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David N, Lakha S, Walsh S, Fried E, DeMaria S. Novel inhaled pulmonary vasodilators in adult cardiac surgery: a scoping review. Can J Anaesth 2024:10.1007/s12630-024-02770-w. [PMID: 38782851 DOI: 10.1007/s12630-024-02770-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/08/2024] [Accepted: 02/18/2024] [Indexed: 05/25/2024] Open
Abstract
PURPOSE Pulmonary hypertension (PH) is a common cause of postoperative mortality in cardiac surgery that is commonly treated with conventional inhaled therapies, specifically nitric oxide and prostacyclin. Alternative therapies include inhaled milrinone and levosimendan, which are receiving more research interest and are increasing in clinical use as they may cut costs while allowing for easier administration. We sought to conduct a scoping review to appraise the evidence base for the use of these two novel inhaled vasodilators as an intervention for PH in cardiac surgery. SOURCE We searched Embase and MEDLINE for relevant articles from 1947 to 2022. PRINCIPAL FINDINGS We identified 17 studies including 969 patients. The included studies show that inhaled milrinone and levosimendan are selective pulmonary vasodilators with potential benefits ranging from ease of weaning from cardiopulmonary bypass to reduction in ventricular dysfunction. Nevertheless, high-quality data are limited, and study design and comparators are extremely heterogeneous, limiting the potential validity and generalizability of findings. CONCLUSION The findings of this scoping review suggest that milrinone and levosimendan may be effective alternatives to current inhaled therapies for cardiac dysfunction in the setting of PH. Nevertheless, randomized trials have focused on specific agents and consistent outcome measures are needed to better validate the early-stage promise of these agents. STUDY REGISTRATION Open Science Framework ( https://osf.io/z3k6f/ ); first posted 21 July 2022.
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Affiliation(s)
- Navindra David
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA.
| | - Sameer Lakha
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samantha Walsh
- Hunter College, City University of New York, New York, NY, USA
| | - Eric Fried
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel DeMaria
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Pilia E, Silvetti S, Bohane SM, Pusceddu E, Belletti A. Safety of Levosimendan in Pediatric Patients: An Up-to-Date Systematic Review. J Cardiothorac Vasc Anesth 2024; 38:820-828. [PMID: 38135567 DOI: 10.1053/j.jvca.2023.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND The potential risks associated with the use of levosimendan in the pediatric population has not been systematically evaluated. This study aimed to review the available evidence regarding the safety of this treatment. METHODS Bio Med Central, PubMed, Embase, and the Cochrane Central Register of clinical trials were searched for studies describing levosimendan administration in the pediatric population in any setting. Relevant studies were independently screened, selected, and their data extracted by two investigators. The authors excluded: reviews, meta-analyses, as well as basic research and trials involving patients >18 years old. The primary outcome was the number and the type of adverse side effects reported during levosimendan administration. RESULTS The updated systematic review included 48 studies, enrolling a total of 1,271 pediatric patients who received levosimendan as treatment (790 patients in the 11 studies that reported side effects). The primary adverse effects of levosimendan administration were hypotension and cardiac arrhythmias, particularly tachycardia. Hypotension occurred in approximately 28.9% of patients, while arrhythmia occurred in about 12.3% of patients. Meta analysis of RCTs revealed a rate of all-cause mortality of 2.0% (8 out of 385) in the levosimendan group compared to 3.9% (15 out of 378) in the control group (dobutamine, milrinone or placebo) (risk ratio [RR] = 0.55; 95% confidence interval [CI] = 0.25-1.21; P = 0.14; I2 = 0%) CONCLUSIONS: Hypotension and cardiac arrhythmia are the most reported side effects of levosimendan in pediatric patients. However, adverse events remain underreported, especially in randomized trials.
