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Elsaeidy AS, Abuelazm M, Ghaly R, Soliman Y, Amin AM, El-Gohary M, Elshenawy S, Seri AR, Abdelazeem B, Patel B, Bianco C. The Efficacy and Safety of Levosimendan in Patients with Advanced Heart Failure: An Updated Meta-Analysis of Randomized Controlled Trials. Am J Cardiovasc Drugs 2024:10.1007/s40256-024-00675-z. [PMID: 39261444 DOI: 10.1007/s40256-024-00675-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND Intermittent ambulatory levosimendan administration has been shown in several small randomized controlled trials to benefit patients with advanced heart failure, preventing heart failure rehospitalization and mortality. We aim to investigate the totality of high-quality evidence regarding the efficacy and safety of intermittent levosimendan in advanced heart failure patients. METHODS Up to September 2023, we systematically reviewed the randomized controlled trials indexed in PubMed, Embase Cochrane, SCOPUS, and Web of Science. We used mean difference (MD) to estimate the continuous outcomes, and risk ratio (RR) for the dichotomous outcomes with a 95% confidence interval (CI), using the random-effects model. Ultimately, a trial sequential analysis was employed to enhance the reliability of our findings and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework for certainty leveling. RESULTS Fifteen randomized controlled trials with 1181 patients were included. Intermittent levosimendan was significantly associated with an improved left ventricular ejection fraction compared with placebo (MD 6.39 [95% CI 3.04-9.73], P = 0.002; I2 = 75, P = 0.0005), with cumulative z-score of change after ≤ 1 week passing the monitoring boundaries, favoring the levosimendan, but did not cross the required information size. Additionally, levosimendan reduced the all-cause mortality rate (RR 0.60 [95% CI 0.40-0.90], P = 0.01; I2 = 9, P = 0.36). However, we found no difference between levosimendan and placebo in all-cause rehospitalization rate (RR 0.75 [95% CI 0.46-1.22], P = 0.25; I2 = 70, P = 0.04), event-free survival rate (RR 0.97 [95% CI 0.72-1.30], P = 0.84; I2 = 63, P = 0.03), or any adverse event (RR 1 [95% CI 0.73-1.37], P = 1.00, I2 = 0%, P = 0.70). CONCLUSION In patients with advanced heart failure, intermittent levosimendan significantly improved left ventricular ejection fraction, brain natriuretic peptide values, and all-cause mortality rate. Levosimendan use is not associated with a change in rehospitalization or event-free survival. REGISTRATION PROSPERO identifier number (CRD42023487838).
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Affiliation(s)
| | | | - Ramy Ghaly
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, USA
| | | | | | - Mohamed El-Gohary
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, USA
| | - Salem Elshenawy
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Amith Reddy Seri
- Department of Internal Medicine, McLaren Health Care/Michigan State University, Flint, MI, USA
| | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, West Virginia, USA
| | - Brijesh Patel
- Department of Cardiology, West Virginia University, West Virginia, USA
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Loomba RS, Savorgnan F, Acosta S, Elhoff JJ, Farias JS, Villarreal EG, Flores S. Clinical Interventions and Hemodynamic Monitoring in the Setting of Left Ventricular Systolic Heart Failure in Children: Insights From a Physiologic Simulator. Am J Ther 2024; 31:e531-e540. [PMID: 39292830 DOI: 10.1097/mjt.0000000000001711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2024]
Abstract
BACKGROUND In pediatric critical care, vasoactive/inotropic support is widely used in patients with heart failure, but it remains controversial because the influence of multiple medications and the interplay between their inotropic and vasoactive effects on a given patient are hard to predict. Robust evidence supporting their use and quantifying their effects in this group of patients is scarce. STUDY QUESTION The aim of this study was to characterize the effect of vasoactive medications on various cardiovascular parameters in pediatric patient with decreased ejection fraction. STUDY DESIGN Clinical-data based physiologic simulator study. MEASURE AND OUTCOMES We used a physics-based computer simulator for quantifying the response of cardiovascular parameters to the administration of various types of vasoactive/inotropic medications in pediatric patients with decreased ejection fraction. The simulator allowed us to study the impact of increasing medication dosage and the simultaneous administration of some vasoactive agents. Correlation and linear regression analyses yielded the quantified effects on the vasoactive/inotropic support. RESULTS Cardiac output and systemic venous saturation significantly increased with the administration of dobutamine and milrinone in isolation, and combination of milrinone with dobutamine, dopamine, or epinephrine. Both parameters decreased with the administration of epinephrine and norepinephrine in isolation. No significant change in these hemodynamic parameters was observed with the administration of dopamine in isolation. CONCLUSIONS Milrinone and dobutamine were the only vasoactive medications that, when used in isolation, improved systemic oxygen delivery. Milrinone in combination with dobutamine, dopamine, or epinephrine also increased systemic oxygen delivery. The induced increment on afterload can negatively affect systemic oxygen delivery.
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Affiliation(s)
- Rohit S Loomba
- Division of Cardiology, Advocate Children's Hospital, Oak Lawn, IL
- Department of Pediatrics, Chicago Medical School/Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Fabio Savorgnan
- Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, TX
- Department of Pediatrics, Baylor College of Medicine, Houston, TX; and
| | - Sebastian Acosta
- Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, TX
- Department of Pediatrics, Baylor College of Medicine, Houston, TX; and
| | - Justin J Elhoff
- Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, TX
- Department of Pediatrics, Baylor College of Medicine, Houston, TX; and
| | - Juan S Farias
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico
| | - Enrique G Villarreal
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico
| | - Saul Flores
- Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, TX
- Department of Pediatrics, Baylor College of Medicine, Houston, TX; and
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Kipka H, Liebchen U, Hübner M, Höfner G, Frey O, Wanner KT, Kilger E, Hagl C, Tomasi R, Mannell H. Serum concentrations of levosimendan and its metabolites OR-1855 and OR-1896 in cardiac surgery patients with cardiopulmonary bypass. Front Cardiovasc Med 2024; 11:1406338. [PMID: 39175630 PMCID: PMC11338783 DOI: 10.3389/fcvm.2024.1406338] [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: 03/24/2024] [Accepted: 04/19/2024] [Indexed: 08/24/2024] Open
Abstract
Background The inotropic drug levosimendan is often used as an individualized therapeutic approach perioperatively in cardiac surgery patients with cardiopulmonary bypass (CPB). Data regarding serum concentrations of levosimendan and its metabolites within this context is lacking. Methods In this retrospective descriptive proof-of-concept study, total serum concentrations (TSC) and unbound fractions (UF) of levosimendan and its metabolites OR-1896 and OR-1855 in cardiac surgery patients with CPB were measured using LC-ESI-MS/MS. Simulation of expected levosimendan TSC was performed using Pharkin 4.0. Serum NT-proBNP was assessed with ELISA. Results After levosimendan infusion (1.25 mg or 2.5 mg, respectively) after anaesthesia induction, a median TSC of 1.9 ng/ml and 10.4 ng/ml was determined in samples taken directly after surgery (T1). Median TSC of 7.6 ng/ml and 22.0 ng/ml, respectively, were simulated at T1. Whereas 1.1 ng/ml and 1.6 ng/ml TSC of OR-1896, respectively, was quantified the day after surgery (T2), TSC of the intermediate metabolite OR-1855 was mostly below the lower limit of quantification (LLOQ). The UF was 0.5% and 1.1% for levosimendan and 64.1% and 52.1% for OR-1896, respectively, with over half the samples being below LLOQ. NT-proBNP concentrations before surgery and T2 did not differ. Discussion The low TSC, UF and unchanged NT-proBNP levels in combination with high variation of serum levels between patients suggest a need for optimized dosing regimen of levosimendan combined with therapeutic drug monitoring for such an individualized approach. In addition, the differences between the measured and estimated concentrations may suggest a possible influence of CPB on levosimendan serum concentrations.
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Affiliation(s)
- Hannah Kipka
- Doctoral Program Clinical Pharmacy, LMU University Hospital, LMU Munich, Germany
- Institute of Cardiovascular Physiology and Pathophysiology, Biomedical Center, LMU Munich, Planegg, Germany
| | - Uwe Liebchen
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Max Hübner
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
- Walter Brendel Center of Experimental Medicine, LMU Munich, LMU University Hospital, Munich, Germany
| | - Georg Höfner
- Department of Pharmacy, Center for Drug Research, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Otto Frey
- Department of Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Klaus T. Wanner
- Department of Pharmacy, Center for Drug Research, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Erich Kilger
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Germany
- DZHK (German Centre of Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Roland Tomasi
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Hanna Mannell
- Doctoral Program Clinical Pharmacy, LMU University Hospital, LMU Munich, Germany
- Institute of Cardiovascular Physiology and Pathophysiology, Biomedical Center, LMU Munich, Planegg, Germany
- Physiology, Institute for Theoretical Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
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Iorio AM, Lucà F, Pozzi A, Rao CM, Di Fusco SA, Colivicchi F, Grimaldi M, Oliva F, Gulizia MM. Inotropic Agents: Are We Still in the Middle of Nowhere? J Clin Med 2024; 13:3735. [PMID: 38999301 PMCID: PMC11242653 DOI: 10.3390/jcm13133735] [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: 04/01/2024] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 07/14/2024] Open
Abstract
Inotropes are prescribed to enhance myocardial contractility while vasopressors serve to improve vascular tone. Although these medications remain a life-saving therapy in cardiovascular clinical scenarios with hemodynamic impairment, the paucity of evidence on these drugs makes the choice of the most appropriate vasoactive agent challenging. As such, deep knowledge of their pharmacological and hemodynamic effects becomes crucial to optimizing hemodynamic profile while reducing the potential adverse effects. Given this perspective, it is imperative for cardiologists to possess a comprehensive understanding of the underlying mechanisms governing these agents and to discern optimal strategies for their application across diverse clinical contexts. Thus, we briefly review these agents' pharmacological and hemodynamic properties and their reasonable clinical applications in cardiovascular settings. Critical interpretation of available data and the opportunities for future investigations are also highlighted.
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Affiliation(s)
- Anna Maria Iorio
- Cardiology Department, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy;
| | - Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, 89129 Reggio Calabria, Italy;
| | - Andrea Pozzi
- Cardiology Division, Valduce Hospital, 22100 Como, Italy;
| | | | - Stefania Angela Di Fusco
- Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Rome, Italy; (S.A.D.F.); (F.C.)
| | - Furio Colivicchi
- Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Rome, Italy; (S.A.D.F.); (F.C.)
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy;
| | - Fabrizio Oliva
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy;
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de Juan Bagudá J, de Frutos F, López-Vilella R, Couto Mallón D, Guzman-Bofarull J, Blazquez-Bermejo Z, Cobo-Belaustegui M, Mitroi C, Pastor-Pérez FJ, Moliner-Abós C, Rangel-Sousa D, Díaz-Molina B, Tobar-Ruiz J, Salterain Gonzalez N, García-Pinilla JM, García-Cosío Carmena MD, Crespo-Leiro MG, Dobarro D, Almenar L, Delgado-Jiménez JF, Paredes-Galán E, González-Vílchez F, González-Costello J. Repetitive ambulatory levosimendan as a bridge to heart transplantation. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:290-301. [PMID: 37516313 DOI: 10.1016/j.rec.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 07/07/2023] [Indexed: 07/31/2023]
Abstract
INTRODUCTION AND OBJECTIVES Repetitive ambulatory doses of levosimendan are an option as a bridge to heart transplantation (HT), but evidence regarding the safety and efficacy of this treatment is scarce. The objective of the LEVO-T Registry is to describe the profile of patients on the HT list receiving levosimendan, prescription patterns, and clinical outcomes compared with patients not on levosimendan. METHODS We retrospectively reviewed all patients listed for elective HT from 2015 to 2020 from 14 centers in Spain. RESULTS A total of 1015 consecutive patients were included, of whom 238 patients (23.4%) received levosimendan. Patients treated with levosimendan had more heart failure (HF) admissions in the previous year and a worse clinical profile. The most frequent prescription pattern were fixed doses triggered by the patients' clinical needs. Nonfatal ventricular arrhythmias occurred in 2 patients (0.8%). No differences in HF hospitalizations were found between patients who started levosimendan in the first 30 days after listing and those who did not (33.6% vs 34.5%; P=.848). Among those who did not, 102 patients (32.9%) crossed over to levosimendan after an HF admission. These patients had a rate of 0.57 HF admissions per month before starting levosimendan and 0.21 afterwards. Propensity score matching analysis showed no differences in survival at 1 year after listing between patients receiving levosimendan and those who did not (HR, 1.03; 95%CI, 0.36-2.97; P=.958) or in survival after HT (HR, 0.97; 95%CI, 0.60-1.56; P=.958). CONCLUSIONS Repetitive levosimendan in an ambulatory setting as a bridge to heart transplantation is commonly used, is safe, and may reduce HF hospitalizations.
