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Kipka H, Liebchen U, Hübner M, Höfner G, Frey O, Wanner KT, Kilger E, Hagl C, Tomasi R, Mannell H. Serum concentrations of levosimendan and its metabolites OR-1855 and OR-1896 in cardiac surgery patients with cardiopulmonary bypass. Front Cardiovasc Med 2024; 11:1406338. [PMID: 39175630 PMCID: PMC11338783 DOI: 10.3389/fcvm.2024.1406338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 04/19/2024] [Indexed: 08/24/2024] Open
Abstract
Background The inotropic drug levosimendan is often used as an individualized therapeutic approach perioperatively in cardiac surgery patients with cardiopulmonary bypass (CPB). Data regarding serum concentrations of levosimendan and its metabolites within this context is lacking. Methods In this retrospective descriptive proof-of-concept study, total serum concentrations (TSC) and unbound fractions (UF) of levosimendan and its metabolites OR-1896 and OR-1855 in cardiac surgery patients with CPB were measured using LC-ESI-MS/MS. Simulation of expected levosimendan TSC was performed using Pharkin 4.0. Serum NT-proBNP was assessed with ELISA. Results After levosimendan infusion (1.25 mg or 2.5 mg, respectively) after anaesthesia induction, a median TSC of 1.9 ng/ml and 10.4 ng/ml was determined in samples taken directly after surgery (T1). Median TSC of 7.6 ng/ml and 22.0 ng/ml, respectively, were simulated at T1. Whereas 1.1 ng/ml and 1.6 ng/ml TSC of OR-1896, respectively, was quantified the day after surgery (T2), TSC of the intermediate metabolite OR-1855 was mostly below the lower limit of quantification (LLOQ). The UF was 0.5% and 1.1% for levosimendan and 64.1% and 52.1% for OR-1896, respectively, with over half the samples being below LLOQ. NT-proBNP concentrations before surgery and T2 did not differ. Discussion The low TSC, UF and unchanged NT-proBNP levels in combination with high variation of serum levels between patients suggest a need for optimized dosing regimen of levosimendan combined with therapeutic drug monitoring for such an individualized approach. In addition, the differences between the measured and estimated concentrations may suggest a possible influence of CPB on levosimendan serum concentrations.
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Affiliation(s)
- Hannah Kipka
- Doctoral Program Clinical Pharmacy, LMU University Hospital, LMU Munich, Germany
- Institute of Cardiovascular Physiology and Pathophysiology, Biomedical Center, LMU Munich, Planegg, Germany
| | - Uwe Liebchen
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Max Hübner
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
- Walter Brendel Center of Experimental Medicine, LMU Munich, LMU University Hospital, Munich, Germany
| | - Georg Höfner
- Department of Pharmacy, Center for Drug Research, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Otto Frey
- Department of Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Klaus T. Wanner
- Department of Pharmacy, Center for Drug Research, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Erich Kilger
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Germany
- DZHK (German Centre of Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Roland Tomasi
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Hanna Mannell
- Doctoral Program Clinical Pharmacy, LMU University Hospital, LMU Munich, Germany
- Institute of Cardiovascular Physiology and Pathophysiology, Biomedical Center, LMU Munich, Planegg, Germany
- Physiology, Institute for Theoretical Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
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Sulman D, Beaupré F, Devos P, Procopi N, Kerneis M, Guedeney P, Barthélémy O, Elhadad A, Rouanet S, Brugier D, Hekimian G, Chommeloux J, Combes A, Silvain J, Collet JP, Montalescot G, Zeitouni M. Ten-year trends in characteristics, management and outcomes of patients admitted with cardiogenic shock in the ACTION-SHOCK cohort. Arch Cardiovasc Dis 2024:S1875-2136(24)00280-8. [PMID: 39153876 DOI: 10.1016/j.acvd.2024.07.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 07/23/2024] [Accepted: 07/24/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND The ACTION-SHOCK registry offers a decade-long perspective on patients admitted with cardiogenic shock (CS). AIMS To assess trends in the management and outcomes of patients with CS over 10 years. METHODS Trends in the characteristics, management and outcomes of patients with CS admitted into the cardiac intensive care unit of Pitié-Salpêtrière hospital from 2011 to 2020 were analysed. Short-term outcomes included in-hospital mortality, heart transplantation or ventricular assist device. Long-term outcomes were all-cause death or readmission for acute heart failure at 1 year. RESULTS Over a 10-year period, data from 700 patients with CS (median [interquartile range] age 61 [50-72] years; 73% of men) were analysed. The proportion of CS related to acute myocardial infarction decreased (from 45% in 2011-2012 to 27% in 2019-2020) while the proportions related to chronic coronary syndrome (18% to 23%) and non-ischaemic cardiomyopathies (37 to 51%) increased (P<0.01). The use of rescue extracorporeal membrane oxygenation remained stable (19 to 14%) and intra-aortic balloon pump use decreased (22% to 7%) (P<0.01). In-hospital mortality remained stable (27 to 29%) as did the proportions of patients discharged after transplantation (17 to 14%) or with a durable ventricular assist device (2 to 4%). Among patients discharged alive, death or readmission for acute heart failure at 1 year remained high (37 to 47%). CONCLUSION CS remained associated with a poor prognosis over the last decade. There are significant unmet needs in the management strategies of patients with CS.
