1
|
Wang X, Zhao X, Wang X, Cao L, Lu B, Wang Z, Zhang W, Ti Y, Zhong M. Effect of levosimendan on ventricular remodelling in patients with left ventricular systolic dysfunction: a meta-analysis. ESC Heart Fail 2024; 11:1352-1376. [PMID: 38419326 PMCID: PMC11098670 DOI: 10.1002/ehf2.14714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 03/02/2024] Open
Abstract
Heart failure is the final stage of several cardiovascular diseases, and the key to effectively treating heart failure is to reverse or delay ventricular remodelling. Levosimendan is a novel inotropic and vasodilator agent used in heart failure, whereas the impact of levosimendan on ventricular remodelling is still unclear. This study aims to investigate the impact of levosimendan on ventricular remodelling in patients with left ventricular systolic dysfunction. Electronic databases were searched to identify eligible studies. A total of 66 randomized controlled trials involving 7968 patients were included. Meta-analysis results showed that levosimendan increased left ventricular ejection fraction [mean difference (MD) = 3.62, 95% confidence interval (CI) (2.88, 4.35), P < 0.00001] and stroke volume [MD = 6.59, 95% CI (3.22, 9.96), P = 0.0001] and significantly reduced left ventricular end-systolic volume [standard mean difference (SMD) = -0.52, 95% CI (-0.67, -0.37), P < 0.00001], left ventricular end-diastolic volume index [SMD = -1.24, 95% CI (-1.61, -0.86), P < 0.00001], and left ventricular end-systolic volume index [SMD = -1.06, 95% CI (-1.43, -0.70), P < 0.00001]. In terms of biomarkers, levosimendan significantly reduced the level of brain natriuretic peptide [SMD = -1.08, 95% CI (-1.60, -0.56), P < 0.0001], N-terminal pro-brain natriuretic peptide [SMD = -0.99, 95% CI (-1.41, -0.56), P < 0.00001], and interleukin-6 [SMD = -0.61, 95% CI (-0.86, -0.35), P < 0.00001]. Meanwhile, levosimendan may increase the incidence of hypotension [risk ratio (RR) = 1.24, 95% CI (1.12, 1.39), P < 0.0001], hypokalaemia [RR = 1.57, 95% CI (1.08, 2.28), P = 0.02], headache [RR = 1.89, 95% CI (1.50, 2.39), P < 0.00001], atrial fibrillation [RR = 1.31, 95% CI (1.12, 1.52), P = 0.0005], and premature ventricular complexes [RR = 1.86, 95% CI (1.27, 2.72), P = 0.001]. In addition, levosimendan reduced all-cause mortality [RR = 0.83, 95% CI (0.74, 0.94), P = 0.002]. In conclusion, our study found that levosimendan might reverse ventricular remodelling when applied in patients with left ventricular systolic dysfunction, especially in patients undergoing cardiac surgery, decompensated heart failure, and septic shock.
Collapse
Affiliation(s)
- Xia Wang
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Xiu‐Zhi Zhao
- Department of CardiologyPeople's Hospital of Lixia District of JinanJinanShandongChina
| | - Xi‐Wen Wang
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Lu‐Ying Cao
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Bin Lu
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Zhi‐Hao Wang
- Department of Geriatric MedicineShandong Key Laboratory of Cardiovascular Proteomics, Qilu Hospital, Cheeloo College of Medicine, Shandong UniversityJinanChina
| | - Wei Zhang
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Yun Ti
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Ming Zhong
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| |
Collapse
|
2
|
Xu J, Zhang Y, Jiang J, Yang Y, Guo F. The effect of intravenous milrinone in adult critically ill patients: A meta-analysis of randomized clinical trials. J Crit Care 2024; 79:154431. [PMID: 39255050 DOI: 10.1016/j.jcrc.2023.154431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 06/27/2023] [Accepted: 09/10/2023] [Indexed: 09/12/2024]
Abstract
BACKGROUND Milrinone is widely used for enhancing myocardial contractility, however, there is inadequate data to suggest whether it is preferable to other inotropic agents in critically ill patients. To observe the effect of milrinone on prognosis in adult critically ill patients, we conducted this meta-analysis. METHODS A search of the following databases was conducted: Medline, Elsevier, Cochrane Central Register of Controlled Trials and Web of Science databases, and eligible randomized controlled trials including adult critically ill patients were screened. Two reviewers collected data separately, information was retrieved including study design, center number, sample size, gender, age, intervention and outcome. Data were analyzed using methods recommended by the Cochrane Collaboration Review Manager 4.2 software. Random errors were evaluated by trial sequential analysis (TSA). RESULTS Twenty studies including 2036 critically ill patients which compared milrinone with control group were enrolled. When compared to control group, there was no significant difference of all-cause mortality, while the incidence of ventricular arrhythmia decreased significantly in patients with cardiac surgery who using milrinone, but not in patients with cardiac dysfunction and shock. There was no significant reduction in the incidence of myocardial infarction and no improvement of hemodynamic parameters in the milrinone group. TSA indicated lack of firm evidence for a beneficial effect. CONCLUSION The meta-analysis showed when compared with control group, although no significant reduction in mortality and the incidence of myocardial infarction was found in the milrinone group, the incidence of ventricular arrhythmia decreased significantly in patients with cardiac surgery. More randomized controlled trials are needed to determine the reliable and conclusive evidence for milrinone's effects.
Collapse
Affiliation(s)
- Jingyuan Xu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China
| | - Yanjie Zhang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China
| | - Jie Jiang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Nanjing Central Hospital, Nanjing 210009, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China
| | - Fengmei Guo
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China.
| |
Collapse
|
3
|
Wang LH, Wang XH, Tan JC, He LX, Fu RQ, Lin Y, Yao YT. Levosimendan administration is not associated with increased risk of bleeding and blood transfusion requirement in patients undergoing off-pump coronary artery bypass grafting: a retrospective study from single center. Perfusion 2023; 38:270-276. [PMID: 34619997 DOI: 10.1177/02676591211049022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Levosimendan (LEVO) is a positive inotropic drug which could increase myocardial contractility and reduce the mortality rate in cardiac surgical patients. However, Whether LEVO is associated with postoperative bleeding and blood transfusion in cardiac surgical patients is controversial. Therefore, the current study was designed to investigate the impact of LEVO administration on bleeding and blood transfusion requirement in off-pump coronary artery bypass grafting (OPCAB) patients. METHODS In a retrospective analysis, a total of 292 patients, aged 40-87 years, undergoing elective OPCAB between January 2019 and July 2019, were divided into LEVO group (n = 151) and Control group (n = 141). Patients in LEVO group continuously received LEVO at a rate of 0.1-0.2 μg kg-1 min-1 after anesthesia induction until 24 hours after OPCAB or patients in Control group received no LEVO. The primary outcome was postoperative chest drainage volume. The secondary outcomes were reoperation for postoperative bleeding, transfusion requirement of red blood cells (RBCs), fresh frozen plasma (FFP) and platelet concentrate (PC), etc. Comparisons of two groups were performed with the Student's t-test or Wilcoxon-Mann-Whitney test. RESULTS There was no significant difference with respect to chest drainage volume ((956.29 ± 555.45) ml vs (1003.19 ± 572.25) ml, p = 0.478) and the incidence of reoperation for postoperative bleeding (1.32% vs 1.42%, p = 0.945) between LEVO group and Control group. The transfusion incidence and volume of allogeneic RBCs, FFP, and PC were comparable between two groups. CONCLUSIONS LEVO administration was neither associated with more postoperative blood loss nor increased allogeneic blood transfusion requirement in OPCAB patients.
Collapse
Affiliation(s)
- Li-Hong Wang
- Department of Anesthesiology, Chuiyangliu Hospital of Tsinghua University, Beijing, China
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Hong Wang
- Department of Nutrition and Food, Tangshan City Center for Disease Control and Prevention, Tangshan, China
| | - Jie-Chao Tan
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Department of Anesthesiology, Shunde Hospital of Southern Medical University, Foshan, China
| | - Li-Xian He
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Run-Qiao Fu
- Department of Anesthesiology, Chuiyangliu Hospital of Tsinghua University, Beijing, China
| | - Yong Lin
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yun-Tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
4
|
Akhtar MS, Hassan MQ, Siddiqui A, Alavudeen SS, Afzal O, Altamimi ASA, Rahman SO, Khurana M, Ahsan MJ, Sharma AK, Tabassum F. Levosimendan: mechanistic insight and its diverse future aspects in cardiac care. Acta Cardiol 2022; 78:170-187. [PMID: 36222590 DOI: 10.1080/00015385.2022.2115761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Inotropic agents are generally recommended to use in patients with acute decompensated heart failure (HF) with reduced ejection fraction (HFrEF) concurrent to end-organ dysfunction. However, due to certain pharmacological limitations like developing life threatening arrhythmia and tolerance, cannot be employed as much as needed. Meanwhile, Calcium ion (Ca2+) sensitisers exhibits their inotropic action by increasing the sensitivity of the cardiomyocyte to intracellular Ca2+ ion and have been reported as emerging therapeutic alternative in HF cases. Levosimendan (LEVO) is an inodilator and with its unique pharmacology justifying its use in a wide range of cardiac alterations in HF particularly in undergoing cardiac surgery. It is also reported to be better than classical inotropes in maintaining cardiac mechanical efficacy and reducing congestion in acute HF with hypotension. This review paper was designed to compile various evidence about basic pharmacology and potential clinical aspects of LEVO in cardiac surgery and other HF associated alterations. This will benefit directly to the researcher in initiating research and to fill the gaps in the area of thrust.