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Affiliation(s)
- Javier de Juan Bagudá
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Departamento de Medicina, Facultad de Ciencias Biomédicas y de la Salud, Universidad Europea de Madrid, Spain.
| | - Fernando de Frutos
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Unidad de Insuficiencia Cardíaca Avanzada y Trasplante, Servicio de Cardiología, Hospital Universitari de Bellvitge. BIOHEART-Cardiovascular diseases group; Cardiovascular, Respiratory and Systemic Diseases and cellular aging Program, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Raquel López-Vilella
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - David Couto Mallón
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
| | | | | | - Manuel Cobo-Belaustegui
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Cristina Mitroi
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Instituto Investigación Sanitaria Puerta de Hierro - Segovia de Arana (IDIPHISA), Madrid, Spain
| | | | - Carlos Moliner-Abós
- Servicio de Cardiología, Instituto Investigación Biomédica (IIB) SANT PAU, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Diego Rangel-Sousa
- Unidad de Insuficiencia Cardíaca y Trasplante Cardíaco, Servicio de Cardiología, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Beatriz Díaz-Molina
- Servicio de Cardiología, Área Gestión Clínica (AGC) del Corazón, Hospital Universitario Central de Asturias, Asturias, Spain
| | - Javier Tobar-Ruiz
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - José Manuel García-Pinilla
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Unidad de Insuficiencia Cardiaca y Cardiopatías Familiares, Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain; Departamento de Medicina y Dermatología, Universidad de Málaga, Málaga, Spain
| | - María Dolores García-Cosío Carmena
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - María Generosa Crespo-Leiro
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain; Grupo de Investigación Cardiovascular (GRINCAR), Universidad de A Coruña (UDC), A Coruña, Spain
| | - David Dobarro
- Unidad de Insuficiencia Cardiaca e Hipertensión Pulmonar, Hospital Álvaro Cunqueiro, Complexo Hospitalario Universitario de Vigo, Vigo, Pontevedra, Spain
| | - Luis Almenar
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Juan F Delgado-Jiménez
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Francisco González-Vílchez
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - José González-Costello
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Unidad de Insuficiencia Cardíaca Avanzada y Trasplante, Servicio de Cardiología, Hospital Universitari de Bellvitge. BIOHEART-Cardiovascular diseases group; Cardiovascular, Respiratory and Systemic Diseases and cellular aging Program, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
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Hansen BL, Kristensen SL, Gustafsson F. Use of Inotropic Agents in Advanced Heart Failure: Pros and Cons. Cardiology 2024; 149:423-437. [PMID: 38237564 DOI: 10.1159/000536373] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/15/2024] [Indexed: 10/04/2024]
Abstract
BACKGROUND Use of inotropic agents in advanced heart failure (HF) has over time been evaluated in several randomized, controlled clinical trials (RCTs). However, the evidence for both efficacy and safety is conflicting. SUMMARY In this narrative review, the evidence for and role of inotropes in advanced HF are outlined. Readers are provided with a comprehensive overview of key-findings from 23 important RCTs comparing orally or intravenously administered inotropes. Clinically relevant pros and cons of inotropic regimens are summarized to guide the clinician in the management of advanced HF patients in different settings (e.g., out-patient, in-patient, and intensive care unit). Finally, future perspectives and potential new agents are discussed. KEY MESSAGES Long-term use of inotropes in advanced HF is controversial and should only be considered in selected patients (e.g., as palliative or bridging strategy). However, short-term use continues to play a large role in hospitalized patients with cardiogenic shock or severe decompensated acute HF.
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Affiliation(s)
- Benjamin Lautrup Hansen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren Lund Kristensen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Arfaras-Melainis A, Ventoulis I, Polyzogopoulou E, Boultadakis A, Parissis J. The current and future status of inotropes in heart failure management. Expert Rev Cardiovasc Ther 2023; 21:573-585. [PMID: 37458248 DOI: 10.1080/14779072.2023.2237869] [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: 04/09/2023] [Revised: 07/08/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023]
Abstract
INTRODUCTION Heart failure (HF) is a complex syndrome with a wide range of presentations and acuity, ranging from outpatient care to inpatient management due to acute decompensated HF, cardiogenic shock or advanced HF. Frequently, the etiology of a patient's decompensation is diminished cardiac output and peripheral hypoperfusion. Consequently, there is a need for use of inotropes, agents that increase cardiac contractility, optimize hemodynamics and ensure adequate perfusion. AREAS COVERED Inotropes are divided into 3 major classes: beta agonists, phosphodiesterase III inhibitors and calcium sensitizers. Additionally, as data from prospective studies accumulates, novel agents are emerging, including omecamtiv mecarbil and istaroxime. The aim of this review is to summarize current data on the optimal use of inotropes and to provide an expert opinion regarding their current and future use in the management of HF. EXPERT OPINION The use of inotropes has long been linked to worsening mortality, tachyarrhythmias, increased myocardial oxygen consumption and ischemia. Therefore, individualized and evidence-based treatment plans for patients who require inotropic support are necessary. Also, better quality data on the use of existing inotropes is imperative, while the development of newer and safer agents will lead to more effective management of patients with HF in the future.
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Affiliation(s)
- Angelos Arfaras-Melainis
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, Ptolemaida, Greece
| | - Effie Polyzogopoulou
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Boultadakis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - John Parissis
- Emergency Department, Heart Failure Unit, Attikon University Hospital, Athens, Greece
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The importance of pharmacokinetics, pharmacodynamic and repetitive use of levosimendan. Biomed Pharmacother 2022; 153:113391. [DOI: 10.1016/j.biopha.2022.113391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 12/15/2022] Open
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Iravani Saadi M, Salami J, Abdi H, Kheradmand N, Nabi Bdolyousefi E, Torkamani M, Karimi Z, Agah S, Rahimian Z, Manafi A. Expression of interleukin 1, interleukin 27, and TNF α genes in patients with ischemic cardiomyopathy versus idiopathic dilated cardiomyopathy: A case-control study. Health Sci Rep 2022; 5:e701. [PMID: 35782303 PMCID: PMC9234474 DOI: 10.1002/hsr2.701] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/29/2022] [Accepted: 05/31/2022] [Indexed: 11/12/2022] Open
Abstract
Background and Aims Congestive heart failure is a complex multifactorial syndrome due to tissue hypoperfusion that is affected by some factors like inflammatory cytokines. In our study, we investigated the exact gene expression of three inflammatory cytokines in ischemic and idiopathic cardiomyopathy patients. Methods From 49 studied recipients in the ischemic group, 23 (46.9%) were male and from 40 studied recipients in the idiopathic dilated cardiomyopathy group, 19 (47.5%) were male. For the quantitative analysis of interleukin (IL)-1, IL-27, and tumor necrosis factor (TNF)-α messenger RNAs expression level, the SYBR Green real-time polymerase chain reaction method was performed using SYBRPremix Ex TaqTM II (Tli RNaseH Plus; Takara) and designed primers specific for each gene in an iQ5 thermocycler (BioRad Laboratories) according to the manufacturer's instructions. Results Our results showed that the expression level of IL-1 and TNF-α were significantly higher in the ischemic patients compared to healthy controls (p < 0.001, p < 0.01, respectively); also, we found higher levels of IL-1 and IL-27 gene expressions in idiopathic patients compared to healthy controls (p < 0.001, p < 0.001, respectively). There were not any significant differences in IL-1, IL-27, and TNF-α expression levels between ischemic patients and idiopathic ones. Conclusion Although we would introduce IL-1, IL-27, and TNF-α as effective inflammatory cytokines on myocardial functions in ischemic and idiopathic cardiomyopathy patients, there is not any difference between these two groups in gene expression of three main inflammatory cytokines.
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Affiliation(s)
| | - Javad Salami
- Department of NursingShiraz University of Medical SciencesShirazIran
| | - Hanieh Abdi
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Nadiya Kheradmand
- Colorectal Research CenterIran University of Medical SciencesTehranIran
| | | | - Mahmoud Torkamani
- Colorectal Research CenterIran University of Medical SciencesTehranIran
| | - Zahed Karimi
- Colorectal Research CenterIran University of Medical SciencesTehranIran
| | - Shahram Agah
- Colorectal Research CenterIran University of Medical SciencesTehranIran
| | - Zahra Rahimian
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Alireza Manafi
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
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Vishram-Nielsen JKK, Tomasoni D, Gustafsson F, Metra M. Contemporary Drug Treatment of Advanced Heart Failure with Reduced Ejection Fraction. Drugs 2022; 82:375-405. [PMID: 35113350 PMCID: PMC8820365 DOI: 10.1007/s40265-021-01666-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 12/11/2022]
Abstract
The introduction of multiple new pharmacological agents over the past three decades in the field of heart failure with reduced ejection fraction (HFrEF) has led to reduced rates of mortality and hospitalizations, and consequently the prevalence of HFrEF has increased, and up to 10% of patients progress to more advanced stages, characterized by high rates of mortality, hospitalizations, and poor quality of life. Advanced HFrEF patients often show persistent or progressive signs of severe HF symptoms corresponding to New York Heart Association class III or IV despite being on optimal medical, surgical, and device therapies. However, a subpopulation of patients with advanced HF, those with the most advanced stages of disease, were often insufficiently represented in the major trials demonstrating efficacy and tolerability of the drugs used in HFrEF due to exclusion criteria such as low BP and kidney dysfunction. Consequently, the results of many landmark trials cannot necessarily be transferred to patients with the most advanced stages of HFrEF. Thus, the efficacy and tolerability of guideline-directed medical therapies in patients with the most advanced stages of HFrEF often remain unsettled, and this knowledge is of crucial importance in the planning and timing of consideration for referral for advanced therapies. This review discusses the evidence regarding the use of contemporary drugs in the advanced HFrEF population, covering components such as guideline HFrEF drugs, diuretics, inotropes, and the use of HFrEF drugs in LVAD recipients, and provides suggestions on how to manage guideline-directed therapy in this patient group.
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Affiliation(s)
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
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11
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García‐González MJ, Aldea Perona A, Lara Padron A, Morales Rull JL, Martínez‐Sellés M, de Mora Martin M, López Díaz J, López Fernandez S, Ortiz Oficialdegui P, Jiménez Sosa A. Efficacy and safety of intermittent repeated levosimendan infusions in advanced heart failure patients: the LAICA study. ESC Heart Fail 2021; 8:4820-4831. [PMID: 34716753 PMCID: PMC8712777 DOI: 10.1002/ehf2.13670] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 09/12/2021] [Accepted: 10/03/2021] [Indexed: 12/12/2022] Open
Abstract
Aims The aim of the LAICA study was to evaluate the long‐term effectiveness and safety of intermittent levosimendan infusion in patients with advanced heart failure (AdHF). Methods and results This was a multicentre, randomized, double‐blind, placebo‐controlled clinical trial of intermittent levosimendan 0.1 μg/kg/min as a continuous 24‐h intravenous infusion administered once monthly for 1 year in patients with AdHF. The primary endpoint [incidence of rehospitalization (admission to the emergency department or hospital ward for >12 h) for acute decompensated HF or clinical deterioration of the underlying HF] occurred in 23/70 (33%) of the levosimendan group (Group I) and 12/27 (44%) of the placebo group (Group II) (P = 0.286). The incidence of hospital readmissions for acute decompensated HF (Group I vs. Group II) at 1, 3, 6, and 12 months was 4.2% vs. 18.2% (P = 0.036); 12.8% vs. 33.3% (P = 0.02); 25.7% vs. 40.7% (P = 0.147); 32.8% vs. 44.4% (P = 0.28), respectively. In a secondary pre‐specified time‐to‐event analysis no differences were observed in admission for acute decompensated HF between patients treated with levosimendan compared with placebo (hazard ratio 0.66; 95% CI, 0.32–1.32; P = 0.24). Cumulative incidence for the aggregated endpoint of acute decompensation of HF and/or death at 1 and 3 months were significatively lower in the levosimendan group than in placebo group [5.7% vs. 25.9% (P = 0.004) and 17.1% vs. 48.1% (P = 0.001), respectively], but not at 6 and 12 months [34.2% vs. 59.2% (P = 0.025); 41.4% vs. 66.6% (P = 0.022), respectively]. Survival probability was significantly higher in patients who received levosimendan compared with those who received placebo (log rank: 4.06; P = 0.044). There were no clinically relevant differences in tolerability between levosimendan and placebo and no new safety signals were observed. Conclusions In our study, intermittent levosimendan in patients with AdHF produced a statistically non‐significant reduction in the incidence of hospital readmissions for acute decompensated HF, a significantly lower cumulative incidence of acute decompensation of HF and/or death at 1 and 3 month of treatment and a significant improvement in survival during 12 months of treatment.
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Affiliation(s)
- Martín J. García‐González
- Acute Cardiac Care Unit, Department of CardiologyHospital Universitario de CanariasCtra. La Cuesta—Taco, Ofra s/n, 38320 San Cristóbal de La LagunaTenerifeSpain
| | - Ana Aldea Perona
- Institut Municipal d'Investigacions Mèdiques (IMIM)BarcelonaSpain
| | - Antonio Lara Padron
- Acute Cardiac Care Unit, Department of CardiologyHospital Universitario de CanariasCtra. La Cuesta—Taco, Ofra s/n, 38320 San Cristóbal de La LagunaTenerifeSpain
| | - José Luis Morales Rull
- Heart Failure Unit, Department of Internal MedicineHospital Arnau de Vilanova, Institut de Recerca Biomédica de Lleida (IRBLleida)LleidaSpain
| | - Manuel Martínez‐Sellés
- Department of CardiologyHospital Universitario Gregorio Marañon, CIBERCV, Universidad Europea, Universidad ComplutenseMadridSpain
| | | | - Javier López Díaz
- Department of CardiologyHospital Clínico Universitario de Valladolid, CIBERCVValladolidSpain
| | - Silvia López Fernandez
- Heart Failure Unit, Department of CardiologyHospital Universitario Virgen de las NievesGranadaSpain
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12
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Venema CS, Erasmus ME, Mariani M, Voors AA, Damman K. Post-transplant inotrope score is associated with clinical outcomes after adult heart transplantation. Clin Transplant 2021; 35:e14347. [PMID: 33969543 PMCID: PMC8519078 DOI: 10.1111/ctr.14347] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 04/28/2021] [Accepted: 05/02/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Inotrope score has been proposed as a marker of clinical outcome after adult heart transplantation (HTx) but is rarely used in practice. METHODS Inotrope score during the first 48 h after HTx was calculated in 81 patients as: dopamine + dobutamine + amrinone + milrinone (dose × 15) + epinephrine (dose × 100) + norepinephrine (dose × 100) + enoximone + isoprenaline (dose × 100), with each drug in µg/kg/min. Determinants of inotrope score were identified with linear regression. Cox regression was used to determine the association of inotrope score with mortality. RESULTS The mean recipient age was 52 ± 11 years, and 32 (39.5%) patients were female. Determinants of inotrope score were preoperative C-reactive protein, serum urea, congenital heart disease, and donor cardiac arrest (R2 = .30). Inotrope score was associated with 5-year mortality, independent of recipient age and gender (HR 1.03, 95% CI 1.00-1.07). This association was attenuated when adjusting for female-to-male transplant and ischemia time. Inotrope score was also strongly associated with continuous veno-venous hemofiltration (OR 1.07, 95% CI 1.03-1.12). CONCLUSION High inotrope score post-HTx was observed in recipient congenital heart disease and was associated with a higher risk of mortality and acute kidney injury.