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Affiliation(s)
- David Sulman
- Département de cardiologie, institut de cardiologie, ACTION Study Group, hôpital Pitié-Salpêtrière (AP-HP), Sorbonne université, Inserm UMRS 1166, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Frederic Beaupré
- Département de cardiologie, institut de cardiologie, ACTION Study Group, hôpital Pitié-Salpêtrière (AP-HP), Sorbonne université, Inserm UMRS 1166, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Perrine Devos
- Département de cardiologie, institut de cardiologie, ACTION Study Group, hôpital Pitié-Salpêtrière (AP-HP), Sorbonne université, Inserm UMRS 1166, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Niki Procopi
- Département de cardiologie, institut de cardiologie, ACTION Study Group, hôpital Pitié-Salpêtrière (AP-HP), Sorbonne université, Inserm UMRS 1166, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Mathieu Kerneis
- Département de cardiologie, institut de cardiologie, ACTION Study Group, hôpital Pitié-Salpêtrière (AP-HP), Sorbonne université, Inserm UMRS 1166, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Paul Guedeney
- Département de cardiologie, institut de cardiologie, ACTION Study Group, hôpital Pitié-Salpêtrière (AP-HP), Sorbonne université, Inserm UMRS 1166, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Olivier Barthélémy
- Département de cardiologie, institut de cardiologie, ACTION Study Group, hôpital Pitié-Salpêtrière (AP-HP), Sorbonne université, Inserm UMRS 1166, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Anthony Elhadad
- Département de cardiologie, institut de cardiologie, ACTION Study Group, hôpital Pitié-Salpêtrière (AP-HP), Sorbonne université, Inserm UMRS 1166, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Stephanie Rouanet
- Statistician Unit, StatEthic, ACTION Study Group, 92300 Levallois-Perret, France
| | - Delphine Brugier
- Département de cardiologie, institut de cardiologie, ACTION Study Group, hôpital Pitié-Salpêtrière (AP-HP), Sorbonne université, Inserm UMRS 1166, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Guillaume Hekimian
- Service de médecine intensive-réanimation, institut de cardiologie, université Hôpital Pitié-Salpêtrière (AP-HP), Sorbonne université, 75013 Paris, France
| | - Juliette Chommeloux
- Service de médecine intensive-réanimation, institut de cardiologie, université Hôpital Pitié-Salpêtrière (AP-HP), Sorbonne université, 75013 Paris, France
| | - Alain Combes
- Service de médecine intensive-réanimation, institut de cardiologie, université Hôpital Pitié-Salpêtrière (AP-HP), Sorbonne université, 75013 Paris, France
| | - Johanne Silvain
- Département de cardiologie, institut de cardiologie, ACTION Study Group, hôpital Pitié-Salpêtrière (AP-HP), Sorbonne université, Inserm UMRS 1166, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Jean-Philippe Collet
- Département de cardiologie, institut de cardiologie, ACTION Study Group, hôpital Pitié-Salpêtrière (AP-HP), Sorbonne université, Inserm UMRS 1166, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Gilles Montalescot
- Département de cardiologie, institut de cardiologie, ACTION Study Group, hôpital Pitié-Salpêtrière (AP-HP), Sorbonne université, Inserm UMRS 1166, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - Michel Zeitouni
- Département de cardiologie, institut de cardiologie, ACTION Study Group, hôpital Pitié-Salpêtrière (AP-HP), Sorbonne université, Inserm UMRS 1166, 47-83, boulevard de l'Hôpital, 75013 Paris, France
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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.