Collapse
Affiliation(s)
| | - Md Quamrul Hassan
- Department of Pharmacology, SNS College of Pharmacy, Motihari, India
| | - Aisha Siddiqui
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Selangor, Malaysia
| | | | - Obaid Afzal
- Department of Pharmaceutical Chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Abdulmalik S A Altamimi
- Department of Pharmaceutical Chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Syed Obaidur Rahman
- Department of Pharmacology, School of Pharmaceutical Education and Research, New Delhi, India
| | - Mallika Khurana
- Department of Pharmacology, School of Pharmaceutical Education and Research, New Delhi, India
| | - Mohamed Jawed Ahsan
- Department of Pharmaceutical Chemistry, Maharishi Arvind College of Pharmacy, Jaipur, India
| | - Arun Kumar Sharma
- Department of Pharmacology, Amity Institute of Pharmacy, Noida, India
| | - Fauzia Tabassum
- Department of Pharmacology, College of Dentistry and Pharmacy, Buraydah, Saudi Arabia
| |
Collapse
|
5
|
Fakher M, Aboelghet M, Moharam A, Khaled M, Abdelaziz A. The Role of Perioperative Levosimendan in Patients with Reduced Ejection Fraction undergoing Cardiac surgery in Reducing Post-operative Hemodynamic Support. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Acute perioperative left ventricular dysfunction is a major complication affecting patients subjected to cardiac surgery and is associated with increased mortality. Levosimendan as a “calcium sensitizers” with inodilator effect improves myocardial contractility by sensitizing troponin C to calcium without increasing myocardial oxygen consumption and without impairing relaxation and diastolic function.
AIM: The aim of this study was to evaluate the effect of perioperative levosimendan compared to the conventional management used in the patient with poor left ventricular function undergoing cardiac surgery to reduce the need of post-operative pharmacological and mechanical circulatory support.
METHODS: It is prospective observational studies were patients undergoing cardiac surgery divided into two groups of 25 patients each. The first group received conventional management while the other group received levosimendan additionally duration and type of post-operative pharmacological support, duration of mechanical ventilation, durations of ICU and hospital stays, and major outcomes, and data about the need of mechanical support were collected.
RESULTS: In the levosimendan, fewer patients required vasoactive agents post-surgery (Noradrenaline) compared to the conventional group, yet the use of inotropic support (adrenaline) in the 2nd day and the need of mechanical circulatory support was equal in both groups. The mortality was equal in both groups.
CONCLUSION: Perioperative levosimendan may reduce the need of vasoactive agents postoperatively, but it does not reduce the need of inotropic nor mechanical support.
Collapse
|
6
|
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.
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
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.
Collapse
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
| | | |
Collapse
|
9
|
Amin SW, Abd-Elgalil SM, Mohamed SA, Ahmed MM, Hamawy TY, Fathi LM. Levosimendan Versus Milrinone in the Management of Impaired Left Ventricular Function in Patients Undergoing Coronary Artery Bypass Graft Surgery. THE OPEN ANESTHESIA JOURNAL 2019; 13:59-67. [DOI: 10.2174/2589645801913010059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/17/2019] [Accepted: 06/26/2019] [Indexed: 09/02/2023]
Abstract
Background:
Patients undergoing cardiac surgery are at risk of postcardiotomy myocardial dysfunction. This condition causes delayed recovery, organ failure, prolonged intensive care unit and hospital stays, and an increased risk of mortality; these patients often require inotropic agent support. Levosimendan is a calcium sensitizer with a unique mechanism of action, binding to cardiac troponin C and enhancing myofilament responsiveness to calcium, increasing myocardial contraction without increasing myocardial oxygen consumption. Phosphodiesterase III inhibitors such as milrinone provide an alternative means of inotropic support by increasing the concentration of cyclic AMP and intracellular calcium. They also have vasodilatory effects.
Objective:
The aim of this study was the comparison between levosimendan versus milrinone regarding their effects on the hemodynamics, need for additional mechanical (intra aortic balloon pump) or pharmacological support to the heart, weaning from mechanical ventilation and duration of intensive care unit stay for patients after Off-Pump Coronary Artery Bypass Graft (OPCABG) surgery suffering from impaired left ventricular function (preoperative ejection fraction ≤ 40%).
Methods:
60 patients between 40 and 70 years of both sexes with impaired left ventricular function (ejection fraction ≤ 40%), New York Heart Association (NYHA III & IV), undergoing elective Off-Pump Coronary Artery Bypass Graft (OPCABG) surgery were selected for this study. After induction of anesthesia, patients were randomly assigned to one of two equal groups each containing 30 patients:
Group L (Levosimendan group) included patients who received levosimendan 0.1- 0.2 µg/kg/min. Started immediately with the induction of anesthesia.
Group M (Milrinone group) included patients who received milrinone 0.4-0.6 µg/kg/min. Started immediately with the induction of anesthesia.
In both groups, norepinephrine was titrated (8 mg norepinephrine in 50 ml saline) to keep mean arterial pressure MAP ≥ 70 mmHg.
Hemodynamic findings included Preoperative and post ICU discharge ejection fraction, systemic and pulmonary artery pressures, systemic and pulmonary vascular resistance, cardiac output and stroke volume. Also laboratory findings included Serum lactate and Troponin I., in addition, to post operative findings were: Need for intra aortic balloon pump, time of weaning from the ventilator, days of ICU stay and appearance of drug allergy compared in both groups.
Results:
There was a significant increase in the ejection fraction in both groups that was greater in the levosimendan group. The decrease in pulmonary pressure in the levosimendan group was more significant than milrinone group. There was a gradual decrease in pulmonary and systemic vascular resistance in both groups with a more significant decrease in the levosimendan group. There was a gradual increase in cardiac output and stroke volume in both groups that was greater in the levosimendan group. Serum lactate gradually decreased in both groups with an insignificant difference; there was an increase in serum troponin I level in both groups which was more significant in the milrinone group. Weaning from mechanical ventilation and length of ICU stay was shown to be significantly shorter in time in the levosimendan group.
Conclusion:
Both levosimendan and milrinone caused a significant increase in cardiac output, stroke volume and ejection fraction, with a decrease in pulmonary and systemic vascular resistance. These effects improved cardiac performance by decreasing afterload and increasing cardiac inotropism. It was noticed that these effects were more significant with levosimendan than milrinone. Also, there was a decrease in ICU stay, mechanical ventilation timing and hospital stay with levosimendan than milrinone which decreased the costs of treatment for the patients.
Collapse
|
10
|
Khaled M, Almogy AN, Shehata M, Ragab F, Zeineldin K. Effect of Levosimendan Compared to Conventional Inotropic Agents on Hemodynamics and Outcome in Patient with Poor LV Function Undergoing Cardiac Surgery. Open Access Maced J Med Sci 2019; 7:3205-3210. [PMID: 31949517 PMCID: PMC6953938 DOI: 10.3889/oamjms.2019.675] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/14/2019] [Accepted: 07/15/2019] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Patients undergoing heart surgery involving cardiopulmonary bypass (CPB) experience global myocardial ischemia with subsequent reperfusion which, despite cardioplegic protection, may result in different degrees of transient ventricular dysfunction. Levosimendan is a "calcium sensitisers", it improves myocardial contractility by sensitising troponin C to calcium without increasing myocardial oxygen consumption and without impairing relaxation and diastolic function. AIM To evaluate the adding effect of a calcium sensitiser (levosimendan) compared to the conventional inotropic and vasoactive agent used in the patient with poor left ventricular function undergoing cardiac surgery on different measured hemodynamic variables and the effect on the outcome. METHODS It is prospective observational studies were patients were divided into 2 groups of 30 patients each. The first Group received conventional inotropic and vasoactive treatment at different doses, while the other group received levosimendan additionally at a loading dose of 6-12mic/kg according to mean arterial pressure over 0.5 hr followed by 24 hrs infusion at 0.05 to 0.2 mic/kg/min. Hemodynamic data were collected at the end and 30 minutes after CPB, after that at 6, 12, 24, and 36 hours post CPB. Mean arterial pressure (MAP), central venous pressure (CVP), heart rate (HR), mixed venous saturation (Svo2), and base deficit (BD) were measured. RESULTS Levosimendan had significantly improved postoperative hemodynamic values as in the mixed venous pressure at different times postoperative (p < 0.05), also the base deficit at different times postoperative (p < 0.05), while there was a significant reduction in systemic vascular resistance as decreased mean arterial pressure in levosimendan group compared to conventional group at 6hrs postoperative mean 77.50 ± 10.81 vs 83.73 ± 10.81 with (p = 0.029), and at 12 hrs postoperative mean 77.37 ± 10.10vs 84.23 ± 13.81 with (p = 0.032), and there was no significant difference in heart rate at different times postoperative between both groups (p > 0.05), while there was no significant effect on mortality between both groups (p = 0.781). CONCLUSION Levosimendan had improved hemodynamic parameters significantly with no effect on mortality compared to conventional inotropic agents in a patient with poor left ventricular function undergoing cardiac surgery.
