02101 Espoo, Finland
| | - Minja Hyttilä-Hopponen
- Critical Care Proprietary Products, Orion Pharma, Orionintie 1, P.O. Box 65, FI-02101 Espoo, Finland
| | - Mikko Kuoppamäki
- Critical Care Proprietary Products, Orion Pharma, Orionintie 1, P.O. Box 65, FI-02101 Espoo, Finland
| | - Kristiina Haasio
- Critical Care Proprietary Products, Orion Pharma, Orionintie 1, P.O. Box 65, FI-02101 Espoo, Finland
| | - Olli Gröhn
- A.I.Virtanen Institute for Molecular Sciences, Neulaniementie 2, P.O. Box 1627, FIN-70211 Kuopio, Finland
| | - Riitta Miettinen
- Tampere University of Technology, Korkeakoulunkatu 10, FI-33720 Tampere, Finland
| | - Jukka Puoliväli
- Cerebricon Ltd., c/o Charles River Laboratories, Microkatu 1, FI-70210 Kuopio, Finland
| | - Leena Tähtivaara
- Cerebricon Ltd., c/o Charles River Laboratories, Microkatu 1, FI-70210 Kuopio, Finland
| | - Juha Yrjänheikki
- Cerebricon Ltd., c/o Charles River Laboratories, Microkatu 1, FI-70210 Kuopio, Finland
| | - Antti Haapalinna
- Critical Care Proprietary Products, Orion Pharma, Orionintie 1, P.O. Box 65, FI-02101 Espoo, Finland
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