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Affiliation(s)
- Constantijn S. Venema
- Department of Cardiothoracic SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
- Department of CardiologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Michiel E. Erasmus
- Department of Cardiothoracic SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Massimo Mariani
- Department of Cardiothoracic SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Adriaan A. Voors
- Department of CardiologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Kevin Damman
- Department of CardiologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
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Comprehensive Comparisons among Inotropic Agents on Mortality and Risk of Renal Dysfunction in Patients Who Underwent Cardiac Surgery: A Network Meta-Analysis of Randomized Controlled Trials. J Clin Med 2021; 10:jcm10051032. [PMID: 33802296 PMCID: PMC7959132 DOI: 10.3390/jcm10051032] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 02/23/2021] [Accepted: 02/26/2021] [Indexed: 02/07/2023] Open
Abstract
Several kinds of inotropes have been used in critically ill patients to improve hemodynamics and renal dysfunction after cardiac surgery; however, the treatment strategies for reducing mortality and increasing renal protection in patients who underwent cardiac surgery remain controversial. Therefore, we performed a comprehensive network meta-analysis to overcome the lack of head-to-head comparisons. A systematic database was searched up to 31 December 2020, for randomized controlled trials that compared different inotropes on mortality outcomes and renal protective effects after cardiac surgery. A total of 29 trials were included and a frequentist network meta-analysis was performed. Inconsistency analyses, publication bias, and subgroup analyses were also conducted. Compared with placebo, use of levosimendan significantly decreased the risks of mortality (odds ratio (OR): 0.74; 95% confidence interval (CI): 0.56–0.97) and risk of acute renal injury (OR: 0.61; 95% CI: 0.45–0.82), especially in low systolic function patients. Use of levosimendan also ranked the best treatment based on the P-score (90.1%), followed by placebo (64.5%), milrinone (49.6%), dopamine (49.5%), dobutamine (29.1%), and fenoldopam (17.0%). Taking all the available data into consideration, levosimendan was a safe renal-protective choice for the treatment of patients undergoing cardiac surgery, especially for those with low systolic function.
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14
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Glinka L, Mayzner-Zawadzka E, Onichimowski D, Jalali R, Glinka M. Levosimendan in the modern treatment of patients with acute heart failure of various aetiologies. Arch Med Sci 2021; 17:296-303. [PMID: 33747264 PMCID: PMC7959091 DOI: 10.5114/aoms.2018.77055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 11/29/2017] [Indexed: 11/17/2022] Open
Abstract
Acute decompensated heart failure (ADHF) is a common clinical problem associated with a high mortality rate. Because ADHF has various aetiologies, there are a range of therapeutic options, among others, positive inotropes (inotropic drugs). As an inotropic agent whose mechanism is different than that of "classical" medicines, levosimendan (LSM) is one of the most common therapeutic options. Despite many publications on LSM, some issues related to its application remain unclear. The authors of this paper have attempted to summarise expert recommendations and reports available in the literature.
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Affiliation(s)
- Lidia Glinka
- 2 Anaesthesiology and Intensive Care Clinical Ward, Clinical University Hospital, Department of Anaesthesiology and Intensive Care, University of Warmia and Mazury, Olsztyn, Poland
| | - Ewa Mayzner-Zawadzka
- 2 Anaesthesiology and Intensive Care Clinical Ward, Clinical University Hospital, Department of Anaesthesiology and Intensive Care, University of Warmia and Mazury, Olsztyn, Poland
| | - Dariusz Onichimowski
- 1 Clinical Department of Anaesthesiology and Intensive Care, Regional Specialist Hospital, Olsztyn, Poland
| | - Rakesh Jalali
- Emergency Department, Regional Specialist Hospital, Olsztyn, Poland
| | - Maciej Glinka
- Department of Cardiology, Regional Specialist Hospital, Olsztyn, Poland
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15
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Levosimendan Plus Dobutamine in Acute Decompensated Heart Failure Refractory to Dobutamine. J Clin Med 2020; 9:jcm9113605. [PMID: 33182314 PMCID: PMC7695257 DOI: 10.3390/jcm9113605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/28/2020] [Accepted: 11/02/2020] [Indexed: 01/20/2023] Open
Abstract
Randomized studies showed that Dobutamine and Levosimendan have similar impact on outcome but their combination has never been assessed in acute decompensated heart failure (ADHF) with low cardiac output. This is a retrospective, single-center study that included 89 patients (61 ± 15 years) admitted for ADHF requiring inotropic support. The first group consisted of patients treated with dobutamine alone (n = 42). In the second group, levosimendan was administered on top of dobutamine, when the superior vena cava oxygen saturation (ScVO2) remained <60% after 3 days of dobutamine treatment (n = 47). The primary outcome was the occurrence of major cardiovascular events (MACE) at 6 months, defined as all cause death, heart transplantation or need for mechanical circulatory support. Baseline clinical characteristics were similar in both groups. At day-3, the ScVO2 target (>60%) was reached in 36% and 32% of patients in the dobutamine and dobutamine-levosimendan group, respectively. After adding levosimendan, 72% of the dobutamine-levosimendan-group reached the ScVO2 target value at dobutamine weaning. At six months, 42 (47%) patients experienced MACE (n = 29 for death). MACE was less frequent in the dobutamine-levosimendan (32%) than in the dobutamine-group (64%, p = 0.003). Independent variables associated with outcome were admission systolic blood pressure and dobutamine-levosimendan strategy (OR = 0.44 (0.23–0.84), p = 0.01). In conclusion, levosimendan added to dobutamine may improve the outcome of ADHF refractory to dobutamine alone.
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16
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Uhlig K, Efremov L, Tongers J, Frantz S, Mikolajczyk R, Sedding D, Schumann J. Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev 2020; 11:CD009669. [PMID: 33152122 PMCID: PMC8094388 DOI: 10.1002/14651858.cd009669.pub4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cardiogenic shock (CS) and low cardiac output syndrome (LCOS) are potentially life-threatening complications of acute myocardial infarction (AMI), heart failure (HF) or cardiac surgery. While there is solid evidence for the treatment of other cardiovascular diseases of acute onset, treatment strategies in haemodynamic instability due to CS and LCOS remains less robustly supported by the given scientific literature. Therefore, we have analysed the current body of evidence for the treatment of CS or LCOS with inotropic and/or vasodilating agents. This is the second update of a Cochrane review originally published in 2014. OBJECTIVES Assessment of efficacy and safety of cardiac care with positive inotropic agents and vasodilator agents in CS or LCOS due to AMI, HF or after cardiac surgery. SEARCH METHODS We conducted a search in CENTRAL, MEDLINE, Embase and CPCI-S Web of Science in October 2019. We also searched four registers of ongoing trials and scanned reference lists and contacted experts in the field to obtain further information. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials (RCTs) enrolling patients with AMI, HF or cardiac surgery complicated by CS or LCOS. DATA COLLECTION AND ANALYSIS We used standard methodological procedures according to Cochrane standards. MAIN RESULTS We identified 19 eligible studies including 2385 individuals (mean or median age range 56 to 73 years) and three ongoing studies. We categorised studies into 11 comparisons, all against standard cardiac care and additional other drugs or placebo. These comparisons investigated the efficacy of levosimendan versus dobutamine, enoximone or placebo; enoximone versus dobutamine, piroximone or epinephrine-nitroglycerine; epinephrine versus norepinephrine or norepinephrine-dobutamine; dopexamine versus dopamine; milrinone versus dobutamine and dopamine-milrinone versus dopamine-dobutamine. All trials were published in peer-reviewed journals, and analyses were done by the intention-to-treat (ITT) principle. Eighteen of 19 trials were small with only a few included participants. An acknowledgement of funding by the pharmaceutical industry or missing conflict of interest statements occurred in nine of 19 trials. In general, confidence in the results of analysed studies was reduced due to relevant study limitations (risk of bias), imprecision or indirectness. Domains of concern, which showed a high risk in more than 50% of included studies, encompassed performance bias (blinding of participants and personnel) and bias affecting the quality of evidence on adverse events. All comparisons revealed uncertainty on the effect of inotropic/vasodilating drugs on all-cause mortality with a low to very low quality of evidence. In detail, the findings were: levosimendan versus dobutamine (short-term mortality: RR 0.60, 95% CI 0.36 to 1.03; participants = 1701; low-quality evidence; long-term mortality: RR 0.84, 95% CI 0.63 to 1.13; participants = 1591; low-quality evidence); levosimendan versus placebo (short-term mortality: no data available; long-term mortality: RR 0.55, 95% CI 0.16 to 1.90; participants = 55; very low-quality evidence); levosimendan versus enoximone (short-term mortality: RR 0.50, 0.22 to 1.14; participants = 32; very low-quality evidence; long-term mortality: no data available); epinephrine versus norepinephrine-dobutamine (short-term mortality: RR 1.25; 95% CI 0.41 to 3.77; participants = 30; very low-quality evidence; long-term mortality: no data available); dopexamine versus dopamine (short-term mortality: no deaths in either intervention arm; participants = 70; very low-quality evidence; long-term mortality: no data available); enoximone versus dobutamine (short-term mortality RR 0.21; 95% CI 0.01 to 4.11; participants = 27; very low-quality evidence; long-term mortality: no data available); epinephrine versus norepinephrine (short-term mortality: RR 1.81, 0.89 to 3.68; participants = 57; very low-quality evidence; long-term mortality: no data available); and dopamine-milrinone versus dopamine-dobutamine (short-term mortality: RR 1.0, 95% CI 0.34 to 2.93; participants = 20; very low-quality evidence; long-term mortality: no data available). No information regarding all-cause mortality were available for the comparisons milrinone versus dobutamine, enoximone versus piroximone and enoximone versus epinephrine-nitroglycerine. AUTHORS' CONCLUSIONS At present, there are no convincing data supporting any specific inotropic or vasodilating therapy to reduce mortality in haemodynamically unstable patients with CS or LCOS. Considering the limited evidence derived from the present data due to a high risk of bias and imprecision, it should be emphasised that there is an unmet need for large-scale, well-designed randomised trials on this topic to close the gap between daily practice in critical care of cardiovascular patients and the available evidence. In light of the uncertainties in the field, partially due to the underlying methodological flaws in existing studies, future RCTs should be carefully designed to potentially overcome given limitations and ultimately define the role of inotropic agents and vasodilator strategies in CS and LCOS.
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Affiliation(s)
- Konstantin Uhlig
- Department of Anaesthesiology and Surgical Intensive Care, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
| | - Ljupcho Efremov
- Institute for Medical Epidemiology, Biometrics and Informatics (IMEBI), Interdisciplinary Center for Health Sciences, Medical School of the Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Jörn Tongers
- Cardiology, Angiology and Intensive Care Medicine, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Stefan Frantz
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Rafael Mikolajczyk
- Institute for Medical Epidemiology, Biometrics and Informatics (IMEBI), Interdisciplinary Center for Health Sciences, Medical School of the Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Daniel Sedding
- Cardiology, Angiology and Intensive Care Medicine, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Julia Schumann
- Department of Anaesthesiology and Surgical Intensive Care, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
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17
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Gotic M, Egyed M, Gercheva L, Warzocha K, Kvasnicka HM, Achenbach H, Wu J. Cardiovascular Safety of Anagrelide Hydrochloride versus Hydroxyurea in Essential Thrombocythaemia. Cardiovasc Toxicol 2020; 21:236-247. [PMID: 33123978 PMCID: PMC7847982 DOI: 10.1007/s12012-020-09615-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 10/16/2020] [Indexed: 11/30/2022]
Abstract
Essential thrombocythaemia (ET) is a rare myeloproliferative neoplasm. This multicentre, Phase 3b, randomised, open-label, non-inferiority study investigated the cardiac safety, efficacy and tolerability of first-line treatment with anagrelide or hydroxyurea in high-risk ET patients for up to 3 years. Eligible patients aged ≥ 18 years with a diagnosis of high-risk ET confirmed by bone marrow biopsy within 6 months of randomisation received anagrelide (n = 75) or hydroxyurea (n = 74), administered twice daily. Treatment dose for either compound was titrated to the lowest dose needed to achieve a response. Planned primary outcome measures were change in left ventricular ejection fraction from baseline over time and platelet count at Month 6. Planned secondary outcome measures were platelet count change from baseline at Months 3 and 36; percentage of patients with complete or partial response; time to complete or partial response; number of patients with thrombohaemorrhagic events; and changes in white blood cell count or red blood cell count over time. Neither treatment altered cardiac function. There were no significant differences in adverse events between treatment groups, and no reports of malignant transformation. The incidence of disease-related thrombotic or haemorrhagic events was numerically higher in anagrelide-treated patients. Both treatments controlled platelet counts at 6 months, with the majority of patients experiencing complete or partial responses. In conclusion, these results suggest that long-term treatment with anagrelide is not associated with adverse effects on cardiac function. This is one of the few studies using left ventricular ejection fraction assessment and central biopsy reading to confirm the diagnosis of ET. Trial registration number: Clinicaltrials.gov NCT00202644
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Affiliation(s)
- Mirjana Gotic
- Clinic for Hematology Clinical Centre of Serbia Belgrade, Medical Faculty, University of Belgrade, Koste Todorovica 2, 11000, Belgrade, Serbia.