Collapse
Affiliation(s)
- Mahmoud Khaled
- Department of Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Ahmad Naem Almogy
- Department of Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Mohammed Shehata
- Department of Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Fahim Ragab
- Department of Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Khaled Zeineldin
- Department of Critical Care Medicine, Cairo University, Cairo, Egypt
| |
Collapse
|
11
|
Perioperative use of levosimendan in patients undergoing cardiac surgery. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2019. [DOI: 10.1097/cj9.0000000000000121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
12
|
Perioperative Use of Levosimendan Improves Clinical Outcomes in Patients After Cardiac Surgery: A Systematic Review and Meta-Analysis. J Cardiovasc Pharmacol 2019; 72:11-18. [PMID: 29672418 DOI: 10.1097/fjc.0000000000000584] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Severe postoperative complications can affect cardiac surgery patients. Levosimendan is a novel calcium sensitizer commonly administered after cardiac surgery. However, the patient benefits are controversial. PubMed, Embase, and the Cochrane library were systematically searched for randomized controlled trials comparing levosimendan with control in adult cardiac surgery patients. Twenty-five studies (3247 patients) were included. Pooled data indicated that levosimendan reduced mortality after cardiac surgery [odds ratio (OR) 0.63, 95% confidence interval (CI): 0.47-0.84, P = 0.001]. However, this reduction was restricted to patients with low (<50%) left ventricular ejection fraction (OR 0.49, 95% CI: 0.35-0.70, P = 0.0001). It significantly reduced the incidence of postoperative acute kidney injury (OR 0.55, 95% CI: 0.41-0.74, P < 0.0001) and renal replacement therapy use (OR 0.56, 95% CI: 0.39-0.80, P = 0.002). Moreover, levosimendan significantly shortened the duration of the intensive care unit stay (weighted mean differences -0.49 day, 95% CI: -0.75 to -0.24, P = 0.0002) and mechanical ventilation use (weighted mean differences -2.30 hours, 95% CI: -3.76 to -0.84, P = 0.002). In conclusion, levosimendan reduced the mortality in patients with low left ventricular ejection fraction and decreased the incidence of acute renal injury and renal replacement therapy use. In addition, it shortened the duration of the intensive care unit stay and mechanical ventilation use.
Collapse
|
13
|
Wang W, Zhou X, Liao X, Liu B, Yu H. The efficacy and safety of prophylactic use of levosimendan on patients undergoing coronary artery bypass graft: a systematic review and meta-analysis. J Anesth 2019; 33:543-550. [PMID: 31025104 DOI: 10.1007/s00540-019-02643-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/06/2019] [Indexed: 02/05/2023]
Abstract
Prophylactic use of levosimendan in cardiac surgery remains controversial and no meta-analysis has been done exclusively about that in patients undergoing coronary artery bypass graft (CABG) surgery. We conducted this systematic review and meta-analysis of levosimendan in CABG using PubMed, Embase, Scopus, and Cochrane Library (till April 20, 2018). Two-hundred and forty manuscripts were identified and 21 randomized trials (1727 patients in total) investigating the effect of levosimendan on the patients undergoing CABG surgery were finally included in this analysis. We found that levosimendan was an effective, well-tolerated inotropic agent in CABG, which was associated with a significantly reduced mortality rate [odds ratio (OR) 0.43, 95% confidence interval (CI) (0.26, 0.71), p = 0.001, I2 = 0%] and postoperative atrial fibrillation [OR 0.50, 95% CI (0.26, 0.97), p = 0.04, I2 = 76%], but a higher incidence of hypotension [OR 2.26, 95% CI (1.05, 4.85), p = 0.04, I2 = 79%]. Subgroup analyses revealed that such a benefit was mainly observed in the isolated CABG, the preoperative administration, with-bolus and on-pump subgroups. More high-quality and well-designed prospective studies are needed to confirm or disprove our findings in future.
Collapse
Affiliation(s)
- Wanyu Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Xiaoshuang Zhou
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Xinyang Liao
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
| | - Hai Yu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
| |
Collapse
|
14
|
Faisal SA, Apatov DA, Ramakrishna H, Weiner MM. Levosimendan in Cardiac Surgery: Evaluating the Evidence. J Cardiothorac Vasc Anesth 2019; 33:1146-1158. [DOI: 10.1053/j.jvca.2018.05.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Indexed: 11/11/2022]
|
15
|
Use of Levosimendan in Cardiac Surgery: An Update After the LEVO-CTS, CHEETAH, and LICORN Trials in the Light of Clinical Practice. J Cardiovasc Pharmacol 2019; 71:1-9. [PMID: 29076887 PMCID: PMC5768218 DOI: 10.1097/fjc.0000000000000551] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Levosimendan is a calcium sensitizer and adenosine triphosphate-dependent potassium channel opener, which exerts sustained hemodynamic, symptomatic, and organ-protective effects. It is registered for the treatment of acute heart failure, and when inotropic support is considered appropriate. In the past 15 years, levosimendan has been widely used in clinical practice and has also been tested in clinical trials to stabilize at-risk patients undergoing cardiac surgery. Recently, 3 randomized, placebo-controlled, multicenter studies (LICORN, CHEETAH, and LEVO-CTS) have been published reporting on the perioperative use of levosimendan in patients with compromised cardiac ventricular function. Taken together, many smaller trials conducted in the past suggested beneficial outcomes with levosimendan in perioperative settings. By contrast, the latest 3 studies were neutral or inconclusive. To understand the reasons for such dissimilarity, a group of experts from Austria, Belgium, Finland, France, Germany, Italy, Switzerland, and Russia, including investigators from the 3 most recent studies, met to discuss the study results in the light of both the previous literature and current clinical practice. Despite the fact that the null hypothesis could not be ruled out in the recent multicenter trials, we conclude that levosimendan can still be viewed as a safe and effective inodilator in cardiac surgery.
Collapse
|
16
|
Santillo E, Migale M, Massini C, Incalzi RA. Levosimendan for Perioperative Cardioprotection: Myth or Reality? Curr Cardiol Rev 2018; 14:142-152. [PMID: 29564979 PMCID: PMC6131406 DOI: 10.2174/1573403x14666180322104015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 02/23/2018] [Accepted: 03/06/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Levosimendan is a calcium sensitizer drug causing increased contractility in the myocardium and vasodilation in the vascular system. It is mainly used for the therapy of acute decompensated heart failure. Several studies on animals and humans provided evidence of the cardioprotective properties of levosimendan including preconditioning and anti-apoptotic. In view of these favorable effects, levosimendan has been tested in patients undergoing cardiac surgery for the prevention or treatment of low cardiac output syndrome. However, initial positive results from small studies have not been confirmed in three recent large trials. AIM To summarize levosimendan mechanisms of action and clinical use and to review available evidence on its perioperative use in a cardiac surgery setting. METHODS We searched two electronic medical databases for randomized controlled trials studying levosimendan in cardiac surgery patients, ranging from January 2000 to August 2017. Metaanalyses, consensus documents and retrospective studies were also reviewed. RESULTS In the selected interval of time, 54 studies on the use of levosimendan in heart surgery have been performed. Early small size studies and meta-analyses have suggested that perioperative levosimendan infusion could diminish mortality and other adverse outcomes (i.e. intensive care unit stay and need for inotropic support). Instead, three recent large randomized controlled trials (LEVO-CTS, CHEETAH and LICORN) showed no significant survival benefits from levosimendan. However, in LEVO-CTS trial, prophylactic levosimendan administration significantly reduced the incidence of low cardiac output syndrome. CONCLUSIONS Based on most recent randomized controlled trials, levosimendan, although effective for the treatment of acute heart failure, can't be recommended as standard therapy for the management of heart surgery patients. Further studies are needed to clarify whether selected subgroups of heart surgery patients may benefit from perioperative levosimendan infusion.