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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
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4
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Tan R, Guo H, Yang Z, Yang H, Li Q, Zhu Q, Du Q. Efficacy and safety of levosimendan in patients with sepsis: a systematic review and network meta-analysis. Front Pharmacol 2024; 15:1358735. [PMID: 38523635 PMCID: PMC10957638 DOI: 10.3389/fphar.2024.1358735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/21/2024] [Indexed: 03/26/2024] Open
Abstract
Objective: We conducted a systematic review to assess the advantages and disadvantages of levosimendan in patients with sepsis compared with placebo, milrinone, and dobutamine and to explore the clinical efficacy of different concentrations of levosimendan. Methods: PubMed, Web of Science, Cochrane Library, Embase, CNKI, Wanfang data, VIP, and CBM databases were searched using such keywords as simendan, levosimendan, and sepsis. The search time was from the establishment of the database to July 2023. Two researchers were responsible for literature screening and data collection respectively. After the risk of bias in the included studies was evaluated, network meta-analysis was performed using R software gemtc and rjags package. Results: Thirty-two randomized controlled trials (RCTs) were included in the network meta-analysis. Meta-analysis results showed that while levosimendan significantly improved CI levels at either 0.1 µg/kg/min (mean difference [MD] [95%CrI] = 0.41 [-0.43, 1.4]) or 0.2 µg/kg/min (MD [95%CrI] =0.54 [0.12, 0.99]). Levosimendan, at either 0.075 µg/kg/min (MD [95% CrI] =0.033 [-0.75, 0.82]) or 0.2 µg/kg/min (MD [95% CrI] = -0.014 [-0.26, 0.23]), had no significant advantage in improving Lac levels. Levosimendan, at either 0.1 µg/kg/min (RR [95% CrI] = 0.99 [0.73, 1.3]) or 0.2 µg/kg/min (RR [95% CrI] = 1.0 [0.88, 1.2]), did not have a significant advantage in reducing mortality. Conclusion: The existing evidence suggests that levosimendan can significantly improve CI and lactate levels in patients with sepsis, and levosimendan at 0.1 µg/kg/min might be the optimal dose. Unfortunately, all interventions in this study failed to reduce the 28-day mortality. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023441220.
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Affiliation(s)
- Ruimin Tan
- School of Clinical Medical, North China University of Science and Technology, Tangshan, Hebei, China
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - He Guo
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
- School of Graduate, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Zinan Yang
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
- School of Graduate, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Huihui Yang
- School of Clinical Medical, North China University of Science and Technology, Tangshan, Hebei, China
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Qinghao Li
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
- School of Graduate, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Qiong Zhu
- Department of Orthopaedics, The People’s Hospital of Shizhu, Chongqing, China
| | - Quansheng Du
- Critical Care Department, Hebei General Hospital, Shijiazhuang, Hebei, China
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5
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Ayala R, Gewehr DM, Godoi A, Velasquez C, Fernandez M, Carvalho PEP, Goebel N. Preoperative Levosimendan in Patients With Severe Left Ventricular Dysfunction Undergoing Isolated Coronary Artery Bypass Grafting: A Meta-Analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2024; 38:649-659. [PMID: 38228424 DOI: 10.1053/j.jvca.2023.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/21/2023] [Accepted: 11/26/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE To verify the impact of preoperative levosimendan on patients with severe left ventricular dysfunction (ejection fraction <35%) undergoing isolated coronary artery bypass grafting. DESIGN A meta-analysis. SETTING Hospitals. PARTICIPANTS The authors included 1,225 patients from 6 randomized controlled trials. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The authors performed a meta-analysis of trials that compared preoperative levosimendan with placebo or no therapy, reporting efficacy and safety endpoints. Statistical analyses used mean differences and risk ratios (RR), with a random effects model. Six studies were included, comprising 1,225 patients, of whom 615 (50.2%) received preoperative levosimendan, and 610 (49.8%) received placebo/no therapy. Preoperative levosimendan showed a lower risk of all-cause mortality (RR 0.31; 95% CI 0.16-0.60; p < 0.01; I2 = 0%), postoperative acute kidney injury (RR 0.44; 95% CI 0.25-0.77; p < 0.01; I2 = 0%), low-cardiac-output syndrome (RR 0.45; 95% CI 0.30-0.66; p < 0.001; I2 = 0%), and postoperative atrial fibrillation (RR 0.49; 95% CI 0.25-0.98; p = 0.04; I2 = 85%) compared to control. Moreover, levosimendan significantly reduced the need for postoperative inotropes and increased the cardiac index at 24 hours postoperatively. There were no differences between groups for perioperative myocardial infarction, hypotension, or any adverse events. CONCLUSION Preoperative levosimendan in patients with severe left ventricular dysfunction undergoing isolated coronary artery bypass grafting was associated with reduced all-cause mortality, low-cardiac-output syndrome, acute kidney injury, postoperative atrial fibrillation, and the need for circulatory support without compromising safety.