| | - Miklos Egyed
- Somogy Megyei Kaposi Mór Oktató Kórház, Kaposvár, 7400, Hungary
| | - Liana Gercheva
- Clinic of Hematology, University Hospital St. Marina, 9010, Varna, Bulgaria
| | - Krzysztof Warzocha
- Institute of Hematology and Transfusion Medicine, Department of Haematology, 00-791, Warsaw, Poland
| | - Hans Michael Kvasnicka
- Institute of Pathology, University Clinic Wuppertal, University of Witten / Herdecke, Wuppertal, Germany
| | - Heinrich Achenbach
- Research & Development, Shire International GmbH (a Member of the Takeda Group of Companies), 6300, Zug, Switzerland
| | - Jingyang Wu
- Research & Development, Shire (a Member of the Takeda Group of Companies), Lexington, MA, 02421, USA
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18
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Safety of Outpatient Milrinone Infusion in End-Stage Heart Failure: ICD-Level Data on Atrial Fibrillation and Ventricular Tachyarrhythmias. Am J Med 2020; 133:857-864. [PMID: 31883773 DOI: 10.1016/j.amjmed.2019.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Milrinone infusion is one of a few select "non-device" therapies for patients with New York Heart Association (NYHA) class IV, stage D heart failure, which has been associated with an increase in ventricular tachyarrhythmia and atrial fibrillation. Milrinone improves hemodynamics and provides symptomatic relief. Many patients with end-stage heart failure die from cardiac pump failure, and the impact of ventricular tachyarrhythmia and atrial fibrillation on their mortality is unclear. METHODS This is a retrospective study of 98 consecutive patients receiving outpatient milrinone in a single center from 2008 to 2016. The primary endpoint of the study was overall survival on milrinone. Secondary endpoints were incidence of post-milrinone implantable cardioverter defibrillator (ICD) shocks and development of ventricular tachyarrhythmia or atrial fibrillation. RESULTS Median survival was 581 ± 96 days with no difference between those with prior ventricular tachyarrhythmia and those without at 1 month (92% vs 97%, P = 0.34), 6 months (67% vs 73%, P = 0.75), and 12 months (67% vs 61%, P = 0.88). Seven out of 12 (58%) patients with prior ventricular tachyarrhythmia had ICD shocks, as compared to 5 out of 78 (6.4%) (P <0.001). Thirty-five patients had atrial fibrillation prior to starting milrinone, which decreased to 72% (P <0.05) by the third follow-up time period (7-9 months). Amiodarone use was protective against new onset atrial fibrillation. CONCLUSIONS Patients with stage D heart failure with a history of ventricular tachyarrhythmia have similar survival on outpatient milrinone compared to those without. However, those with prior ventricular tachyarrhythmia received more ICD shocks for more ventricular tachyarrhythmias. Milrinone remains a viable therapy for patients with stage D heart failure with limited therapeutic options.
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19
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Chioncel O, Collins SP, Butler J. Istaroxime in acute heart failure: the holy grail is at HORIZON? Eur J Heart Fail 2020; 22:1694-1697. [PMID: 32374050 DOI: 10.1002/ejhf.1843] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/09/2020] [Indexed: 12/28/2022] Open
Affiliation(s)
- Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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20
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Guo N, Wang Z, Bow LM, Cui X, Zhang L, Xian W, Sun H, Tian J. Cardiac Inotropes Offer Protection of Renal Function in Patients with Kidney Transplantation. Kidney Blood Press Res 2020; 45:331-338. [PMID: 31982885 DOI: 10.1159/000504543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/01/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Impaired cardiac function is one of the most concomitant symptoms in patients with kidney failure after long-term dialysis. In addition, the preservation of adequate perfusion pressure to the graft plays a significant role in the intraoperative management during kidney transplantation, but the use of positive inotropic drugs in kidney transplant patients has been studied less. We investigated the protective effects of renal function by means of cardiac inotropes in kidney transplant patients. METHODS Eighty-nine patients that received kidney transplantation between April 2014 and December 2016 at Qilu Hospital were included and randomly divided into the treatment group receiving levosimendan and a control group. All kidney recipients received ABO-compatible donors. A poor outcome was defined as one of the following: delayed graft function, graft hemorrhage, or nephrectomy. RESULTS The treatment group had a better composite outcome and the level of neutrophil gelatinase-associated lipocalin was also lower than in the control group. CONCLUSION Inotropic drugs may play a protective role in renal function in kidney transplantation.
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Affiliation(s)
- Ning Guo
- Department of Surgery and Transplantation, Qilu Hospital, Shandong University, Jinan, China
| | - Zehua Wang
- Department of Urology Surgery, Qilu Hospital, Shandong University, Jinan, China
| | - Laurine M Bow
- Transplant Immunology Laboratory, Hartford Hospital, Hartford, Connecticut, USA.,Department of Transplantation Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Xianquan Cui
- Department of Surgery and Transplantation, Qilu Hospital, Shandong University, Jinan, China
| | - Luwei Zhang
- Department of Surgery and Transplantation, Qilu Hospital, Shandong University, Jinan, China
| | - Wanhua Xian
- Department of Surgery and Transplantation, Qilu Hospital, Shandong University, Jinan, China
| | - Huaibin Sun
- Department of Surgery and Transplantation, Qilu Hospital, Shandong University, Jinan, China
| | - Jun Tian
- Department of Surgery and Transplantation, Qilu Hospital, Shandong University, Jinan, China,
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21
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Carubelli V, Zhang Y, Metra M, Lombardi C, Felker GM, Filippatos G, O'Connor CM, Teerlink JR, Simmons P, Segal R, Malfatto G, La Rovere MT, Li D, Han X, Yuan Z, Yao Y, Li B, Lau LF, Bianchi G, Zhang J. Treatment with 24 hour istaroxime infusion in patients hospitalised for acute heart failure: a randomised, placebo-controlled trial. Eur J Heart Fail 2020; 22:1684-1693. [PMID: 31975496 DOI: 10.1002/ejhf.1743] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/22/2019] [Accepted: 12/22/2019] [Indexed: 12/28/2022] Open
Abstract
AIM Istaroxime is a first-in-class agent which acts through inhibition of the sarcolemmal Na+ /K+ pump and activation of the SERCA2a pump. This study assessed the effects of a 24 h infusion of istaroxime in patients hospitalised for acute heart failure (AHF). METHODS AND RESULTS We included patients hospitalised for AHF with left ventricular ejection fraction ≤40% and E/e' > 10. Patients were randomised to a 24 h intravenous infusion of placebo or istaroxime at doses of 0.5 μg/kg/min (cohort 1: placebo n = 19; istaroxime n = 41) or 1.0 μg/kg/min (cohort 2: placebo n = 20, istaroxime n = 40). The primary endpoint of change in E/e' ratio from baseline to 24 h decreased with istaroxime vs. placebo (cohort 1: -4.55 ± 4.75 istaroxime 0.5 μg/kg/min vs. -1.55 ± 4.11 placebo, P = 0.029; cohort 2: -3.16 ± 2.59 istaroxime 1.0 μg/kg/min vs. -1.08 ± 2.72 placebo, P = 0.009). Both istaroxime doses significantly increased stroke volume index and decreased heart rate. Systolic blood pressure increased with istaroxime, achieving significance with the high dose. Self-reported dyspnoea and N-terminal pro-brain natriuretic peptide improved in all groups without significant differences between istaroxime and placebo. No significant differences in cardiac troponin absolute values or clinically relevant arrhythmias were observed during or after istaroxime infusion. Serious cardiac adverse events (including arrhythmias and hypotension) did not differ between placebo and istaroxime groups. The most common adverse events were injection site reactions and gastrointestinal events, the latter primarily with istaroxime 1.0 μg/kg/min. CONCLUSIONS In patients hospitalised for AHF with reduced ejection fraction, a 24 h infusion of istaroxime improved parameters of diastolic and systolic cardiac function without major cardiac adverse effects.
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Affiliation(s)
- Valentina Carubelli
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University and Civil Hospital of Brescia, Brescia, Italy
| | - Yuhui Zhang
- Heart Failure Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, China
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University and Civil Hospital of Brescia, Brescia, Italy
| | - Carlo Lombardi
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University and Civil Hospital of Brescia, Brescia, Italy
| | - G Michael Felker
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, NC, USA
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, Athens, Greece.,Medical School, University of Cyprus, Nicosia, Cyprus
| | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.,School of Medicine, University of California, San Francisco, CA, USA
| | | | - Robert Segal
- Windtree Therapeutics, Inc., Warrington, PA, USA
| | - Gabriella Malfatto
- IRCCS Istituto Auxologico Italiano, Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Milan, Italy
| | - Maria Teresa La Rovere
- Istituti Clinici Scientifici Maugeri IRCCS, Department of Cardiology, Institute of Montescano, Pavia, Italy
| | - Dianfu Li
- Jiangsu Provincial People's Hospital, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiumin Han
- The General Hospital of Shenyang Military Region of Chinese People's Liberation Arm, Shenyang, China
| | - Zuyi Yuan
- The First Affiliated Hospital of Xi'An Jiaotong University, Xi'an, China
| | - Yali Yao
- The First Hospital of Lanzhou University, Lanzhou, China
| | - Benjamin Li
- Lee's Pharmaceutical Limited, Taipei, Taiwan
| | | | | | - Jian Zhang
- Heart Failure Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, China
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22
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Buttà C, Roberto M, Tuttolomondo A, Petrantoni R, Miceli G, Zappia L, Pinto A. Old and New Drugs for Treatment of Advanced Heart Failure. Curr Pharm Des 2019; 26:1571-1583. [PMID: 31878852 DOI: 10.2174/1381612826666191226165402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 12/23/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Advanced heart failure (HF) is a progressive disease with high mortality and limited medical therapeutic options. Long-term mechanical circulatory support and heart transplantation remain goldstandard treatments for these patients; however, access to these therapies is limited by the advanced age and multiple comorbidities of affected patients, as well as by the limited number of organs available. METHODS Traditional and new drugs available for the treatment of advanced HF have been researched. RESULTS To date, the cornerstone for the treatment of patients with advanced HF remains water restriction, intravenous loop diuretic therapy and inotropic support. However, many patients with advanced HF experience loop diuretics resistance and alternative therapeutic strategies to overcome this problem have been developed, including sequential nephron blockade or use of the hypertonic saline solution in combination with high-doses of furosemide. As classic inotropes augment myocardial oxygen consumption, new promising drugs have been introduced, including levosimendan, istaroxime and omecamtiv mecarbil. However, pharmacological agents still remain mainly short-term or palliative options in patients with acute decompensation or excluded from mechanical therapy. CONCLUSION Traditional drugs, especially when administered in combination, and new medicaments represent important therapeutic options in advanced HF. However, their impact on prognosis remains unclear. Large trials are necessary to clarify their therapeutic potential and prognostic role in these fragile patients.
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Affiliation(s)
- Carmelo Buttà
- Unità Operativa Complessa, Cardiologia, Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi di Messina, Messina, Italy
| | - Marco Roberto
- Servizio di Cardiologia, Cardiocentro Ticino Lugano, Lugano, Switzerland
| | - Antonino Tuttolomondo
- Unità Operativa Complessa, Medicina Interna e con Stroke Care, Dipartimento di Promozione della Salute, Materno-infantile, Medicina Interna e Specialistica di Eccellenza, Università degli Studi di Palermo, Palermo, Italy
| | - Rossella Petrantoni
- Pronto Soccorso, Fondazione Istituto G. Giglio di Cefalù, 90015 Cefalù PA, Italy
| | - Giuseppe Miceli
- Unità Operativa Complessa, Medicina Interna e con Stroke Care, Dipartimento di Promozione della Salute, Materno-infantile, Medicina Interna e Specialistica di Eccellenza, Università degli Studi di Palermo, Palermo, Italy
| | - Luca Zappia
- Unità Operativa Complessa, Cardiologia, Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi di Messina, Messina, Italy
| | - Antonio Pinto
- Unità Operativa Complessa, Medicina Interna e con Stroke Care, Dipartimento di Promozione della Salute, Materno-infantile, Medicina Interna e Specialistica di Eccellenza, Università degli Studi di Palermo, Palermo, Italy
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23
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Long L, Zhao HT, Shen LM, He C, Ren S, Zhao HL. Hemodynamic effects of inotropic drugs in heart failure: A network meta-analysis of clinical trials. Medicine (Baltimore) 2019; 98:e18144. [PMID: 31764856 PMCID: PMC6882628 DOI: 10.1097/md.0000000000018144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND There is currently no consensus on the appropriate selection of inotropic therapy in ventricular dysfunction. The objective of the study was to detect the effects of different inotropes on the hemodynamics of patients who developed low cardiac output. METHODS PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched (all updated December 31, 2017). The inclusion criteria were as follows: low cardiac index (CI < 2.5 L/min/m) or New York Heart Association class II-IV, and at least 1 group receiving an inotropic drug compared to another group receiving a different inotropic/placebo treatment. The exclusion criteria were studies published as an abstract only, crossover studies, and studies with a lack of data on the cardiac index. RESULTS A total of 1402 patients from 37 trials were included in the study. Inotropic drugs were shown to increase the cardiac index (0.32, 95%CI:0.25, 0.38), heart rate (7.68, 95%CI:6.36, 9.01), and mean arterial pressure (3.17, 95%CI:1.96, 4.38) than the placebo. Overall, the pooled estimates showed no difference in terms of cardiac index, heart rate, mean arterial pressure, systemic vascular resistance, and mean pulmonary arterial pressure among the groups receiving different inotropes. CONCLUSIONS Our systematic review found that inotrope therapy is not associated with the amelioration of hemodynamics. An accurate evaluation of the benefits and risks, and selection of the correct inotropic agent is required in all clinical settings.