Collapse
Affiliation(s)
- Elpidio Santillo
- Geriatric-Rehabilitative Department, Italian National Research Center on Aging (INRCA), Fermo, Italy
| | - Monica Migale
- Geriatric-Rehabilitative Department, Italian National Research Center on Aging (INRCA), Fermo, Italy
| | - Carlo Massini
- Cardiac, Thoracic and Vascular Surgery Ward, Salus Hospital-GVM Care & Research, Reggio Emilia, Italy
| | | |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Xing Z, Tang L, Chen P, Huang J, Peng X, Hu X. Levosimendan in patients with left ventricular dysfunction undergoing cardiac surgery: a meta-analysis and trial sequential analysis of randomized trials. Sci Rep 2018; 8:7775. [PMID: 29773835 PMCID: PMC5958056 DOI: 10.1038/s41598-018-26206-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/08/2018] [Indexed: 01/18/2023] Open
Abstract
Patients with left ventricular dysfunction (LVD) undergoing cardiac surgery have a high mortality rate. Levosimendan, a calcium sensitizer, improves myocardial contractility without increasing myocardial oxygen demand. It is not clear whether levosimendan can reduce mortality in cardiac surgery patients with LVD. The PubMed, Embase, and Cochrane Central databases were searched to identify randomized trials comparing levosimendan with conventional treatment in cardiac surgery patients with LVD. We derived pooled risk ratios (RRs) with random effects models. The primary endpoint was perioperative mortality. Secondary endpoints were renal replacement treatment, atrial fibrillation, myocardial infarction, ventricular arrhythmia, and hypotension. Fifteen studies enrolling 2606 patients were included. Levosimendan reduced the incidence of perioperative mortality (RR: 0.64, 95%CI: 0.45–0.91) and renal replacement treatment (RR:0.71, 95%CI:0.52–0.95). However, sensitivity analysis, subgroup analysis and Trial Sequential Analysis (TSA) indicated that more evidence was needed. Furthermore, levosimendan did not reduce the incidence of atrial fibrillation (RR:0.82, 95%CI:0.64–1.07), myocardial infarction (RR:0.56, 95%CI:0.26–1.23), or ventricular arrhythmia (RR:0.74, 95%CI:0.49–1.11), but it increased the incidence of hypotension (RR:1.11,95%CI:1.00–1.23). There was not enough high-quality evidence to either support or contraindicate the use of levosimendan in cardiac surgery patients with LVD.
Collapse
Affiliation(s)
- Zhenhua Xing
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Liang Tang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Pengfei Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Jiabing Huang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Xiaofan Peng
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Xinqun Hu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China.
| |
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Zhou X, Hu C, Xu Z, Liu P, Zhang Y, Sun L, Wang Y, Gao X. Effect of levosimendan on clinical outcomes in adult patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials. Interact Cardiovasc Thorac Surg 2018; 26:1016-1026. [PMID: 29415177 DOI: 10.1093/icvts/ivy017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 01/09/2018] [Indexed: 12/11/2022] Open
Affiliation(s)
- Xiaoyang Zhou
- Department of Intensive Care Unit, Ningbo No. 2 Hospital, Ningbo, China
| | - Caibao Hu
- Department of Intensive Care Unit, Zhejiang Hospital, Hangzhou, China
| | - Zhaojun Xu
- Department of Intensive Care Unit, Ningbo No. 2 Hospital, Ningbo, China
| | - Peng Liu
- Department of Intensive Care Unit, Ningbo No. 2 Hospital, Ningbo, China
| | - Yuchu Zhang
- Department of Intensive Care Unit, Ningbo No. 2 Hospital, Ningbo, China
| | - Lingling Sun
- Department of Geriatrics, Ningbo No. 2 Hospital, Ningbo, China
| | - Yang Wang
- Department of Intensive Care Unit, Ningbo No. 2 Hospital, Ningbo, China
| | - Xiaofei Gao
- Department of Cardiology, Hangzhou First People’s Hospital, Hangzhou, China
| |
Collapse
|
22
|
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.
Collapse
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
| | | |
Collapse
|
23
|
Putzu A, Clivio S, Belletti A, Cassina T. Perioperative levosimendan in cardiac surgery: A systematic review with meta-analysis and trial sequential analysis. Int J Cardiol 2017; 251:22-31. [PMID: 29126653 DOI: 10.1016/j.ijcard.2017.10.077] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/24/2017] [Accepted: 10/17/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Several studies suggested beneficial effects of perioperative levosimendan on postoperative outcome after cardiac surgery. However, three large randomized controlled trials (RCTs) have been recently published and presented neutral results. We performed a systematic review with meta-analysis and trial sequential analysis (TSA) to assess benefits and harms of perioperative levosimendan therapy in cardiac surgery. METHODS Electronic databases were searched up to September 2017 for RCTs on preoperative levosimendan versus any type of control. The Cochrane methodology was employed. We calculated odds ratio (OR) or Risk Ratio (OR) and 95% confidence interval (CI) using fixed-effects meta-analyses and we further performed TSA. RESULTS We included data from 40 RCTs and 4246 patients. Pooled analysis of 5 low risk of bias trials (1910 patients) showed no association between levosimendan and mortality (OR 0.86 [95% CI, 0.62, 1.18], p=0.34, TSA inconclusive), acute kidney injury, need of renal replacement therapy, myocardial infarction, ventricular arrhythmias, and serious adverse events, but an association with higher incidence of supraventricular arrhythmias (RR 1.11 [95% CI, 1.00, 1.24], p=0.05, TSA inconclusive) and hypotension (RR 1.15 [95% CI, 1.01, 1.30], p=0.04, TSA inconclusive). Analysis including all 40 trials found that levosimendan was associated with lower postoperative mortality (OR 0.56 [95% CI, 0.44, 0.71], p<0.00001, TSA conclusive), acute kidney injury, and renal replacement therapy, and higher incidence of hypotension. CONCLUSIONS There is not enough high-quality evidence to neither support nor discourage the systematic use of levosimendan in cardiac surgery.
Collapse
Affiliation(s)
- Alessandro Putzu
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland.
| | - Sara Clivio
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland.
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Tiziano Cassina
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland.
| |
Collapse
|
24
|
Chen QH, Zheng RQ, Lin H, Shao J, Yu JQ, Wang HL. Effect of levosimendan on prognosis in adult patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:253. [PMID: 29041948 PMCID: PMC5645931 DOI: 10.1186/s13054-017-1848-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 09/28/2017] [Indexed: 01/24/2023]
Abstract
Background Small trials suggest that levosimendan is associated with a favorable outcome in patients undergoing cardiac surgery. However, recently published larger-scale trials did not provide evidence for a similar benefit from levosimendan. We performed a meta-analysis to assess the survival benefits of levosimendan in patients undergoing cardiac surgery and to investigate its effects in subgroups of patients with preoperative low-ejection fraction (EF). Methods We identified randomized clinical trials through 20 April 2017 that investigated levosimendan therapy versus control in patients undergoing cardiac surgery. Individual patient data from each study were compiled. Meta-analyses were performed for primary outcomes, secondary outcomes and serious adverse events, and subgroup analyses according to the preoperative EF of enrolled patients were also conducted. The risk of bias was assessed using the Cochrane risk-of-bias tool. Results Seventeen studies involving a total of 2756 patients were included. Levosimendan therapy was associated with a significant reduction in 30-day mortality (RR 0.67; 95% CI, 0.49 to 0.93; p = 0.02) and reduced the risk of death in single-center trials (RR 0.49; 95% CI, 0.30 to 0.79; p = 0.004) and in subgroup trials of inferior quality (RR 0.39; 95% CI, 0.17 to 0.92; p = 0.02); however, in multicenter and in high-quality subgroup-analysis trials, no significant difference in mortality was observed between patients who received levosimendan therapy and controls (p > 0.05). However, in high-quality subgroup trials, levosimendan therapy was associated with reduced mortality in patients in a preoperative low-EF subgroup (RR 0.58; 95% CI, 0.38 to 0.88; p = 0.01). Similarly, only patients in the preoperative low-EF subgroup benefited in terms of reduced risk of renal replacement therapy (RR 0.54; 95% CI, 0.34 to 0.85; p = 0.007). Furthermore, levosimendan therapy was associated with a significant reduction in intensive care unit (ICU) length of stay (MDR −17.19; 95% CI, −34.43 to −2.94; p = 0.02). Conclusions In patients undergoing cardiac surgery, the benefit of levosimendan in terms of survival was not shown in multicenter or in high-quality trials; however, levosimendan therapy was associated with reduced mortality in patients with preoperative ventricular systolic dysfunction. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1848-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Qi-Hong Chen
- Department of Critical Care Medicine, Subei People's Hospital, School of Medicine, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu, 225001, People's Republic of China
| | - Rui-Qiang Zheng
- Department of Critical Care Medicine, Subei People's Hospital, School of Medicine, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu, 225001, People's Republic of China
| | - Hua Lin
- Department of Critical Care Medicine, Subei People's Hospital, School of Medicine, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu, 225001, People's Republic of China
| | - Jun Shao
- Department of Critical Care Medicine, Subei People's Hospital, School of Medicine, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu, 225001, People's Republic of China
| | - Jiang-Quan Yu
- Department of Critical Care Medicine, Subei People's Hospital, School of Medicine, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu, 225001, People's Republic of China
| | - Hua-Ling Wang
- Department of Critical Care Medicine, Subei People's Hospital, School of Medicine, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu, 225001, People's Republic of China. .,Department of Cardiology, Subei People's Hospital, School of Medicine, Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China.