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Affiliation(s)
- Eros Pilia
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy; ARNAS G. Brotzu, Anesthesia and Intensive Care Unit, Liver Transplantation Center, Cagliari, Italy
| | - Simona Silvetti
- Dipartimento di Cardioanestesia e Terapia Intensiva, Ospedale Policlinico San Martino IRCCS - IRCCS Cardiovascular Network, Genova, Italy
| | - Shai Marc Bohane
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elisabetta Pusceddu
- ARNAS G. Brotzu, Anesthesia and Intensive Care Unit, Liver Transplantation Center, Cagliari, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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Ftikos P, Falara A, Rellia P, Leontiadis E, Samanidis G, Kamperi N, Piperakis A, Tamvakopoulos C, Antoniou T, Theodoraki K. Monitoring of Levosimendan Administration in Patients with Pulmonary Hypertension Undergoing Cardiac Surgery and Effect of Two Different Dosing Schemes on Hemodynamic and Echocardiographic Parameters. Pharmaceuticals (Basel) 2023; 16:815. [PMID: 37375762 DOI: 10.3390/ph16060815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/17/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION The perioperative management of patients with pulmonary hypertension (PH) undergoing cardiac surgery represents one of the most challenging clinical scenarios. This fact mainly depends on the relationship existing between PH and right ventricular failure (RVF). Levosimendan (LS) is an inodilator that might be an effective agent in the treatment of PH and RVF. The aim of this study was to examine the impact of the duration of cardiopulmonary bypass (CPB) on the therapeutic drug monitoring of LS and to evaluate the effect of preemptive administration of LS on perioperative hemodynamic and echocardiographic parameters in cardiac surgical patients with preexisting PH. MATERIALS AND METHODS In this study, LS was administered in adult patients undergoing cardiac surgery before CPB in order to prevent exacerbation of preexisting PH and subsequent right ventricular dysfunction. Thirty cardiac surgical patients with preoperatively confirmed PH were randomized to receive either 6 μg/kg or 12 μg/kg of LS after the induction of anesthesia. The plasma concentration of LS was measured after CPB. In this study, a low sample volume was used combined with a simple sample preparation protocol. The plasma sample was extracted by protein precipitation and evaporated; then, the analyte was reconstituted and detected using specific and sensitive bioanalytical liquid chromatography with mass spectrometry (LC-MS/MS) methodology. The clinical, hemodynamic, and echocardiographic parameters were registered and evaluated before and after the administration of the drug. RESULTS A fast bioanalytical LC-MS/MS methodology (a run time of 5.5 min) was developed for the simultaneous determination of LS and OR-1896, its main metabolite in human plasma. The LC-MS/MS method was linear over a range of 0.1-50 ng/mL for LS and 1-50 ng/mL for its metabolite OR-1896. Measured plasma concentrations of LS were inversely related to the duration of CPB. LS administration before CPB during cardiac surgery was effective in reducing pulmonary artery pressure and improving hemodynamic parameters after CPB, with a more pronounced and durable effect of the drug at the dose of 12 μg/kg. Additionally, administration of LS at a dose of 12 μg/kg in cardiac surgical patients with PH before CPB improved right ventricular function. CONCLUSION LS administration decreases pulmonary artery pressure and may improve right ventricular function in patients with PH undergoing cardiac surgery.
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Affiliation(s)
- Panagiotis Ftikos
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece
| | - Areti Falara
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece
| | - Panagiota Rellia
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece
| | | | - George Samanidis
- Department of Cardiac Surgery, Onassis Cardiac Surgery Center, 176 74 Athens, Greece
| | - Natalia Kamperi
- Center of Clinical Research, Experimental Surgery and Translational Research, Division of Pharmacology-Pharmacotechnology, Biomedical Research Foundation, Academy of Athens, 115 27 Athens, Greece
| | - Artemios Piperakis
- Center of Clinical Research, Experimental Surgery and Translational Research, Division of Pharmacology-Pharmacotechnology, Biomedical Research Foundation, Academy of Athens, 115 27 Athens, Greece
| | - Constantin Tamvakopoulos
- Center of Clinical Research, Experimental Surgery and Translational Research, Division of Pharmacology-Pharmacotechnology, Biomedical Research Foundation, Academy of Athens, 115 27 Athens, Greece
| | - Theofani Antoniou
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece
| | - Kassiani Theodoraki
- Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece
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Weisert M, Su JA, Menteer J, Shaddy RE, Kantor PF. Drug Treatment of Heart Failure in Children: Gaps and Opportunities. Paediatr Drugs 2022; 24:121-136. [PMID: 35084696 DOI: 10.1007/s40272-021-00485-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 12/11/2022]
Abstract
Medical therapy for pediatric heart failure is based on a detailed mechanistic understanding of the underlying causes, which are diverse and unlike those encountered in most adult patients. Diuresis and improved perfusion are the immediate goals of care in the child with acute decompensated heart failure. Conversion to maintenance oral therapy for heart failure is based on the results of landmark studies in adults, as well as recent pediatric clinical trials and heart failure guidelines. There will continue to be an important role for newer drugs, some of which are in active trials in adults, and some of which are already approved for use in children. The need to plan for clinical trials in children during drug development for heart failure is emphasized.
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Affiliation(s)
- Molly Weisert
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Division of Cardiology, Heart Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jennifer A Su
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Division of Cardiology, Heart Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jondavid Menteer
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Division of Cardiology, Heart Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Robert E Shaddy
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Division of Cardiology, Heart Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Paul F Kantor
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
- Division of Cardiology, Heart Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA.
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Dumitrescu D, Koster A, Erdoes G, Denault AY. Perioperative Management of Pulmonary Hypertension During Cardiac Surgery: A Call for Interdisciplinary Networking. J Cardiothorac Vasc Anesth 2022; 36:1549-1551. [DOI: 10.1053/j.jvca.2022.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 11/11/2022]
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Zang H, Yan W, Xie W. Comment on "The direct comparison of inhaled versus intravenous levosimendan in children with pulmonary hypertension undergoing on-cardiopulmonary bypass cardiac surgery: A randomized, controlled, non-inferiority study". J Clin Anesth 2021; 76:110572. [PMID: 34763274 DOI: 10.1016/j.jclinane.2021.110572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Honggang Zang
- Department of Anaesthesia, Gansu Provincial Hospital, Lanzhou 730000, Gansu, China
| | - Wenjun Yan
- Department of Anaesthesia, Gansu Provincial Hospital, Lanzhou 730000, Gansu, China
| | - Wanxia Xie
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou 730000, Gansu, China.
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Evans MA, Suresh S. Inhaled levosimendan: New opportunities with an old drug. J Clin Anesth 2021; 73:110337. [PMID: 33984811 DOI: 10.1016/j.jclinane.2021.110337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Michael A Evans
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States of America; Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America.
| | - Santhanam Suresh
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States of America; Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
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