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Affiliation(s)
- Rafael Ayala
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany.
| | | | - Amanda Godoi
- Cardiff University School of Medicine, Wales, United Kingdom
| | | | - Miguel Fernandez
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil
| | - Pedro E P Carvalho
- Department of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Nora Goebel
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
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Tigges E, Michels G, Preusch MR, Wengenmayer T, Staudacher DL. [Extracorporeal life support (ECLS)-update 2023]. Med Klin Intensivmed Notfmed 2024; 119:136-140. [PMID: 38206378 DOI: 10.1007/s00063-023-01103-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/12/2024]
Affiliation(s)
- Eike Tigges
- Kardiologie und Internistische Intensivmedizin, Asklepios Klinik St. Georg, Hamburg, Deutschland
| | - Guido Michels
- Krankenhaus der Barmherzigen Brüder Trier, Medizincampus Trier der Universitätsmedizin Mainz, Notfallzentrum, Trier, Deutschland.
- Krankenhaus der Barmherzigen Brüder Trier, Medizincampus Trier der Universitätsmedizin Mainz, Notfallzentrum, Nordallee 1, 54292, Trier, Deutschland.
| | - Michael R Preusch
- Sektion Internistische Intensivmedizin, Medizinische Klinik III, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Tobias Wengenmayer
- Interdisziplinäre Medizinische Intensivtherapie (IMIT), Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Dawid L Staudacher
- Interdisziplinäre Medizinische Intensivtherapie (IMIT), Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
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7
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Lamy A, Chertow GM, Jessen M, Collar A, Brown CD, Mack CA, Marzouk M, Scavo V, Washburn TB, Savage D, Smith J, Bennetts J, Assi R, Shults C, Arghami A, Butler J, Devereaux P, Zager R, Wang C, Snapinn S, Browne A, Rodriguez J, Ruiz S, Singh B. Effects of RBT-1 on preconditioning response biomarkers in patients undergoing coronary artery bypass graft or heart valve surgery: a multicentre, double-blind, randomised, placebo-controlled phase 2 trial. EClinicalMedicine 2024; 68:102364. [PMID: 38586479 PMCID: PMC10994969 DOI: 10.1016/j.eclinm.2023.102364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 04/09/2024] Open
Abstract
Background RBT-1 is a combination drug of stannic protoporfin (SnPP) and iron sucrose (FeS) that elicits a preconditioning response through activation of antioxidant, anti-inflammatory, and iron-scavenging pathways, as measured by heme oxygenase-1 (HO-1), interleukin-10 (IL-10), and ferritin, respectively. Our primary aim was to determine whether RBT-1 administered before surgery would safely and effectively elicit a preconditioning response in patients undergoing cardiac surgery. Methods This phase 2, double-blind, randomised, placebo-controlled, parallel-group, adaptive trial, conducted in 19 centres across the USA, Canada, and Australia, enrolled patients scheduled to undergo non-emergent coronary artery bypass graft (CABG) and/or heart valve surgery with cardiopulmonary bypass. Patients were randomised (1:1:1) to receive either a single intravenous infusion of high-dose RBT-1 (90 mg SnPP/240 mg FeS), low-dose RBT-1 (45 mg SnPP/240 mg FeS), or placebo within 24-48 h before surgery. The primary outcome was a preoperative preconditioning response, measured by a composite of plasma HO-1, IL-10, and ferritin. Safety was assessed by adverse events and laboratory parameters. Prespecified adaptive criteria permitted early stopping and enrichment. This trial is registered with ClinicalTrials.gov, NCT04564833. Findings Between Aug 4, 2021, and Nov 9, 2022, of 135 patients who were enrolled and randomly allocated to a study group (46 high-dose, 45 low-dose, 44 placebo), 132 (98%) were included in the primary analysis (46 high-dose, 42 low-dose, 44 placebo). At interim, the trial proceeded to full enrollment without enrichment. RBT-1 led to a greater preconditioning response than did placebo at high-dose (geometric least squares mean [GLSM] ratio, 3.58; 95% CI, 2.91-4.41; p < 0.0001) and low-dose (GLSM ratio, 2.62; 95% CI, 2.11-3.24; p < 0.0001). RBT-1 was generally well tolerated by patients. The primary drug-related adverse event was dose-dependent photosensitivity, observed in 12 (26%) of 46 patients treated with high-dose RBT-1 and in six (13%) of 45 patients treated with low-dose RBT-1 (safety population). Interpretation RBT-1 demonstrated a statistically significant cytoprotective preconditioning response and a manageable safety profile. Further research is needed. A phase 3 trial is planned. Funding Renibus Therapeutics, Inc.