| |
Collapse
|
25
|
Ushio M, Egi M, Wakabayashi J, Nishimura T, Miyatake Y, Obata N, Mizobuchi S. Impact of Milrinone Administration in Adult Cardiac Surgery Patients: Updated Meta-Analysis. J Cardiothorac Vasc Anesth 2016; 30:1454-1460. [DOI: 10.1053/j.jvca.2016.07.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Indexed: 11/11/2022]
|
26
|
Koster G, Bekema HJ, Wetterslev J, Gluud C, Keus F, van der Horst ICC. Milrinone for cardiac dysfunction in critically ill adult patients: a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis. Intensive Care Med 2016; 42:1322-35. [PMID: 27448246 PMCID: PMC4992029 DOI: 10.1007/s00134-016-4449-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 07/09/2016] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Milrinone is an inotrope widely used for treatment of cardiac failure. Because previous meta-analyses had methodological flaws, we decided to conduct a systematic review of the effect of milrinone in critically ill adult patients with cardiac dysfunction. METHODS This systematic review was performed according to The Cochrane Handbook for Systematic Reviews of Interventions. Searches were conducted until November 2015. Patients with cardiac dysfunction were included. The primary outcome was serious adverse events (SAE) including mortality at maximum follow-up. The risk of bias was evaluated and trial sequential analyses were conducted. The quality of evidence was assessed by the Grading of Recommendations Assessment, Development and Evaluation criteria. RESULTS A total of 31 randomised clinical trials fulfilled the inclusion criteria, of which 16 provided data for our analyses. All trials were at high risk of bias, and none reported the primary composite outcome SAE. Fourteen trials with 1611 randomised patients reported mortality data at maximum follow-up (RR 0.96; 95% confidence interval 0.76-1.21). Milrinone did not significantly affect other patient-centred outcomes. All analyses displayed statistical and/or clinical heterogeneity of patients, interventions, comparators, outcomes, and/or settings and all featured missing data. DISCUSSION The current evidence on the use of milrinone in critically ill adult patients with cardiac dysfunction suffers from considerable risks of both bias and random error and demonstrates no benefits. The use of milrinone for the treatment of critically ill patients with cardiac dysfunction can be neither recommended nor refuted. Future randomised clinical trials need to be sufficiently large and designed to have low risk of bias.
Collapse
Affiliation(s)
- Geert Koster
- Department of Critical Care, University of Groningen, University Medical Centre Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Hanneke J Bekema
- Department of Anaesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Jørn Wetterslev
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, 2100, Copenhagen, Denmark
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, 2100, Copenhagen, Denmark
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Centre Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Centre Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| |
Collapse
|
27
|
Anastasiadis K, Antonitsis P, Vranis K, Kleontas A, Asteriou C, Grosomanidis V, Tossios P, Argiriadou H. Effectiveness of prophylactic levosimendan in patients with impaired left ventricular function undergoing coronary artery bypass grafting: a randomized pilot study. Interact Cardiovasc Thorac Surg 2016; 23:740-747. [PMID: 27378790 DOI: 10.1093/icvts/ivw213] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 05/01/2016] [Accepted: 05/10/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Perioperative low cardiac output syndrome occurs in 3-14% of patients undergoing isolated coronary artery bypass grafting (CABG), leading to significant increase in major morbidity and mortality. Considering the unique pharmacological and pharmacokinetic properties of levosimendan, we conducted a prospective, double-blind, randomized pilot study to evaluate the effectiveness of prophylactic levosimendan in patients with impaired left ventricular function undergoing CABG. METHODS Thirty-two patients undergoing CABG with low left ventricular ejection fraction (LVEF ≤ 40%) were randomized to receive either a continuous infusion of levosimendan at a dose of 0.1 μg/kg/min for 24 h without a loading dose or a placebo. The primary outcome of the study was the change in the LVEF assessed with transthoracic echocardiography on the seventh postoperative day. Secondary outcomes included the physiological and clinical effects of levosimendan. RESULTS All patients tolerated preoperative infusion of levosimendan well. The LVEF improved in both groups; this increase was statistically significant in the levosimendan group (from 35.8 ± 5% preoperatively to 42.8 ± 7.8%, P = 0.001) compared with the control group (from 37.5 ± 3.4% preoperatively to 41.2 ± 8.3%, P = 0.1). The cardiac index, SvO2, pulmonary capillary wedge pressure and right ventricular stroke work index showed a similar trend, which was optimized in patients treated with levosimendan. Moreover, an increase in extravascular lung water was noticed in this group during the first 24 h after surgery. CONCLUSIONS This pilot study shows that prophylactic levosimendan infusion is safe and effective in increasing the LVEF postoperatively in patients with impaired cardiac function undergoing coronary surgery. This finding may be translated to 'optimizing' patients' status before surgery.
Collapse
MESH Headings
- Cardiac Output, Low/etiology
- Cardiotonic Agents/administration & dosage
- Coronary Artery Bypass/adverse effects
- Coronary Artery Disease/complications
- Coronary Artery Disease/diagnosis
- Coronary Artery Disease/surgery
- Dose-Response Relationship, Drug
- Double-Blind Method
- Female
- Finland/epidemiology
- Follow-Up Studies
- Humans
- Hydrazones/administration & dosage
- Incidence
- Infusions, Intravenous
- Male
- Middle Aged
- Pilot Projects
- Postoperative Complications/epidemiology
- Postoperative Complications/prevention & control
- Prospective Studies
- Pyridazines/administration & dosage
- Simendan
- Stroke Volume/drug effects
- Stroke Volume/physiology
- Survival Rate/trends
- Tomography, Emission-Computed, Single-Photon
- Ventricular Dysfunction, Left/complications
- Ventricular Dysfunction, Left/drug therapy
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Function, Left/drug effects
- Ventricular Function, Left/physiology
Collapse
|
28
|
Bozhinovska M, Taleska G, Fabian A, Šoštarič M. The Role of Levosimendan in Patients with Decreased Left Ventricular Function Undergoing Cardiac Surgery. Open Access Maced J Med Sci 2016; 4:510-516. [PMID: 27703584 PMCID: PMC5042644 DOI: 10.3889/oamjms.2016.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 06/21/2016] [Accepted: 06/25/2016] [Indexed: 11/05/2022] Open
Abstract
The postoperative low cardiac output is one of the most important complications following cardiac surgery and is associated with increased morbidity and mortality. The condition requires inotropic support to achieve adequate hemodynamic status and tissue perfusion. While catecholamines are utilised as a standard therapy in cardiac surgery, their use is limited due to increased oxygen consumption. Levosimendan is calcium sensitising inodilatator expressing positive inotropic effect by binding with cardiac troponin C without increasing oxygen demand. Furthermore, the drug opens potassium ATP (KATP) channels in cardiac mitochondria and in the vascular muscle cells, showing cardioprotective and vasodilator properties, respectively. In the past decade, levosimendan demonstrated promising results in treating patients with reduced left ventricular function when administered in peri- or post- operative settings. In addition, pre-operative use of levosimendan in patients with severely reduced left ventricular ejection fraction may reduce the requirements for postoperative inotropic support, mechanical support, duration of intensive care unit stay as well as hospital stay and a decrease in post-operative mortality. However, larger studies are needed to clarify clinical advantages of levosimendan versus conventional inotropes.
Collapse
Affiliation(s)
- Marija Bozhinovska
- Clinical Department of Anesthesiology and Perioperative Intensive Therapy, Division of Cardiac Anesthesiology and Intensive Therapy, University Clinical Center Ljubljana, Zaloska 7, 1000 Ljubljana, Slovenia
| | - Gordana Taleska
- Clinical Department of Anesthesiology and Perioperative Intensive Therapy, Division of Cardiac Anesthesiology and Intensive Therapy, University Clinical Center Ljubljana, Zaloska 7, 1000 Ljubljana, Slovenia
| | - Andrej Fabian
- Institute of Physiology, Medical Faculty, University of Ljubljana, Slovenia; Department of Vascular Neurology and Neurological Intensive Therapy, University Clinical Centre Ljubljana, Slovenia
| | - Maja Šoštarič
- Clinical Department of Anesthesiology and Perioperative Intensive Therapy, Division of Cardiac Anesthesiology and Intensive Therapy, University Clinical Center Ljubljana, Zaloska 7, 1000 Ljubljana, Slovenia
| |
Collapse
|
29
|
Mishra A, Kumar B, Dutta V, Arya V, Mishra AK. Comparative Effect of Levosimendan and Milrinone in Cardiac Surgery Patients With Pulmonary Hypertension and Left Ventricular Dysfunction. J Cardiothorac Vasc Anesth 2016; 30:639-46. [DOI: 10.1053/j.jvca.2016.01.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Indexed: 11/11/2022]
|
30
|
Zhou C, Gong J, Chen D, Wang W, Liu M, Liu B. Levosimendan for Prevention of Acute Kidney Injury After Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials. Am J Kidney Dis 2015; 67:408-16. [PMID: 26518388 DOI: 10.1053/j.ajkd.2015.09.015] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 09/03/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Levosimendan has been shown to confer direct renoprotection in renal endotoxemic and ischemia-reperfusion injury and could increase renal blood flow in patients with low-cardiac-output heart failure. Results from clinical trials of levosimendan on acute kidney injury (AKI) following cardiac surgery are controversial. STUDY DESIGN A random-effect meta-analysis was conducted based on evidence from PubMed, EMBASE, and Cochrane Library. SETTINGS & POPULATION Adult patients undergoing cardiac surgery. SELECTION CRITERIA FOR STUDIES Randomized controlled trials comparing the renal effect of levosimendan versus placebo or other inotropic drugs during cardiac surgery. INTERVENTION Perioperative levosimendan continuous infusion at a rate of 0.1 to 0.2μg/kg/min following a loading dose (6-24μg/kg) for 24 hours or only 1 loading dose (24μg/kg) within 1 hour. OUTCOMES AKI, need for renal replacement therapy, mechanical ventilation duration, intensive care unit stay during hospitalization, and postoperative mortality (in-hospital or within 30 days). RESULTS 13 trials with a total of 1,345 study patients were selected. Compared with controls, levosimendan reduced the incidence of postoperative AKI (40/460 vs 78/499; OR, 0.51; 95% CI, 0.34-0.76; P=0.001; I(2)=0.0%), renal replacement therapy (22/492 vs 49/491; OR, 0.43; 95% CI, 0.25-0.76; P=0.002; I(2)=0.0%), postoperative mortality (35/658 vs 94/657; OR, 0.41; 95% CI, 0.27-0.62; P<0.001; I(2)=0.0%), mechanical ventilation duration (in days; n=235; weighted mean difference, -0.34; 95% CI, -0.58 to -0.09; P=0.007], and intensive care unit stay (in days; n=500; weighted mean difference, -2.2; 95% CI, -4.21 to -0.13; P=0.04). LIMITATIONS Different definitions for AKI among studies. Small sample size for some trials. CONCLUSIONS Perioperative administration of levosimendan in patients undergoing cardiac surgery may reduce complications. Future trials are needed to determine the dose effect of levosimendan in improving outcomes, especially in patients with decreased baseline kidney function.