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Affiliation(s)
| | - Hao-tian Zhao
- Department of Ultrasound, Hebei General Hospital, Hebei, China
| | | | - Cong He
- Department of Intensive Care Unit
| | - Shan Ren
- Department of Intensive Care Unit
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24
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Inotropes and Vasoactive Agents: Differences Between Europe and the United States. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00323-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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25
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Shah AH, Puri R, Kalra A. Management of cardiogenic shock complicating acute myocardial infarction: A review. Clin Cardiol 2019; 42:484-493. [PMID: 30815887 PMCID: PMC6712338 DOI: 10.1002/clc.23168] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/15/2019] [Accepted: 02/26/2019] [Indexed: 12/21/2022] Open
Abstract
Despite advances in percutaneous coronary interventions and their widespread use, mortality in patients presenting with acute myocardial infarction (MI) complicated by cardiogenic shock (CS) has remained very high, and treatment options are limited. Limited evidences exist, supporting many of the routinely used therapies in treating these patients. In the present article, we discuss CS complicating MI in general and an update on the currently available treatment options, including inotropes and vasopressor, coronary revascularization, mechanical circulatory support devices, mechanical complications, and long‐term outcomes.
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Affiliation(s)
- Ashish H Shah
- St Boniface Hospital and University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rishi Puri
- Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ankur Kalra
- Cleveland Clinic Foundation, Cleveland, Ohio
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26
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Plöchl W, Rajek A. The Use of the Novel Calcium Sensitizer Levosimendan in Critically Ill Patients. Anaesth Intensive Care 2019; 32:471-5. [PMID: 15675206 DOI: 10.1177/0310057x0403200403] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Levosimendan, a novel calcium sensitizer, enhances cardiac contractility by increasing myocyte sensitivity to calcium, and induces vasodilation. In this prospective observational study the haemodynamic effects of levosimendan in postoperative critically ill patients are reported. Twelve patients with the need for inotropic support were studied. One dose of levosimendan (12.5 mg) was administered at a rate of 0.1-0.2 μg.kg−1.min−1, either alone or in addition to pre-existing inotropic therapy. Haemodynamic measurements were obtained at baseline, and at 3 h, 6 h, 12 h, and 24 h after the start of the levosimendan infusion. Levosimendan significantly increased cardiac output from (mean±SD) 4.3±0.9 l.min−1 to 5.2±1.5 l.min−1 after 24 h (P=0.013), by increases in stroke volume (baseline 47±15 ml, after 24 h 57±25 ml, P=0.05), as heart rate remained unchanged. Systemic vascular resistance decreased from 1239±430 dyn.sec.cm−5 at baseline to 963± 322 dyn.sec.cm−5 at 24 h (P<0.001). Pre-existing inotropic therapy present in ten patients remained unchanged or was reduced. In postoperative critically ill patients, infusion of levosimendan exerted favourable haemodynamic responses. Levosimendan increased cardiac output by increasing stroke volume, which might be attributed primarily to its inotropic properties. Due to its cyclic adenosine monophosphate independent positive inotropic effects, levosimendan may be of value as adjunctive therapy to other inotropic drugs in critically ill patients.
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Affiliation(s)
- W Plöchl
- Department of Anaesthesiology and General Intensive Care, Vienna General Hospital, University of Vienna, Austria
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27
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Pölzl G, Allipour Birgani S, Comín-Colet J, Delgado JF, Fedele F, García-Gonzáles MJ, Gustafsson F, Masip J, Papp Z, Störk S, Ulmer H, Vrtovec B, Wikström G, Altenberger J. Repetitive levosimendan infusions for patients with advanced chronic heart failure in the vulnerable post-discharge period. ESC Heart Fail 2018; 6:174-181. [PMID: 30378288 PMCID: PMC6351894 DOI: 10.1002/ehf2.12366] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/16/2018] [Accepted: 08/30/2018] [Indexed: 12/11/2022] Open
Abstract
Hospitalization for acute heart failure (HF) is associated with a substantial morbidity burden and with associated healthcare costs and an increased mortality risk. However, few if any major medical innovations have been witnessed in this area in recent times. Levosimendan is a first‐in‐class calcium sensitizer and potassium channel opener indicated for the management of acute HF. Experience in several clinical studies has indicated that administration of intravenous levosimendan in intermittent cycles may reduce hospitalization and mortality rates in patients with advanced HF; however, none of those trials were designed or powered to give conclusive insights into that possibility. This paper describes the rationale and protocol of LeoDOR (levosimendan infusions for patients with advanced chronic heart failure), a randomized, double‐blind, placebo‐controlled, international, multicentre trial that will explore the efficacy and safety of intermittent levosimendan therapy, in addition to optimized standard therapy, in patients following hospitalization for acute HF. Salient features of LeoDOR include the use of two treatment regimens, in order to evaluate the effects of different schedules and doses of levosimendan during a 12 week treatment phase, and the use of a global rank primary endpoint, in which all patients are ranked across three hierarchical groups ranging from time to death or urgent heart transplantation or implantation of a ventricular assist device to time to rehospitalization and, lastly, time‐averaged proportional change in N‐terminal pro‐brain natriuretic peptide. Secondary endpoints include changes in HF symptoms and functional status at 14 weeks.
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Affiliation(s)
- Gerhard Pölzl
- Department of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | | | - Josep Comín-Colet
- Department of Cardiology, Bellvitge University Hospital and IDIBELL, University of Barcelona Hospitalet de Llobregat, Barcelona, Spain
| | - Juan F Delgado
- Department of Cardiology, University Hospital 12 de Octubre, CIBERCV, Madrid, Spain
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Finn Gustafsson
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Josep Masip
- Intensive Care Department, Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain.,Cardiology Department, Hospital Sanitas CIMA, Barcelona, Spain
| | - Zoltán Papp
- Department of Cardiology, Division of Clinical Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Stefan Störk
- Department of Internal Medicine and Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - Hanno Ulmer
- Department for Medical Statistics, Informatics and Health Economics, Medical University Innsbruck, Innsbruck, Austria
| | - Bojan Vrtovec
- Department of Cardiology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Gerhard Wikström
- Department of Cardiology, Institute of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Johann Altenberger
- Cardiac Rehabilitation Center Grossgmain, Pensionsversicherungsanstalt, Teaching Hospital of Paracelsus Medical Private University, Salzburg, Austria
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28
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Effects of Widespread Inotrope Use in Acute Heart Failure Patients. J Clin Med 2018; 7:jcm7100368. [PMID: 30340408 PMCID: PMC6210304 DOI: 10.3390/jcm7100368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/15/2018] [Accepted: 10/17/2018] [Indexed: 01/06/2023] Open
Abstract
Current guidelines recommend that inotropes should not be used in patients with normal systolic blood pressure (SBP). However, this is not supported with concrete evidence. We aimed to evaluate the effect of inotropes in acute heart failure (HF) patients from a nationwide HF registry. A total of 5625 patients from the Korean Acute Heart Failure (KorAHF) registry were analyzed. The primary outcomes were in-hospital adverse events and 1-month mortality. Among the total population, 1703 (31.1%) received inotropes during admission. Inotrope users had a higher event rate than non-users (in-hospital adverse events: 13.3% vs. 1.4%, p < 0.001; 1-month mortality: 5.5% vs. 2.5%, p < 0.001), while inotrope use was an independent predictor for clinical outcomes (in-hospital adverse events: ORadjusted 5.459, 95% CI 3.622–8.227, p < 0.001; 1-month mortality: HRadjusted 1.839, 95% CI 1.227–2.757, p = 0.003). Subgroup analysis showed that inotrope use was an independent predictor for detrimental outcomes only in patients with normal initial SBP (≥90 mmHg) (in-hospital adverse events: ORadjusted 5.931, 95% CI 3.864–9.104, p < 0.001; 1-month mortality: HRadjusted 3.584, 95% CI 1.280–10.037, p = 0.015), and a propensity score-matched population showed consistent results. Clinicians should be cautious with the usage of inotropes in acute heart failure patients, especially in those with a normal SBP.
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29
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Kalmanovich E, Audurier Y, Akodad M, Mourad M, Battistella P, Agullo A, Gaudard P, Colson P, Rouviere P, Albat B, Ricci JE, Roubille F. Management of advanced heart failure: a review. Expert Rev Cardiovasc Ther 2018; 16:775-794. [PMID: 30282492 DOI: 10.1080/14779072.2018.1530112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Heart failure (HF) has become a global pandemic. Despite recent developments in both medical and device treatments, HF incidences continues to increase. The current definition of HF restricts itself to stages at which clinical symptoms are apparent. In advanced heart failure (AdHF), it is universally accepted that all patients are refractory to traditional therapies. As the number of HF patients increase, so does the need for additional treatments, with an increased proportion of patients requiring advanced therapies. Areas covered: This review discusses extensive evidence for the effect of medical treatment on HF, although the data on the effect on AdHF is scare. Authors review the relevant literature for treating AdHF patients. Furthermore, mechanical circulatory devices (MCD) have emerged as an alternative to heart transplantation and have been shown to enhance quality of life and reduce mortality therefore authors also review the current literature on the different MCD and technologies. Expert commentary: More patients will need advanced therapies, as the access to heart transplantation is limited by the number of available donors. AdHF patients should be identified timely since the window of opportunities for advanced therapy is narrow as their morbidity is progressive and survival is often short.
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Affiliation(s)
- Eran Kalmanovich
- a Department of Cardiology , Montpellier University Hospital , Montpellier , France
| | - Yohan Audurier
- b Pharmacy Department , University Hospital of Montpellier , Montpellier , France
| | - Mariama Akodad
- a Department of Cardiology , Montpellier University Hospital , Montpellier , France
| | - Marc Mourad
- c Department of Anesthesiology and Critical Care Medicine , Arnaud de Villeneuve Hospital , Montpellier , France.,d PhyMedExp , University of Montpellier , Montpellier , France
| | - Pascal Battistella
- a Department of Cardiology , Montpellier University Hospital , Montpellier , France
| | - Audrey Agullo
- a Department of Cardiology , Montpellier University Hospital , Montpellier , France
| | - Philippe Gaudard
- c Department of Anesthesiology and Critical Care Medicine , Arnaud de Villeneuve Hospital , Montpellier , France.,d PhyMedExp , University of Montpellier , Montpellier , France
| | - Pascal Colson
- c Department of Anesthesiology and Critical Care Medicine , Arnaud de Villeneuve Hospital , Montpellier , France.,d PhyMedExp , University of Montpellier , Montpellier , France
| | - Philippe Rouviere
- e Department of Cardiovascular Surgery , University Hospital of Montpellier, University of Montpellier , Montpellier , France
| | - Bernard Albat
- e Department of Cardiovascular Surgery , University Hospital of Montpellier, University of Montpellier , Montpellier , France
| | - Jean-Etienne Ricci
- f Department of Cardiology , Nîmes University Hospital, University of Montpellier , Nîmes , France
| | - François Roubille
- a Department of Cardiology , Montpellier University Hospital , Montpellier , France.,d PhyMedExp , University of Montpellier , Montpellier , France
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30
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Yazdi SG, Geoghegan PH, Docherty PD, Jermy M, Khanafer A. A Review of Arterial Phantom Fabrication Methods for Flow Measurement Using PIV Techniques. Ann Biomed Eng 2018; 46:1697-1721. [DOI: 10.1007/s10439-018-2085-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 06/25/2018] [Indexed: 12/21/2022]
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31
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Bekfani T, Westphal F, Schulze PC. Therapeutic options in advanced heart failure. Clin Res Cardiol 2018; 107:114-119. [PMID: 29987596 DOI: 10.1007/s00392-018-1318-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 06/27/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Tarek Bekfani
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, Friedrich-Schiller-University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Florian Westphal
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, Friedrich-Schiller-University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - P Christian Schulze
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, Friedrich-Schiller-University Jena, Am Klinikum 1, 07747, Jena, Germany.
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32
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Tanaka TD, Sawano M, Ramani R, Friedman M, Kohsaka S. Acute heart failure management in the USA and Japan: overview of practice patterns and review of evidence. ESC Heart Fail 2018; 5:931-947. [PMID: 29932314 PMCID: PMC6165950 DOI: 10.1002/ehf2.12305] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 04/17/2018] [Indexed: 01/23/2023] Open
Abstract
Globally, acute heart failure (AHF) remains an ongoing public health issue with its prevalence and mortality increasing in the east and the west. Effective treatment strategies to stabilize AHF are important to alleviate clinical symptoms and to improve clinical outcomes. However, despite the progress in the management of stable and chronic heart failure, no single agent has been proven to play a definitive role in the management of AHF. As a consequence, contemporary treatment strategies for patients with AHF vary greatly by region. This manuscript reviews the medical treatment options for AHF, with an emphasis on the differences between the treatment strategies in the USA and Japan. This information would provide a framework for clinicians to evaluate and manage patients with AHF and highlight the remaining questions to improve clinical outcomes.