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Affiliation(s)
- Andre Lamy
- Department of Perioperative Medicine and Surgery, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Glenn M. Chertow
- Departments of Medicine and Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Jessen
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alonso Collar
- Department of Thoracic Surgery and Vascular Surgery, MyMichigan Health, Midland, MI, USA
| | - Craig D. Brown
- Department of Cardiac Surgery, New Brunswick Heart Centre, Saint John, New Brunswick, Canada
| | - Charles A. Mack
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Mohamed Marzouk
- Department of Cardiac Surgery, Québec Heart and Lung Institute, Québec, Québec, Canada
| | - Vincent Scavo
- Department of Cardiovascular and Thoracic Surgery, Lutheran Medical Group, Fort Wayne, Indiana, USA
| | - T Benton Washburn
- Department of Cardiothoracic Surgery, Huntsville Hospital Heart Center, Huntsville, AL, USA
| | - David Savage
- Department of Cardiothoracic Surgery, Indiana University Health, Bloomington, IN, USA
| | - Julian Smith
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University and Department of Cardiothoracic Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Jayme Bennetts
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia
- Department of Surgery, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Roland Assi
- Department of Cardiac Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Christian Shults
- Department of Cardiac Surgery, MedStar Heart and Vascular Institute, Washington, DC, USA
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - P.J. Devereaux
- Department of Perioperative Medicine and Surgery, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Richard Zager
- Department of Drug Development & Medical Affairs, Renibus Therapeutics Inc, Southlake, TX, USA
| | - Chao Wang
- Pharma Data Associates LLC, Piscataway, NJ, USA
| | - Steve Snapinn
- Seattle-Quilcene Biostatistics LLC, Seattle, WA, USA
| | - Austin Browne
- Department of Perioperative Medicine and Surgery, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jeannette Rodriguez
- Department of Drug Development & Medical Affairs, Renibus Therapeutics Inc, Southlake, TX, USA
| | - Stacey Ruiz
- Department of Drug Development & Medical Affairs, Renibus Therapeutics Inc, Southlake, TX, USA
| | - Bhupinder Singh
- Department of Drug Development & Medical Affairs, Renibus Therapeutics Inc, Southlake, TX, USA
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8
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Wöhrle T, Kilger E. [Pro: Levosimendan in Cardiac Surgery]. DIE ANAESTHESIOLOGIE 2024; 73:60-61. [PMID: 38051380 DOI: 10.1007/s00101-023-01360-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/07/2023]
Affiliation(s)
- Tobias Wöhrle
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Marchioninistraße 15, 81377, München, Deutschland.