Collapse
Affiliation(s)
- Chenghui Zhou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junsong Gong
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Chen
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weipeng Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingzheng Liu
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Liu
- Department of Anesthesiology, Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China.
| |
Collapse
|
31
|
Lim JY, Deo SV, Rababa'h A, Altarabsheh SE, Cho YH, Hang D, McGraw M, Avery EG, Markowitz AH, Park SJ. Levosimendan Reduces Mortality in Adults with Left Ventricular Dysfunction Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis. J Card Surg 2015; 30:547-54. [PMID: 25989324 DOI: 10.1111/jocs.12562] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Levosimendan is implemented in patients with low cardiac output after cardiac surgery. However, the strength of evidence is limited by randomized controlled trials enrolling a small number of patients. Hence we have conducted a systematic review to determine the role of levosimendan in adult cardiac surgery. METHODS PUBMED, WoS, Cochrane database, and SCOPUS were systematically queried to identify original English language peer-reviewed literature (inception-October 2014) comparing clinical results of adult cardiac surgery between levosimendan and control. Pooled odds ratio (OR) was calculated using the Peto method; p < 0.05 is significant; results are presented within 95% confidence intervals. Continuous data was compared using standardized mean difference/mean difference. RESULTS Fourteen studies were included in the analysis. Levosimendan reduced early mortality in patients with reduced ejection fraction (5.5% vs. 9.1%) (OR 0.48 [0.23-0.76]; p = 0.004). This result was confirmed using sensitivity analysis. Postoperative acute renal failure was lower with levosimendan therapy (7.4% vs. 11.5%). Intensive care unit stay was shorter in the levosimendan cohort comparable in both groups (standardized mean difference -0.31 [-0.53, -0.09]; p = 0.006; I(2) = 33.6%). Levosimendan-treated patients stayed 1.01 (1.61-0.42) days shorter when compared to control (p = 0.001). CONCLUSION Our meta-analysis demonstrates that Levosimendan improves clinical outcomes in patients with left ventricular dysfunction undergoing cardiac surgery. Results of the ongoing multicenter randomized controlled trial are awaited to provide more conclusive evidence regarding the benefit of this drug.
Collapse
Affiliation(s)
- Ju Yong Lim
- Asan Medical Center, Ulsan School of Medicine, Seoul, South Korea
| | - Salil V Deo
- Division of Cardiovascular Surgery, Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Abeer Rababa'h
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | | | - Yang Hyun Cho
- Samsung Hospital, Sungkyunkwan School of Medicine, Seoul, South Korea
| | - Dustin Hang
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Michael McGraw
- Health Sciences Library, Case Western Reserve University, Cleveland, Ohio
| | - Edwin G Avery
- Department of Anesthesia and Peri-operative Medicine, Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Alan H Markowitz
- Division of Cardiovascular Surgery, Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Soon J Park
- Division of Cardiovascular Surgery, Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
32
|
Cui WW, Ramsay JG. Pharmacologic approaches to weaning from cardiopulmonary bypass and extracorporeal membrane oxygenation. Best Pract Res Clin Anaesthesiol 2015; 29:257-70. [DOI: 10.1016/j.bpa.2015.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 03/09/2015] [Accepted: 03/20/2015] [Indexed: 01/12/2023]
|
33
|
Greco T, Calabrò M, Covello R, Greco M, Pasin L, Morelli A, Landoni G, Zangrillo A. A Bayesian network meta-analysis on the effect of inodilatory agents on mortality. Br J Anaesth 2015; 114:746-756. [DOI: 10.1093/bja/aeu446] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
|
34
|
Preoperative and perioperative use of levosimendan in cardiac surgery: European expert opinion. Int J Cardiol 2015; 184:323-336. [DOI: 10.1016/j.ijcard.2015.02.022] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 02/09/2015] [Accepted: 02/21/2015] [Indexed: 01/07/2023]
|
35
|
Shi WY, Li S, Collins N, Cottee DB, Bastian BC, James AN, Mejia R. Peri-operative Levosimendan in Patients Undergoing Cardiac Surgery: An Overview of the Evidence. Heart Lung Circ 2015; 24:667-72. [PMID: 25862519 DOI: 10.1016/j.hlc.2015.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 03/16/2015] [Indexed: 10/23/2022]
Abstract
Levosimendan, a calcium sensitiser, has recently emerged as a valuable agent in the peri-operative management of cardiac surgery patients. Levosimendan is a calcium-sensitising ionodilator. By binding to cardiac troponin C and reducing its calcium-binding co-efficient, it enhances myofilament responsiveness to calcium and thus enhances myocardial contractility without increasing oxygen demand. Current evidence suggests that levosimendan enhances cardiac function after cardiopulmonary bypass in patients with both normal and reduced left ventricular function. In addition to being used as post-operative rescue therapy for low cardiac output syndrome, a pre-operative levosimendan infusion in high risk patients with poor cardiac function may reduce inotropic requirements, the need for mechanical support, the duration of intensive care admissions as well as post-operative mortality. Indeed, it is these higher-risk patients who may experience a greater degree of benefit. Larger, multicentre randomised trials in cardiac surgery will help to elucidate the full potential of this agent.
Collapse
Affiliation(s)
- William Y Shi
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, NSW, Australia; Department of Cardiovascular Medicine, John Hunter Hospital, Newcastle, NSW, Australia; The University of Melbourne, Australia.
| | - Sheila Li
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, NSW, Australia
| | - Nicholas Collins
- Department of Cardiovascular Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - David B Cottee
- Department of Anaesthesia, John Hunter Hospital, Newcastle, NSW, Australia
| | - Bruce C Bastian
- Department of Cardiovascular Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Allen N James
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, NSW, Australia
| | - Ross Mejia
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, NSW, Australia
| |
Collapse
|
36
|
Koster G, Wetterslev J, Gluud C, Zijlstra JG, Scheeren TWL, van der Horst ICC, Keus F. Effects of levosimendan for low cardiac output syndrome in critically ill patients: systematic review with meta-analysis and trial sequential analysis. Intensive Care Med 2014; 41:203-21. [DOI: 10.1007/s00134-014-3604-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 12/04/2014] [Indexed: 11/24/2022]
|
37
|
Balzer F, Treskatsch S, Spies C, Sander M, Kastrup M, Grubitzsch H, Wernecke KD, Braun JP. Early administration of levosimendan is associated with improved kidney function after cardiac surgery - a retrospective analysis. J Cardiothorac Surg 2014; 9:167. [PMID: 25399779 PMCID: PMC4240807 DOI: 10.1186/s13019-014-0167-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 09/26/2014] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Several animal studies suggest beneficial effects on kidney function upon administration of levosimendan. As recent data from clinical studies are heterogeneous, we sought to investigate whether levosimendan is associated with improved postoperative kidney function in cardiac surgery patients with respect to timing of its administration. METHODS Retrospective, single centre, observational analysis at a university hospital in Berlin, Germany. All adult patients without preoperative renal dysfunction that underwent coronary artery bypass grafting and/or valve reconstruction/replacement between 01/01/2007 and 31/12/2011 were considered for analyses. RESULTS Out of 1.095 included patients, 46 patients were treated with levosimendan due to a severely reduced left ventricular systolic function preoperatively (LVEF < 35%) and/or clinical signs of a low cardiac output syndrome. Sixty-one percent received the drug whilst in the OR, 39% after postoperative intensive care unit admission. When levosimendan was given immediately after anaesthesia induction, creatinine plasma levels (p = 0.009 for nonparametric analysis of longitudinal data in a two-factorial design) and incidence of postoperative renal dysfunction (67.9% vs. 94.4%; p = 0.033) were significantly reduced in contrast to a later start of treatment. In addition, duration of renal replacement therapy was significantly shorter (79 [35;332] vs. 272 [132;703] minutes; p = 0.046) in that group. CONCLUSIONS Postoperative kidney dysfunction is a common condition in patients under going cardiac surgery. Patients with severely reduced left ventricular function and/or clinical signs of a low cardiac output syndrome who preoperatively presented with a normal kidney function may benefit from an early start of levosimendan administration, i.e. immediately after anaesthesia. TRIAL REGISTRATION Clinicaltrials.gov-ID: NCT01918618 .