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Affiliation(s)
- Toshikazu D Tanaka
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Ravi Ramani
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mark Friedman
- Section of Cardiology, Sarver Heart Center, Banner University Medical Center, Tucson, AZ, USA
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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33
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Chen P, Wu X, Wang Z, Li Z, Tian X, Wang J, Yan T. Effects of levosimendan on mortality in patients undergoing cardiac surgery: A systematic review and meta-analysis. J Card Surg 2018; 33:322-329. [PMID: 29785788 DOI: 10.1111/jocs.13716] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We sought to determine the impact of levosimendan on mortality following cardiac surgery based on large-scale randomized controlled trials (RCTs). METHODS We searched PubMed, Web of Science, Cochrane databases, and ClinicalTrials.gov for RCTs published up to December 2017, on levosimendan for patients undergoing cardiac surgery. RESULTS A total of 25 RCTs enrolling 2960 patients met the inclusion criteria; data from 15 placebo-controlled randomized trials were included for meta-analysis. Pooled analysis showed that the all-cause mortality rate was 6.4% (71 of 1106) in the levosimendan group and 8.4% (93 of 1108) in the placebo group (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.55-1.04; P = 0.09). There were no significant differences between the two groups in the rates of myocardial infarction (OR: 0.91; 95% CI, 0.68-1.21; P = 0.52), serious adverse events (OR: 0.84; 95% CI, 0.66-1.07; P = 0.17), hypotension (OR: 1.69; 95% CI, 0.94-3.03; P = 0.08), and low cardiac output syndrome (OR: 0.47; 95% CI, 0.22-1.02; P = 0.05). CONCLUSION Levosimendan did not result in a reduction in mortality in adult cardiac surgery patients. Well designed, adequately powered, multicenter trials are necessary to determine the role of levosimendan in adult cardiac surgery.
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Affiliation(s)
- Peili Chen
- Department of Intensive Care, First People's Hospital of Shangqiu, Shangqiu, China
| | - Xiaoqiang Wu
- Department of Urology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Zhiwei Wang
- Department of Urology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Zhenya Li
- Department of Ultrasound, Zhengzhou Central Hospital, Zhengzhou, China
| | - Xiangyong Tian
- Department of Urology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Junpeng Wang
- Department of Urology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Tianzhong Yan
- Department of Urology, Henan Provincial People's Hospital, Zhengzhou, China
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Wang B, He X, Gong Y, Cheng B. Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery: An Update Meta-Analysis and Trial Sequential Analysis. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7563083. [PMID: 29854789 PMCID: PMC5964575 DOI: 10.1155/2018/7563083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/19/2018] [Accepted: 03/28/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Recent studies suggest that levosimendan does not provide mortality benefit in patients with low cardiac output syndrome undergoing cardiac surgery. These results conflict with previous findings. The aim of the current study is to assess whether levosimendan reduces postoperative mortality in patients with impaired left ventricular function (mean EF ≤ 40%) undergoing cardiac surgery. METHODS We conducted a comprehensive search of PubMed, EMBASE, and Cochrane Library Database through November 20, 2017. Inclusion criteria were random allocation to treatment with at least one group receiving levosimendan and another group receiving placebo or other treatments and cardiac surgery patients with a left ventricular ejection fraction of 40% or less. The primary endpoint was postoperative mortality. Secondary outcomes were cardiac index, pulmonary capillary wedge pressure (PCWP), length of intensive care unit (ICU) stay, postoperative atrial fibrillation, and postoperative renal replacement therapy. We performed trial sequential analysis (TSA) to evaluate the reliability of the primary endpoint. RESULTS Data from 2,152 patients in 15 randomized clinical trials were analyzed. Pooled results demonstrated a reduction in postoperative mortality in the levosimendan group [RR = 0.53, 95% CI (0.38-0.73), I2 = 0]. However, the result of TSA showed that the conclusion may be a false positive. Secondary outcomes demonstrated that PCWP, postoperative renal replacement therapy, and length of ICU stay were significantly reduced. Cardiac index was greater in the levosimendan group. No difference was found in the rate of postoperative atrial fibrillation. CONCLUSIONS Levosimendan reduces the rate of death and other adverse outcomes in patients with low ejection fraction who were undergoing cardiac surgery, but results remain inconclusive. More large-volume randomized clinical trials (RCTs) are warranted.
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Affiliation(s)
- Benji Wang
- Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Xiaojie He
- School of Ophthalmology and Optometry and Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Yuqiang Gong
- Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Bihuan Cheng
- Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
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Altenberger J, Pölzl G. Repetitive levosimendan for a LION's heart? Eur J Heart Fail 2018; 20:1137-1138. [PMID: 29722471 DOI: 10.1002/ejhf.1206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 03/30/2018] [Accepted: 03/31/2018] [Indexed: 11/11/2022] Open
Affiliation(s)
- Johann Altenberger
- Cardiac Rehabilitation Center Grossgmain, Pensionsversicherungsanstalt, Teaching Hospital of Paracelsus Medical Private University, Salzburg, Austria
| | - Gerhard Pölzl
- Medical University Innsbruck, Department of Internal Medicine III, Innsbruck, Austria
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Elbadawi A, Elgendy IY, Saad M, Megaly M, Mentias A, Abuzaid AS, Shahin HI, Goswamy V, Abowali H, London B. Meta-Analysis of Trials on Prophylactic Use of Levosimendan in Patients Undergoing Cardiac Surgery. Ann Thorac Surg 2018; 105:1403-1410. [PMID: 29573810 DOI: 10.1016/j.athoracsur.2017.11.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 10/10/2017] [Accepted: 11/06/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND The role of prophylactic levosimendan in patients undergoing cardiac surgery is controversial. METHODS We performed a computerized search of Medline, Embase, and Cochrane databases through September 2017 for randomized trials evaluating the prophylactic use of levosimendan in patients undergoing cardiac surgery (ie, patients without low cardiac output syndrome). The main study outcome was mortality at 30 days. RESULTS The final analysis included 16 randomized trials with total of 2,273 patients. There was no statistically significant difference in mortality at 30 days between levosimendan and control groups (relative risk 0.68, 95% confidence interval [CI]: 0.45 to 1.03). Subgroup analysis showed no statistically significant difference in mortality at 30 days for patients with reduced left ventricular ejection fraction compared with patients having preserved left ventricular ejection fraction (p for interaction = 0.12). Further analysis suggested that levosimendan might be associated with improved mortality at 30 days when compared with active-control but not when compared with placebo (p for interaction = 0.01). The levosimendan group had a significant reduction in acute kidney injury (relative risk 0.59, 95% CI: 0.38 to 0.92), intensive care unit stay (standardized mean difference = -0.21, 95% CI: -0.29 to -0.13), and ventilation time (standardized mean difference = -0.43, 95% CI: -0.61 to -0.25), whereas it had higher rates of atrial fibrillation (relative risk 1.11, 95% CI: 1.00 to 1.24). No statistically significant differences were observed between groups in mortality beyond 30 days, postoperative dialysis, or myocardial infarction. CONCLUSIONS Prophylactic use of levosimendan does not appear to reduce the mortality at 30 days or beyond 30 days in patients undergoing cardiac surgery. This lack of benefit was noted irrespective of the LVEF.
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Affiliation(s)
- Ayman Elbadawi
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York; Department of Cardiovascular Medicine, Ain Shams University, Cairo, Egypt.
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Marwan Saad
- Department of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Michael Megaly
- Division of Cardiovascular Medicine, Hennepin County Medical Center/Minneapolis Heart Institute, Abbot Northwestern Hospital, Minneapolis, Minnesota
| | - Amgad Mentias
- Department of Cardiovascular Medicine, University of Iowa, Iowa City, Iowa
| | - Ahmed S Abuzaid
- Sidney Kimmel Medical College at Thomas Jefferson University/Christiana Care Health System, Newark, Delaware
| | - Hend I Shahin
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmaceutical Sciences and Pharmaceutical Industries, Future University in Egypt, Cairo, Egypt
| | - Vinay Goswamy
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Hesham Abowali
- Department of Cardiovascular Medicine, Ain Shams University, Cairo, Egypt
| | - Barry London
- Department of Cardiovascular Medicine, University of Iowa, Iowa City, Iowa
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Levosimendan: new indications and evidence for reduction in perioperative mortality? Curr Opin Anaesthesiol 2018; 29:454-61. [PMID: 27168089 DOI: 10.1097/aco.0000000000000357] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW In the last years, the perioperative use of levosimendan in cardiac surgery patients is spreading. Moreover, newer indications have been suggested such as the treatment of sepsis-associated myocardial dysfunction. In the present review, we discuss the most recent evidences in these settings. RECENT FINDINGS Levosimendan has been seemingly confirmed to reduce mortality in patients undergoing cardiac surgery. In particular, it appears to be the only inotropic drug to have a favorable effect on survival in any clinical setting. Moreover, levosimendan has been shown to exert a cardioprotective action and to reduce acute kidney injury, renal replacement therapy, and ICU stay in cardiac surgery patients. Finally, levosimendan has been suggested to reduce mortality in patients with severe sepsis and to improve renal outcomes in critically ill patients. SUMMARY Although a strong rationale likely exists to use levosimendan in the setting of perioperative and critical care medicine, evidence mainly comes from small and often poor-quality randomized clinical trials, whose results acquire significance only when pooled in meta-analyses. Moreover, some aspects related to which subgroups of patients may derive the most benefits from receiving levosimendan, to the optimal timing of administration, and to the potential adverse effects need to be further clarified. Important insights will be hopefully provided soon by the several large multicenter investigations which are currently ongoing.
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Comín-Colet J, Manito N, Segovia-Cubero J, Delgado J, García Pinilla JM, Almenar L, Crespo-Leiro MG, Sionis A, Blasco T, Pascual-Figal D, Gonzalez-Vilchez F, Lambert-Rodríguez JL, Grau M, Bruguera J. Efficacy and safety of intermittent intravenous outpatient administration of levosimendan in patients with advanced heart failure: the LION-HEART multicentre randomised trial. Eur J Heart Fail 2018; 20:1128-1136. [PMID: 29405611 DOI: 10.1002/ejhf.1145] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/04/2018] [Accepted: 01/05/2018] [Indexed: 11/07/2022] Open
Abstract
AIMS The LION-HEART study was a multicentre, double-blind, randomised, parallel-group, placebo-controlled trial evaluating the efficacy and safety of intravenous administration of intermittent doses of levosimendan in outpatients with advanced chronic heart failure. METHODS AND RESULTS Sixty-nine patients from 12 centres were randomly assigned at a 2:1 ratio to levosimendan or placebo groups, receiving treatment by a 6-hour intravenous infusion (0.2 μg/kg/min without bolus) every 2 weeks for 12 weeks. The primary endpoint was the effect on serum concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP) throughout the treatment period in comparison with placebo. Secondary endpoints included evaluation of safety, clinical events and health-related quality of life (HRQoL). The area under the curve (AUC, pg.day/mL) of the levels of NT-proBNP over time for patients who received levosimendan was significantly lower than for the placebo group (344 × 103 [95% Confidence Interval (CI) 283 × 103 -404 × 103 ] vs. 535 × 103 [443 × 103 -626 × 103 ], p = 0.003). In comparison with the placebo group, the patients on levosimendan experienced a reduction in the rate of heart failure hospitalisation (hazard ratio 0.25; 95% CI 0.11-0.56; P = 0.001). Patients on levosimendan were less likely to experience a clinically significant decline in HRQoL over time (P = 0.022). Adverse event rates were similar in the two treatment groups. CONCLUSIONS In this small pilot study, intermittent administration of levosimendan to ambulatory patients with advanced systolic heart failure reduced plasma concentrations of NT-proBNP, worsening of HRQoL and hospitalisation for heart failure. The efficacy and safety of this intervention should be confirmed in larger trials.