Collapse
Affiliation(s)
- Felix Balzer
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Michael Sander
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Mark Kastrup
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Herko Grubitzsch
- Department of Cardiovascular Surgery, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | | | - Jan P Braun
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Klinikum Hildesheim GmbH, Hildesheim, Germany.
| |
Collapse
|
38
|
Sponholz C, Schelenz C, Reinhart K, Schirmer U, Stehr SN. Catecholamine and volume therapy for cardiac surgery in Germany--results from a postal survey. PLoS One 2014; 9:e103996. [PMID: 25084362 PMCID: PMC4118968 DOI: 10.1371/journal.pone.0103996] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Accepted: 07/05/2014] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Management of cardiac surgery patients is a very standardized procedure in respective local institutions. Yet only very limited evidence exists concerning optimal indication, safety and efficacy of hemodynamic monitoring catecholamine and fluid therapy. METHODS Between April and May 2013, all 81 German anaesthesia departments involved in cardiac surgery care were asked to participate in a questionnaire addressing the institutional specific current practice in hemodynamic monitoring, catecholamine and volume therapy. RESULTS 51 (63%) questionnaires were completed and returned. All participating centers used basic hemodynamic monitoring (i.e. invasive arterial blood pressure and central venous pressure), supplemented by transesophageal echocardiography. Pulmonary arterial catheter and calibrated trend monitoring devices were also routinely available. In contrast, non-calibrated trend monitoring and esophageal doppler ultrasound devices were not commonly in use. Cerebral oximetry is increasingly emerging, but lacks clear indications. The majority of patients undergoing cardiac surgery, especially in university hospitals, required catecholamines during perioperative care, In case of low cardiac output syndrome, dobutamine (32%), epinephrine (30%) or phosphodiesterase inhibitors (8%) were first choice. In case of hypotension following vasoplegia, norepinephrine (96%) represented the most common catecholamine. 88% of the participating centers reported regular use of colloid fluids, with hydroxyethyl starches (HES) being first choice (64%). CONCLUSIONS Choice of hemodynamic monitoring is homogenous throughout German centers treating cardiac surgery patients. Norepinephrine is the first line catecholamine in cases of decrease in peripheral vascular resistance. However, catecholamine choice for low cardiac output syndrome varies considerably. HES was the primary colloid used for fluid resuscitation. After conduct of this survey, HES use was restricted by European regulatory authorities in critically ill patients and should only be considered as second-line fluid in surgical patients without renal impairment or severe coagulopathy. Large clinical studies addressing catecholamine and fluid therapy in cardiac surgery patients are lacking.
Collapse
Affiliation(s)
- Christoph Sponholz
- Department of Anesthesiology and Critical Care Medicine, University Hospital Jena, Jena, Germany
- * E-mail:
| | - Christoph Schelenz
- Department of Anesthesiology and Critical Care Medicine, University Hospital Jena, Jena, Germany
| | - Konrad Reinhart
- Department of Anesthesiology and Critical Care Medicine, University Hospital Jena, Jena, Germany
- Integrated Research and Treatment Center, Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
| | - Uwe Schirmer
- Institute of Anaesthesiology, Heart and Diabetes Center NRW, Ruhr University of Bochum, Bad Oeynhausen, Germany
| | - Sebastian N. Stehr
- Department of Anesthesiology and Critical Care Medicine, University Hospital Jena, Jena, Germany
- Integrated Research and Treatment Center, Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
| |
Collapse
|
39
|
Erb J, Beutlhauser T, Feldheiser A, Schuster B, Treskatsch S, Grubitzsch H, Spies C. Influence of levosimendan on organ dysfunction in patients with severely reduced left ventricular function undergoing cardiac surgery. J Int Med Res 2014; 42:750-64. [PMID: 24781725 DOI: 10.1177/0300060513516293] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 11/19/2013] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Levosimendan is an inotropic drug with organ-protective properties due to its activation of mitochondrial K(ATP) channels. This prospective, randomized, double-blind, placebo-controlled study investigated whether administration of levosimendan prior to cardiopulmonary bypass could reduce organ dysfunction and influence subsequent secondary endpoints. PATIENTS AND METHODS Patients with left ventricular ejection fraction <30% scheduled for elective coronary artery bypass surgery (with or without valve surgery) received either levosimendan (12.5 mg, 0.1 µg kg(-1) per min; n = 17) or placebo (n = 16) central venous infusion, immediately after anaesthesia induction, as add-on medication to a goal-orientated treatment algorithm. RESULTS A total of 33 patients completed the study. There were no statistically significant differences in Sequential Organ Failure Assessment scores, survival, haemodynamic parameters, time to extubation, time in intensive care unit, need for haemodialysis or health-related quality-of-life at 6 months post operation. The levosimendan group compared with the placebo group had significantly lower use of epinephrine (35% versus 81%) and nitroglycerine (6% versus 44%) 24 h postoperation, and significantly less frequent serious adverse events (13% versus 47%). CONCLUSIONS These preliminary results show that timely perioperative levosimendan treatment is feasible, has a favourable safety profile safe and may help to prevent low cardiac output syndrome. However, organ function was not preserved. Further studies, using larger sample sizes, are required.
Collapse
Affiliation(s)
- Joachim Erb
- Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital of Basel, Basel, Switzerland
| | - Torsten Beutlhauser
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Aarne Feldheiser
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Birgit Schuster
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sascha Treskatsch
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Herko Grubitzsch
- Department of Cardiovascular Surgery, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
40
|
Pierrakos C, Velissaris D, Franchi F, Muzzi L, Karanikolas M, Scolletta S. Levosimendan in critical illness: a literature review. J Clin Med Res 2014; 6:75-85. [PMID: 24578748 PMCID: PMC3935527 DOI: 10.14740/jocmr1702w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2013] [Indexed: 01/30/2023] Open
Abstract
Levosimendan, the active enantiomer of simendan, is a calcium sensitizer developed for treatment of decompensated heart failure, exerts its effects independently of the beta adrenergic receptor and seems beneficial in cases of severe, intractable heart failure. Levosimendan is usually administered as 24-h infusion, with or without a loading dose, but dosing needs adjustment in patients with severe liver or renal dysfunction. Despite several promising reports, the role of levosimendan in critical illness has not been thoroughly evaluated. Available evidence suggests that levosimendan is a safe treatment option in critically ill patients and may reduce mortality from cardiac failure. However, data from well-designed randomized controlled trials in critically ill patients are needed to validate or refute these preliminary conclusions. This literature review is an attempt to synthesize available evidence on the role and possible benefits of levosimendan in critically ill patients with severe heart failure.
Collapse
Affiliation(s)
- Charalampos Pierrakos
- Department of Intensive Care, Universite Catholique de Louvain, Mont-Godinne University Hospital, Yvoir 5530, Belgium
| | - Dimitrios Velissaris
- Department of Internal Medicine, University of Patras School of Medicine, Patras, Greece
| | - Federico Franchi
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Luigi Muzzi
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Menelaos Karanikolas
- Department of Anesthesiology, Washington University School of Medicine, Campus Box 8054, 660 S. Euclid Avenue, St. Louis, MO, USA
| | - Sabino Scolletta
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| |
Collapse
|
41
|
Perioperative Levosimendan Therapy Is Associated With a Lower Incidence of Acute Kidney Injury After Cardiac Surgery. J Cardiovasc Pharmacol 2014; 63:107-12. [DOI: 10.1097/fjc.0000000000000028] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|
42
|
Unverzagt S, Wachsmuth L, Hirsch K, Thiele H, Buerke M, Haerting J, Werdan K, Prondzinsky R. Inotropic agents and vasodilator strategies for acute myocardial infarction complicated by cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev 2014:CD009669. [PMID: 24385385 DOI: 10.1002/14651858.cd009669.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The recently published German-Austrian S3 Guideline for the treatment of infarct related cardiogenic shock (CS) revealed a lack of evidence for all recommended therapeutic measures. OBJECTIVES To determine the effects in terms of efficacy, efficiency and safety of cardiac care with inotropic agents and vasodilator strategies versus placebo or against each other for haemodynamic stabilisation following surgical treatment, interventional therapy (angioplasty, stent implantation) and conservative treatment (that is no revascularization) on mortality and morbidity in patients with acute myocardial infarction (AMI) complicated by CS or low cardiac output syndrome (LCOS). SEARCH METHODS We searched CENTRAL, MEDLINE (Ovid), EMBASE (Ovid) and ISI Web of Science, registers of ongoing trials and proceedings of conferences in January 2013. Reference lists were scanned and experts in the field were contacted to obtain further information. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials in patients with AMI complicated by CS or LCOS. DATA COLLECTION AND ANALYSIS Data collection and analysis were performed according to the published protocol. All trials were analysed individually. Hazard ratios (HRs) and odds ratios with 95% confidence intervals (CI) were extracted but not pooled because of high heterogeneity between the control group interventions. MAIN RESULTS Four eligible, very small studies were identified from a total of 4065 references. Three trials with high overall risk of bias compared levosimendan to standard treatment (enoximone or dobutamine) or placebo. Data from a total of 63 participants were included in our comparisons, 31 were treated with levosimendan and 32 served as controls. Levosimendan showed an imprecise survival benefit in comparison with enoximone based on a very small trial with 32 participants (HR 0.33; 95% CI 0.11 to 0.97). Results from the other similarly small trials were too imprecise to provide any meaningful information about the effect of levosimendan in comparison with dobutamine or placebo. Only small differences in haemodynamics, length of hospital stay and the frequency of major adverse cardiac events or adverse events overall were found between study groups.Only one small randomised controlled trial with three participants was found for vasodilator strategies (nitric oxide gas versus placebo) in AMI complicated by CS or LCOS. This study was too small to draw any conclusions on the effects on our key outcomes. AUTHORS' CONCLUSIONS 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 patients with CS or low cardiac output complicating AMI.
Collapse
Affiliation(s)
- Susanne Unverzagt
- Institute of Medical Epidemiology, Biostatistics and Informatics, Martin Luther University Halle-Wittenberg, Magdeburge Straße 8, Halle/Saale, Germany, 06097
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Harrison RW, Hasselblad V, Mehta RH, Levin R, Harrington RA, Alexander JH. Effect of Levosimendan on Survival and Adverse Events After Cardiac Surgery: A Meta-Analysis. J Cardiothorac Vasc Anesth 2013; 27:1224-32. [DOI: 10.1053/j.jvca.2013.03.027] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Indexed: 11/11/2022]
|
44
|
Yilmaz MB, Grossini E, Silva Cardoso JC, Édes I, Fedele F, Pollesello P, Kivikko M, Harjola VP, Hasslacher J, Mebazaa A, Morelli A, le Noble J, Oldner A, Oulego Erroz I, Parissis JT, Parkhomenko A, Poelzl G, Rehberg S, Ricksten SE, Rodríguez Fernández LM, Salmenperä M, Singer M, Treskatsch S, Vrtovec B, Wikström G. Renal effects of levosimendan: a consensus report. Cardiovasc Drugs Ther 2013; 27:581-90. [PMID: 23929366 PMCID: PMC3830192 DOI: 10.1007/s10557-013-6485-6] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Renal dysfunction is common in clinical settings in which cardiac function is compromised such as heart failure, cardiac surgery or sepsis, and is associated with high morbidity and mortality. Levosimendan is a calcium sensitizer and potassium channel opener used in the treatment of acute heart failure. This review describes the effects of the inodilator levosimendan on renal function. A panel of 25 scientists and clinicians from 15 European countries (Austria, Finland, France, Hungary, Germany, Greece, Italy, Portugal, the Netherlands, Slovenia, Spain, Sweden, Turkey, the United Kingdom, and Ukraine) convened and reached a consensus on the current interpretation of the renal effects of levosimendan described both in non-clinical research and in clinical study reports. Most reports on the effect of levosimendan indicate an improvement of renal function in heart failure, sepsis and cardiac surgery settings. However, caution should be applied as study designs differed from randomized, controlled studies to uncontrolled ones. Importantly, in the largest HF study (REVIVE I and II) no significant changes in the renal function were detected. As it regards the mechanism of action, the opening of mitochondrial KATP channels by levosimendan is involved through a preconditioning effect. There is a strong rationale for randomized controlled trials seeking beneficial renal effects of levosimendan. As an example, a study is shortly to commence to assess the role of levosimendan for the prevention of acute organ dysfunction in sepsis (LeoPARDS).
Collapse
Affiliation(s)
- Mehmet B. Yilmaz
- Department of Cardiology, Cumhuriyet University School of Medicine, Sivas, Turkey
| | - Elena Grossini
- Laboratorio di Fisiologia, Dipartimento di Medicina Traslazionale, Università degli Studi del Piemonte Orientale A. Avogadro, Piemonte, Italy
| | - José C. Silva Cardoso
- Faculdade de Medicina, Alameda Prof. Hernâni Monteiro, Universidade do Porto, Porto, Portugal
| | - István Édes
- Institute of Cardiology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrological, and Geriatric Sciences, La Sapienza University of Rome, Rome, Italy
| | | | - Matti Kivikko
- Cardiology and Critical Care, Orion Pharma, Espoo, Finland
| | - Veli-Pekka Harjola
- Departments of Cardiology, Helsinki University Hospital, Helsinki, Finland
| | - Julia Hasslacher
- Internistische Intensiv- und Notfallmedizin, Universitätsklinik für Innere Medizin, Innsbruck, Austria
| | - Alexandre Mebazaa
- Department of Anaesthesia and Intensive Care, INSERM UMR 942, Lariboisière Hospital, University of Paris, Paris, France
| | - Andrea Morelli
- Department of Cardiovascular, Respiratory, Nephrological, and Geriatric Sciences, La Sapienza University of Rome, Rome, Italy
| | - Jos le Noble
- Department of Intensive Care, VieCuri Medical Center, Venlo, The Netherlands
| | - Anders Oldner
- Department of Physiology & Pharmacology, Section of Anaesthesiology & Intensive CareMedicine, Karolinska Institute, Stockholm, Sweden
| | - Ignacio Oulego Erroz
- Department of Pediatrics, Complejo Asistencial Universitario de León, León, Spain
| | | | | | - Gerhard Poelzl
- Department of Cardiology, Medical University Innsbruck, Innsbruck, Austria
| | - Sebastian Rehberg
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Muenster, Muenster, Germany
| | - Sven-Erik Ricksten
- Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Markku Salmenperä
- Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland
| | - Mervyn Singer
- Intensive Care Medicine, University College London, London, UK
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - University Medicine Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Bojan Vrtovec
- Advanced Heart Failure and Transplantation Center, Department of Cardiology, Ljubljana University Medical Center, Ljubljana, Slovenia
| | | |
Collapse
|
45
|
Majure DT, Greco T, Greco M, Ponschab M, Biondi-Zoccai G, Zangrillo A, Landoni G. Meta-analysis of Randomized Trials of Effect of Milrinone on Mortality in Cardiac Surgery: An Update. J Cardiothorac Vasc Anesth 2013; 27:220-9. [PMID: 23063100 DOI: 10.1053/j.jvca.2012.08.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Indexed: 02/08/2023]
|
46
|
2012 Update to The Society of Thoracic Surgeons Guideline on Use of Antiplatelet Drugs in Patients Having Cardiac and Noncardiac Operations. Ann Thorac Surg 2012; 94:1761-81. [DOI: 10.1016/j.athoracsur.2012.07.086] [Citation(s) in RCA: 228] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 06/19/2012] [Accepted: 07/10/2012] [Indexed: 12/31/2022]
|
47
|
Shibata I, Cho S, Yoshitomi O, Ureshino H, Maekawa T, Hara T, Sumikawa K. Milrinone and levosimendan administered after reperfusion improve myocardial stunning in swine. SCAND CARDIOVASC J 2012; 47:50-7. [DOI: 10.3109/14017431.2012.732236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Itsuko Shibata
- Department of Anesthesiology,
Nagasaki University School of Medicine, Nagasaki, Japan
| | - Sungsam Cho
- Department of Anesthesiology,
Nagasaki University School of Medicine, Nagasaki, Japan
| | - Osamu Yoshitomi
- Department of Anesthesiology,
Nagasaki University School of Medicine, Nagasaki, Japan
| | - Hiroyuki Ureshino
- Department of Anesthesiology,
Nagasaki University School of Medicine, Nagasaki, Japan
| | - Takuji Maekawa
- Department of Anesthesiology,
Nagasaki University School of Medicine, Nagasaki, Japan
| | - Tetsuya Hara
- Department of Anesthesiology,
Nagasaki University School of Medicine, Nagasaki, Japan
| | - Koji Sumikawa
- Department of Anesthesiology,
Nagasaki University School of Medicine, Nagasaki, Japan
| |
Collapse
|
48
|
Toller W, Algotsson L, Guarracino F, Hörmann C, Knotzer J, Lehmann A, Rajek A, Salmenperä M, Schirmer U, Tritapepe L, Weis F, Landoni G. Perioperative use of levosimendan: best practice in operative settings. J Cardiothorac Vasc Anesth 2012; 27:361-6. [PMID: 22658687 DOI: 10.1053/j.jvca.2012.04.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Wolfgang Toller
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Resumen del documento de consenso «Guías de práctica clínica para el manejo del síndrome de bajo gasto cardiaco en el postoperatorio de cirugía cardiaca». Med Intensiva 2012; 36:277-87. [DOI: 10.1016/j.medin.2012.01.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 12/17/2011] [Accepted: 01/07/2012] [Indexed: 11/18/2022]
|
50
|
Pérez Vela J, Martín Benítez J, Carrasco González M, De la Cal López M, Hinojosa Pérez R, Sagredo Meneses V, del Nogal Saez F. Guías de práctica clínica para el manejo del síndrome de bajo gasto cardíaco en el postoperatorio de cirugía cardíaca. Med Intensiva 2012; 36:e1-44. [DOI: 10.1016/j.medin.2012.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 01/07/2012] [Indexed: 01/04/2023]
|