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Affiliation(s)
- Josep Comín-Colet
- Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), and Universitat Autònoma de Barcelona, Barcelona, Spain.,Heart Diseases Institute, Hospital Universitari de Bellvitge, IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Nicolás Manito
- Heart Diseases Institute, Hospital Universitari de Bellvitge, IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | | | - Juan Delgado
- Unidad de Insuficiencia Cardiaca y Trasplante, Servicio de Cardiología, Hospital 12 de Octubre, Madrid, Spain
| | | | - Luis Almenar
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - María G Crespo-Leiro
- Complexo Hospitalario Universitario de A Coruña (CHUAC) e Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidad de A Coruña (UDC), A Coruña, Spain
| | - Alessandro Sionis
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Teresa Blasco
- Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | | | - José Luis Lambert-Rodríguez
- Unidad de Trasplante Cardiaco e Insuficiencia Cardiaca Avanzada, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - María Grau
- Cardiovascular Epidemiology & Genetics, IMIM (Hospital del Mar Medical Research Institute) and University of Barcelona, Barcelona, Spain
| | - Jordi Bruguera
- Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), and Universitat Autònoma de Barcelona, Barcelona, Spain
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Schumann J, Henrich EC, Strobl H, Prondzinsky R, Weiche S, Thiele H, Werdan K, Frantz S, Unverzagt S. Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev 2018; 1:CD009669. [PMID: 29376560 PMCID: PMC6491099 DOI: 10.1002/14651858.cd009669.pub3] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cardiogenic shock (CS) and low cardiac output syndrome (LCOS) as complications of acute myocardial infarction (AMI), heart failure (HF) or cardiac surgery are life-threatening conditions. While there is a broad body of evidence for the treatment of people with acute coronary syndrome under stable haemodynamic conditions, the treatment strategies for people who become haemodynamically unstable or develop CS remain less clear. We have therefore summarised here the evidence on the treatment of people with CS or LCOS with different inotropic agents and vasodilative drugs. This is the first update of a Cochrane review originally published in 2014. OBJECTIVES To assess efficacy and safety of cardiac care with positive inotropic agents and vasodilator strategies in people with CS or LCOS due to AMI, HF or cardiac surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CPCI-S Web of Science in June 2017. We also searched four registers of ongoing trials and scanned reference lists and contacted experts in the field to obtain further information. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials in people with myocardial infarction, heart failure or cardiac surgery complicated by cardiogenic shock or LCOS. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We identified 13 eligible studies with 2001 participants (mean or median age range 58 to 73 years) and two ongoing studies. We categorised studies into eight comparisons, all against cardiac care and additional other active drugs or placebo. These comparisons investigated the efficacy of levosimendan versus dobutamine, enoximone or placebo, epinephrine versus norepinephrine-dobutamine, amrinone versus dobutamine, dopexamine versus dopamine, enoximone versus dopamine and nitric oxide versus placebo.All trials were published in peer-reviewed journals, and analysis was done by the intention-to-treat (ITT) principle. Twelve of 13 trials were small with few included participants. Acknowledgement of funding by the pharmaceutical industry or missing conflict of interest statements emerged in five of 13 trials. In general, confidence in the results of analysed studies was reduced due to serious study limitations, very serious imprecision or indirectness. Domains of concern, which show a high risk of more than 50%, include performance bias (blinding of participants and personnel) and bias affecting the quality of evidence on adverse events.Levosimendan may reduce short-term mortality compared to a therapy with dobutamine (RR 0.60, 95% CI 0.37 to 0.95; 6 studies; 1776 participants; low-quality evidence; NNT: 16 (patients with moderate risk), NNT: 5 (patients with CS)). This initial short-term survival benefit with levosimendan vs. dobutamine is not confirmed on long-term follow up. There is uncertainty (due to lack of statistical power) as to the effect of levosimendan compared to therapy with placebo (RR 0.48, 95% CI 0.12 to 1.94; 2 studies; 55 participants, very low-quality evidence) or enoximone (RR 0.50, 95% CI 0.22 to 1.14; 1 study; 32 participants, very low-quality evidence).All comparisons comparing other positive inotropic, inodilative or vasodilative drugs presented uncertainty on their effect on short-term mortality with very low-quality evidence and based on only one RCT. These single studies compared epinephrine with norepinephrine-dobutamine (RR 1.25, 95% CI 0.41 to 3.77; 30 participants), amrinone with dobutamine (RR 0.33, 95% CI 0.04 to 2.85; 30 participants), dopexamine with dopamine (no in-hospital deaths from 70 participants), enoximone with dobutamine (two deaths from 40 participants) and nitric oxide with placebo (one death from three participants). AUTHORS' CONCLUSIONS Apart from low quality of evidence data suggesting a short-term mortality benefit of levosimendan compared with dobutamine, at present there are no robust and convincing data to support a distinct inotropic or vasodilator drug-based therapy as a superior solution to reduce mortality in haemodynamically unstable people with cardiogenic shock or LCOS.Considering the limited evidence derived from the present data due to a generally high risk of bias and imprecision, it should be emphasised that there remains a great need for large, well-designed randomised trials on this topic to close the gap between daily practice in critical care medicine and the available evidence. It seems to be useful to apply the concept of 'early goal-directed therapy' in cardiogenic shock and LCOS with early haemodynamic stabilisation within predefined timelines. Future clinical trials should therefore investigate whether such a therapeutic concept would influence survival rates much more than looking for the 'best' drug for haemodynamic support.
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Affiliation(s)
- Julia Schumann
- Martin‐Luther‐University Halle‐WittenbergDepartment of Anaesthesiology and Surgical Intensive CareHalle/SaaleGermany
| | - Eva C Henrich
- Martin‐Luther‐University Halle‐WittenbergInstitute of Medical Epidemiology, Biostatistics and InformaticsHalle/SaaleGermany06112
| | - Hellen Strobl
- Martin‐Luther‐University Halle‐WittenbergInstitute of Medical Epidemiology, Biostatistics and InformaticsHalle/SaaleGermany06112
| | - Roland Prondzinsky
- Carl von Basedow Klinikum MerseburgCardiology/Intensive Care MedicineWeisse Mauer 42MerseburgGermany06217
| | - Sophie Weiche
- Martin‐Luther‐University Halle‐WittenbergDepartment of Internal Medicine IIIHalle/SaaleGermany
| | - Holger Thiele
- University Clinic Schleswig‐Holstein, Campus LübeckMedical Clinic II (Kardiology, Angiology, Intensive Care Medicine)Ratzeburger Allee 160LubeckD‐23538Germany
| | - Karl Werdan
- Martin‐Luther‐University Halle‐WittenbergDepartment of Internal Medicine IIIHalle/SaaleGermany
| | - Stefan Frantz
- Martin‐Luther‐University Halle‐WittenbergDepartment of Internal Medicine IIIHalle/SaaleGermany
| | - Susanne Unverzagt
- Martin‐Luther‐University Halle‐WittenbergInstitute of Medical Epidemiology, Biostatistics and InformaticsHalle/SaaleGermany06112
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Shah P, Pellicori P, Cuthbert J, Clark AL. Pharmacological and Non-pharmacological Treatment for Decompensated Heart Failure: What Is New? Curr Heart Fail Rep 2017; 14:147-157. [PMID: 28421408 PMCID: PMC5423987 DOI: 10.1007/s11897-017-0328-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF THE REVIEW Acute heart failure (AHF) is a life-threatening clinical condition that requires prompt medical attention. The aim of the current review is to summarise the results of recent clinical trials conducted in patients with AHF. RECENT FINDINGS Several novel compounds have apparently beneficial acute effects on cardiovascular haemodynamics and patients' symptoms, but their administration has not yet translated into improved survival and has been deleterious in some cases. The management of patients with AHF is challenging and reflects the heterogeneity of patient's presentation, the complexity and severity of a multi-organ syndrome, and the limited therapeutic options, usually restricted to a combination of diuretics and vasodilators. Ongoing trials of novel treatments may provide evidence of an effect on outcomes.
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Affiliation(s)
- Parin Shah
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK.
| | - Pierpaolo Pellicori
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK
| | - Joseph Cuthbert
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK
| | - Andrew L Clark
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK
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Protein Kinase C Inhibition With Ruboxistaurin Increases Contractility and Reduces Heart Size in a Swine Model of Heart Failure With Reduced Ejection Fraction. JACC Basic Transl Sci 2017; 2:669-683. [PMID: 30062182 PMCID: PMC6058945 DOI: 10.1016/j.jacbts.2017.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 05/10/2017] [Accepted: 06/20/2017] [Indexed: 01/15/2023]
Abstract
Inotropic support is often required to stabilize the hemodynamics of patients with acute decompensated heart failure; while efficacious, it has a history of leading to lethal arrhythmias and/or exacerbating contractile and energetic insufficiencies. Novel therapeutics that can improve contractility independent of beta-adrenergic and protein kinase A-regulated signaling, should be therapeutically beneficial. This study demonstrates that acute protein kinase C-α/β inhibition, with ruboxistaurin at 3 months' post-myocardial infarction, significantly increases contractility and reduces the end-diastolic/end-systolic volumes, documenting beneficial remodeling. These data suggest that ruboxistaurin represents a potential novel therapeutic for heart failure patients, as a moderate inotrope or therapeutic, which leads to beneficial ventricular remodeling.
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Key Words
- ADHF, acute decompensated heart failure
- DIG, digitalis
- DOB, dobutamine
- ECG, electrocardiogram
- EDPVR, end-diastolic pressure-volume relationship
- EDV, end-diastolic volume
- ESPVR, end-systolic pressure-volume relationship
- ESV, end-systolic volume
- Ees, elastance end-systole
- HF, heart failure
- HFrEF, heart failure with reduced ejection fraction
- IR, ischemia–reperfusion
- LAD, left anterior descending coronary artery
- LV, left ventricle/ventricular
- LVEDV, left ventricular end-diastolic volume
- LVEF, left ventricular ejection fraction
- LVVPed10, left ventricular end-diastolic volume at a pressure of 10 mm Hg
- LVVPes80, left ventricular end- systolic volume at a pressure of 80 mm Hg
- MI, myocardial infarction
- PKA, protein kinase A
- PKC, protein kinase C
- PKCα/β inhibitor
- PLN, phospholamban
- PRSW, pre-load recruitable stroke work
- RBX, ruboxistaurin
- acute myocardial infarction
- heart failure with reduced ejection fraction
- invasive hemodynamics
- positive inotropy
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Emami A, Ebner N, von Haehling S. Publishing in a heart failure journal-where lies the scientific interest? ESC Heart Fail 2017; 4:389-401. [PMID: 29131547 PMCID: PMC5695188 DOI: 10.1002/ehf2.12233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 10/06/2017] [Indexed: 01/09/2023] Open
Affiliation(s)
- Amir Emami
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, D-37075, Göttingen, Germany
| | - Nicole Ebner
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, D-37075, Göttingen, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, D-37075, Göttingen, Germany
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Mebazaa A, Motiejunaite J, Gayat E, Crespo-Leiro MG, Lund LH, Maggioni AP, Chioncel O, Akiyama E, Harjola VP, Seferovic P, Laroche C, Julve MS, Roig E, Ruschitzka F, Filippatos G. Long-term safety of intravenous cardiovascular agents in acute heart failure: results from the European Society of Cardiology Heart Failure Long-Term Registry. Eur J Heart Fail 2017; 20:332-341. [PMID: 28990358 DOI: 10.1002/ejhf.991] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/24/2017] [Accepted: 08/08/2017] [Indexed: 12/28/2022] Open
Abstract
AIMS The aim of this study was to assess long-term safety of intravenous cardiovascular agents-vasodilators, inotropes and/or vasopressors-in acute heart failure (AHF). METHODS AND RESULTS The European Society of Cardiology Heart Failure Long-Term (ESC-HF-LT) registry was a prospective, observational registry conducted in 21 countries. Patients with unscheduled hospitalizations for AHF (n = 6926) were included: 1304 (18.8%) patients received a combination of intravenous (i.v.) vasodilators and diuretics, 833 (12%) patients received i.v. inotropes and/or vasopressors. Primary endpoint was long-term all-cause mortality. Main secondary endpoints were in-hospital and post-discharge mortality. Adjusted hazard ratio (HR) showed no association between the use of i.v. vasodilator and diuretic and long-term mortality [HR 0.784, 95% confidence interval (CI) 0.596-1.032] nor in-hospital mortality (HR 1.049, 95% CI 0.592-1.857) in the matched cohort (n = 976 paired patients). By contrast, adjusted HR demonstrated a detrimental association between the use of i.v. inotrope and/or vasopressor and long-term all-cause mortality (HR 1.434, 95% CI 1.128-1.823), as well as in-hospital mortality (HR 1.873, 95% CI 1.151-3.048) in the matched cohort (n = 606 paired patients). No association was found between the use of i.v. inotropes and/or vasopressors and long-term mortality in patients discharged alive (HR 1.078, 95% CI 0.769-1.512). A detrimental association with inotropes and/or vasopressors was seen in all geographic regions and, among catecholamines, dopamine was associated with the highest risk of death (HR 1.628, 95% CI 1.031-2.572 vs. no inotropes). CONCLUSIONS Vasodilators did not demonstrate any association with long-term clinical outcomes, while inotropes and/or vasopressors were associated with increased risk of all-cause death, mostly related to excess of in-hospital mortality in AHF.
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Affiliation(s)
- Alexandre Mebazaa
- INSERM U942, BIOmarkers in CArdioNeuroVAScular diseases, Paris, France.,APHP, Department of Anesthesiology and Critical Care, Saint Louis Lariboisière Hospitals, Paris, France.,Université Paris Diderot, Paris, France
| | - Justina Motiejunaite
- INSERM U942, BIOmarkers in CArdioNeuroVAScular diseases, Paris, France.,APHP, Department of Anesthesiology and Critical Care, Saint Louis Lariboisière Hospitals, Paris, France.,Department of Cardiology, Lithuanian University of Health Sciences Hospital Kaunas Clinics, Kaunas, Lithuania
| | - Etienne Gayat
- INSERM U942, BIOmarkers in CArdioNeuroVAScular diseases, Paris, France.,APHP, Department of Anesthesiology and Critical Care, Saint Louis Lariboisière Hospitals, Paris, France.,Université Paris Diderot, Paris, France
| | - Maria G Crespo-Leiro
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco-CIBERCV and Instituto Investigación Biomedica A Coruna (INIBIC), Complexo Hospitalario Universitario A Coruna (CHUAC), La Coruna, Spain
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | | | - Ovidiu Chioncel
- Institutul De Urgente Boli Cardiovasculare CC Iliescu, Universitatea de Medicina Carol Davila, Bucharest, Romania
| | - Eiichi Akiyama
- INSERM U942, BIOmarkers in CArdioNeuroVAScular diseases, Paris, France.,Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Veli-Pekka Harjola
- University of Helsinki, Emergency Medicine, Department of Emergency Care and Services, Helsinki University Hospital, Helsinki, Finland
| | - Petar Seferovic
- Department of Cardiology, Clinical Centre of Serbia, Belgrade, Serbia
| | - Cecile Laroche
- EURObservational Research Programme, European Society of Cardiology, Sophia-Antipolis, France
| | | | - Eulalia Roig
- Department of Cardiology, Heart Failure and Transplantation Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Frank Ruschitzka
- Department of Cardiology, Heart Failure Clinic and Transplantation, University Heart Centre Zurich, Zurich, Switzerland
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Pan Y, Lu Z, Hang J, Ma S, Ma J, Wei M. Effects of Low-Dose Recombinant Human Brain Natriuretic Peptide on Anterior Myocardial Infarction Complicated by Cardiogenic Shock. Braz J Cardiovasc Surg 2017; 32:96-103. [PMID: 28492790 PMCID: PMC5409251 DOI: 10.21470/1678-9741-2016-0007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 11/28/2016] [Indexed: 01/22/2023] Open
Abstract
Introduction The mortality due to cardiogenic shock complicating acute myocardial
infarction (AMI) is high even in patients with early revascularization.
Infusion of low dose recombinant human brain natriuretic peptide (rhBNP) at
the time of AMI is well tolerated and could improve cardiac function. Objective The objective of this study was to evaluate the hemodynamic effects of rhBNP
in AMI patients revascularized by emergency percutaneous coronary
intervention (PCI) who developed cardiogenic shock. Methods A total of 48 patients with acute ST segment elevation myocardial infarction
(STEMI) complicated by cardiogenic shock and whose hemodynamic status was
improved following emergency PCI were enrolled. Patients were randomly
assigned to rhBNP (n=25) and control (n=23) groups. In addition to standard
therapy, study group individuals received rhBNP by continuous infusion at
0.005 µg kg−1 min−1 for 72 hours. Results Baseline characteristics, medications, and peak of cardiac troponin I (cTnI)
were similar between both groups. rhBNP treatment resulted in consistently
improved pulmonary capillary wedge pressure (PCWP) compared to the control
group. Respectively, 7 and 9 patients died in experimental and control
groups. No drug-related serious adverse events occurred in either group. Conclusion When added to standard care in stable patients with cardiogenic shock
complicating anterior STEMI, low dose rhBNP improves PCWP and is well
tolerated.
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Affiliation(s)
- Yesheng Pan
- Heart Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - ZhiGang Lu
- Heart Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Jingyu Hang
- Heart Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Shixin Ma
- Heart Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Jian Ma
- Heart Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
| | - Meng Wei
- Heart Center, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, P.R. China
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45
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Medications to Avoid in Acute Decompensated Heart Failure. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2017. [DOI: 10.1007/s40138-017-0134-5] [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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46
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Mehta RH, Leimberger JD, van Diepen S, Meza J, Wang A, Jankowich R, Harrison RW, Hay D, Fremes S, Duncan A, Soltesz EG, Luber J, Park S, Argenziano M, Murphy E, Marcel R, Kalavrouziotis D, Nagpal D, Bozinovski J, Toller W, Heringlake M, Goodman SG, Levy JH, Harrington RA, Anstrom KJ, Alexander JH. Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery. N Engl J Med 2017; 376:2032-2042. [PMID: 28316276 DOI: 10.1056/nejmoa1616218] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Levosimendan is an inotropic agent that has been shown in small studies to prevent or treat the low cardiac output syndrome after cardiac surgery. METHODS In a multicenter, randomized, placebo-controlled, phase 3 trial, we evaluated the efficacy and safety of levosimendan in patients with a left ventricular ejection fraction of 35% or less who were undergoing cardiac surgery with the use of cardiopulmonary bypass. Patients were randomly assigned to receive either intravenous levosimendan (at a dose of 0.2 μg per kilogram of body weight per minute for 1 hour, followed by a dose of 0.1 μg per kilogram per minute for 23 hours) or placebo, with the infusion started before surgery. The two primary end points were a four-component composite of death through day 30, renal-replacement therapy through day 30, perioperative myocardial infarction through day 5, or use of a mechanical cardiac assist device through day 5; and a two-component composite of death through day 30 or use of a mechanical cardiac assist device through day 5. RESULTS A total of 882 patients underwent randomization, 849 of whom received levosimendan or placebo and were included in the modified intention-to-treat population. The four-component primary end point occurred in 105 of 428 patients (24.5%) assigned to receive levosimendan and in 103 of 421 (24.5%) assigned to receive placebo (adjusted odds ratio, 1.00; 99% confidence interval [CI], 0.66 to 1.54; P=0.98). The two-component primary end point occurred in 56 patients (13.1%) assigned to receive levosimendan and in 48 (11.4%) assigned to receive placebo (adjusted odds ratio, 1.18; 96% CI, 0.76 to 1.82; P=0.45). The rate of adverse events did not differ significantly between the two groups. CONCLUSIONS Prophylactic levosimendan did not result in a rate of the short-term composite end point of death, renal-replacement therapy, perioperative myocardial infarction, or use of a mechanical cardiac assist device that was lower than the rate with placebo among patients with a reduced left ventricular ejection fraction who were undergoing cardiac surgery with the use of cardiopulmonary bypass. (Funded by Tenax Therapeutics; LEVO-CTS ClinicalTrials.gov number, NCT02025621 .).
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Affiliation(s)
- Rajendra H Mehta
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Jeffrey D Leimberger
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Sean van Diepen
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - James Meza
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Alice Wang
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Rachael Jankowich
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Robert W Harrison
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Douglas Hay
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Stephen Fremes
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Andra Duncan
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Edward G Soltesz
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - John Luber
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Soon Park
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Michael Argenziano
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Edward Murphy
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Randy Marcel
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Dimitri Kalavrouziotis
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Dave Nagpal
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - John Bozinovski
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Wolfgang Toller
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Matthias Heringlake
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Shaun G Goodman
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Jerrold H Levy
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Robert A Harrington
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Kevin J Anstrom
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - John H Alexander
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
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Landoni G, Lomivorotov VV, Alvaro G, Lobreglio R, Pisano A, Guarracino F, Calabrò MG, Grigoryev EV, Likhvantsev VV, Salgado-Filho MF, Bianchi A, Pasyuga VV, Baiocchi M, Pappalardo F, Monaco F, Boboshko VA, Abubakirov MN, Amantea B, Lembo R, Brazzi L, Verniero L, Bertini P, Scandroglio AM, Bove T, Belletti A, Michienzi MG, Shukevich DL, Zabelina TS, Bellomo R, Zangrillo A. Levosimendan for Hemodynamic Support after Cardiac Surgery. N Engl J Med 2017; 376:2021-2031. [PMID: 28320259 DOI: 10.1056/nejmoa1616325] [Citation(s) in RCA: 181] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Acute left ventricular dysfunction is a major complication of cardiac surgery and is associated with increased mortality. Meta-analyses of small trials suggest that levosimendan may result in a higher rate of survival among patients undergoing cardiac surgery. METHODS We conducted a multicenter, randomized, double-blind, placebo-controlled trial involving patients in whom perioperative hemodynamic support was indicated after cardiac surgery, according to prespecified criteria. Patients were randomly assigned to receive levosimendan (in a continuous infusion at a dose of 0.025 to 0.2 μg per kilogram of body weight per minute) or placebo, for up to 48 hours or until discharge from the intensive care unit (ICU), in addition to standard care. The primary outcome was 30-day mortality. RESULTS The trial was stopped for futility after 506 patients were enrolled. A total of 248 patients were assigned to receive levosimendan and 258 to receive placebo. There was no significant difference in 30-day mortality between the levosimendan group and the placebo group (32 patients [12.9%] and 33 patients [12.8%], respectively; absolute risk difference, 0.1 percentage points; 95% confidence interval [CI], -5.7 to 5.9; P=0.97). There were no significant differences between the levosimendan group and the placebo group in the durations of mechanical ventilation (median, 19 hours and 21 hours, respectively; median difference, -2 hours; 95% CI, -5 to 1; P=0.48), ICU stay (median, 72 hours and 84 hours, respectively; median difference, -12 hours; 95% CI, -21 to 2; P=0.09), and hospital stay (median, 14 days and 14 days, respectively; median difference, 0 days; 95% CI, -1 to 2; P=0.39). There was no significant difference between the levosimendan group and the placebo group in rates of hypotension or cardiac arrhythmias. CONCLUSIONS In patients who required perioperative hemodynamic support after cardiac surgery, low-dose levosimendan in addition to standard care did not result in lower 30-day mortality than placebo. (Funded by the Italian Ministry of Health; CHEETAH ClinicalTrials.gov number, NCT00994825 .).
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Affiliation(s)
- Giovanni Landoni
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Vladimir V Lomivorotov
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Gabriele Alvaro
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Rosetta Lobreglio
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Antonio Pisano
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Fabio Guarracino
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Maria G Calabrò
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Evgeny V Grigoryev
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Valery V Likhvantsev
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Marcello F Salgado-Filho
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Alessandro Bianchi
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Vadim V Pasyuga
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Massimo Baiocchi
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Federico Pappalardo
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Fabrizio Monaco
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Vladimir A Boboshko
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Marat N Abubakirov
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Bruno Amantea
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Rosalba Lembo
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Luca Brazzi
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Luigi Verniero
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Pietro Bertini
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Anna M Scandroglio
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Tiziana Bove
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Alessandro Belletti
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Maria G Michienzi
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Dmitriy L Shukevich
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Tatiana S Zabelina
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Rinaldo Bellomo
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
| | - Alberto Zangrillo
- From the Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute (G.L., M.G.C., F.P., F.M., R. Lembo, A.M.S., T.B., A. Belletti, A.Z.), and Vita-Salute San Raffaele University (G.L., A.Z.), Milan, the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Mater Domini Germaneto, Catanzaro (G.A., B.A., M.G.M.), the Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza (R. Lobreglio, L.B.), the Department of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano (A. Bianchi), and the Department of Surgical Sciences, University of Turin (L.B.), Turin, the Division of Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera di Rilievo Nazionale dei Colli-Monaldi Hospital, Naples (A.P., L.V.), Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, the Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa (F.G., P.B.), and the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, University Hospital Policlinico S. Orsola, Bologna (M.B.) - all in Italy; the Department of Anesthesiology and Intensive Care, State Research Institute of Circulation Pathology, Novosibirsk (V.V. Lomivorotov, V.A.B., M.N.A.), the Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo (E.V.G., D.L.S.), the Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow (V.V. Likhvantsev, T.S.Z.), and the Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan (V.V.P.) - all in Russia; Federal University of Juiz de Fora, Juiz de Fora, Brazil (M.F.S.-F.); and the University of Melbourne, Melbourne, VIC, Australia (R.B.)
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Verma S, Bassily E, Leighton S, Mhaskar R, Sunjic I, Martin A, Rihana N, Jarmi T, Bassil C. Renal Function and Outcomes With Use of Left Ventricular Assist Device Implantation and Inotropes in End-Stage Heart Failure: A Retrospective Single Center Study. J Clin Med Res 2017; 9:596-604. [PMID: 28611860 PMCID: PMC5458657 DOI: 10.14740/jocmr3039w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2017] [Indexed: 12/29/2022] Open
Abstract
Background Left ventricular assist device (LVAD) and inotrope therapy serve as a bridge to transplant (BTT) or as destination therapy in patients who are not heart transplant candidates. End-stage heart failure patients often have impaired renal function, and renal outcomes after LVAD therapy versus inotrope therapy have not been evaluated. Methods In this study, 169 patients with continuous flow LVAD therapy and 20 patients with continuous intravenous inotrope therapy were analyzed. The two groups were evaluated at baseline and at 3 and 6 months after LVAD or inotrope therapy was started. The incidence of acute kidney injury (AKI), need for renal replacement therapy (RRT), BTT rate, and mortality for 6 months following LVAD or inotrope therapy were studied. Results between the groups were compared using Mann-Whitney U test and Chi-square with continuity correction or Fischer’s exact at the significance level of 0.05. Results Mean glomerular filtration rate (GFR) was not statistically different between the two groups, with P = 0.471, 0.429, and 0.847 at baseline, 3 and 6 months, respectively. The incidence of AKI, RRT, and BTT was not statistically different. Mortality was less in the inotrope group (P < 0.001). Conclusion Intravenous inotrope therapy in end-stage heart failure patients is non-inferior for mortality, incidence of AKI, need for RRT, and renal function for 6-month follow-up when compared to LVAD therapy. Further studies are needed to compare the effectiveness of inotropes versus LVAD implantation on renal function and outcomes over a longer time period.
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Affiliation(s)
- Sean Verma
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Emmanuel Bassily
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Shane Leighton
- Center for Evidence Based Medicine and Health Outcomes Research, University of South Florida, Tampa, FL, USA
| | - Rahul Mhaskar
- Center for Evidence Based Medicine and Health Outcomes Research, University of South Florida, Tampa, FL, USA
| | - Igor Sunjic
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Angel Martin
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Nancy Rihana
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Tambi Jarmi
- Department of Nephrology and Hypertension, University of South Florida, Tampa, FL, USA
| | - Claude Bassil
- Department of Nephrology and Hypertension, University of South Florida, Tampa, FL, USA
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Cornejo-Avendaño J, Azpiri-López J, Ramírez-Rosales A. Levosimendan in acute decompensated heart failure: Systematic review and meta-analysis. MEDICINA UNIVERSITARIA 2017. [DOI: 10.1016/j.rmu.2017.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Fedele F, Karason K, Matskeplishvili S. Pharmacological approaches to cardio-renal syndrome: a role for the inodilator levosimendan. Eur Heart J Suppl 2017; 19:C22-C28. [PMID: 29249907 PMCID: PMC5932558 DOI: 10.1093/eurheartj/sux002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pathological interplay between the heart and kidneys—also known as cardio-renal syndrome (CRS)—is frequently encountered in heart failure and is linked to worse prognosis and quality of life. Drug therapies for this complex situation may include nitroprusside or the recombinant B-type natriuretic peptide nesiritide for patients with acute CRS with normal or high blood pressure, and inotropes or inodilators for patients with acute CRS with low blood pressure. Clinical data for a renal-protective action of levosimendan are suggestive, and meta-analysis data obtained in a range of low-output states are consistent with a levosimendan-induced benefit. Evidence of favourable organ-specific effects of levosimendan, including pre-glomerular vasodilation and increased renal artery diameter and renal blood flow, were collected both in preclinical and clinical studies. Larger randomized controlled trials are however needed to confirm the renal effects of levosimendan in various clinical settings.
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Affiliation(s)
- Francesco Fedele
- Department of Cardiovascular, Respiratory, Anesthesiology, Nephrology and Geriatric Science, School of Cardiology, La Sapienza University of Rome, Rome, Italy
| | - Kristjan Karason
- Departments of Cardiology and Transplantation, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Simon Matskeplishvili
- Department of Cardiology, University Clinic, Lomonosov Moscow State University, Moscow, Russia
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