| | - Erich Kilger
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Marchioninistraße 15, 81377, München, Deutschland
- Herzklinik der Universität am Augustinum, München, Deutschland
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9
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Zajonz TS, Habicher M, Böning A, Heringlake M, Ender J, Markewitz A, Brenck F, Sander M. Survey on the Updated German S3 Guideline for Intensive Care in Cardiac Surgery Patients. Thorac Cardiovasc Surg 2024; 72:2-10. [PMID: 36893800 DOI: 10.1055/s-0043-1764230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND The German guideline on intensive care treatment of cardiac surgical patients provides evidence-based recommendations on management and monitoring. It remains unclear if, respectively, to which degree the guidelines are implemented into the daily practice. Therefore, this study aims to characterize the implementation of guideline recommendations in German cardiac surgical intensive care units (ICUs). METHODS An internet-based online survey (42 questions, 9 topics) was sent to 158 German head physicians of cardiac surgical ICUs. To compare the effect over time, most questions were based on a previously performed survey (2013) after introduction of the last guideline update in 2008. RESULTS A total of n = 65 (41.1%) questionnaires were included. Monitoring changed to increased provision of available transesophageal echocardiography specialists in 86% (2013: 72.6%), SvO2 measurement in 93.8% (2013: 55.1%), and electroencephalography in 58.5% (2013: 2.6%). The use of hydroxyethyl starch declined (9.4% vs. 2013: 38.7%), gelatin 4% presented the most administered colloid with 23.4% (2013: 17.4%). Low cardiac output syndrome was primarily treated with levosimendan (30.8%) and epinephrine (23.1%), while norepinephrine (44.6%) and dobutamine (16.9%) represented the most favored drug combination. The main way of distribution was web-based (50.9%), with increasing impact on therapy regimens (36.9% vs. 2013: 24%). CONCLUSION Changes were found in all questioned sectors compared with the preceding survey, with persisting variability between ICUs. Recommendations of the updated guideline have increasingly entered clinical practice, with participants valuing the updated publication as clinically relevant.
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Affiliation(s)
- Thomas Simon Zajonz
- Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
| | - Marit Habicher
- Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
| | - Andreas Böning
- Department of Cardiovascular Surgery, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
- Department of Adult and Pediatric Cardiovascular Surgery, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
| | - Matthias Heringlake
- Department of Anesthesiology and Intensive Care Medicine, Heart and Diabetes Center Mecklenburg, Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
| | - Jörg Ender
- Department of Anaesthesiology and Intensive Care Medicine, Leipzig Heart Centre University Hospital, Heart Center Leipzig, Leipzig, Sachsen, Germany
| | - Andreas Markewitz
- Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie, Berlin, Germany
| | - Florian Brenck
- Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
| | - Michael Sander
- Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
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10
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Heinz V, Wiesner G. [Cons: Levosimendan for cardiac surgery]. DIE ANAESTHESIOLOGIE 2024; 73:62-63. [PMID: 38054994 DOI: 10.1007/s00101-023-01361-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/07/2023]
Affiliation(s)
- Valerie Heinz
- Institut für Anästhesiologie, Deutsches Herzzentrum München, Lazarettstraße 36, 80636, München, Deutschland.
| | - Gunther Wiesner
- Institut für Anästhesiologie, Deutsches Herzzentrum München, Lazarettstraße 36, 80636, München, Deutschland
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11
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Scaravilli V, Guzzardella A, Madotto F, Morlacchi LC, Bosone M, Bonetti C, Musso V, Rossetti V, Russo FM, Sorbo LD, Blasi F, Nosotti M, Zanella A, Grasselli G. Hemodynamic failure and graft dysfunction after lung transplant: A possible clinical continuum with immediate and long-term consequences. Clin Transplant 2023; 37:e15122. [PMID: 37694497 DOI: 10.1111/ctr.15122] [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: 06/07/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION The postoperative hemodynamic management after lung transplant (LUTX) is guided by limited evidence. We aimed to describe and evaluate risk factors and outcomes of postoperative vasoactive support of LUTX recipients. METHODS In a single-center retrospective analysis of consecutive adult LUTX, two cohorts were identified: (1) patients needing prolonged vasoactive support (>12 h from ICU admission) (VASO+); (2) or not (VASO-). Postoperative hemodynamic characteristics were thoroughly analyzed. Risk factors and outcomes of VASO+ versus VASO- cohorts were assessed by multivariate logistic regression and propensity score matching. RESULTS One hundred and thirty-eight patients were included (86 (62%) VASO+ versus 52 (38%) VASO-). Vasopressors (epinephrine, norepinephrine, dopamine) were used in the first postoperative days (vasoactive inotropic score at 12 h: 6 [4-12]), while inodilators (dobutamine, levosimendan) later. Length of vasoactive support was 3 [2-4] days. Independent predictors of vasoactive use were: LUTX indication different from cystic fibrosis (p = .003), higher Oto score (p = .020), longer cold ischemia time (p = .031), but not preoperative cardiac catheterization. VASO+ patients showed concomitant hemodynamic and graft impairment, with longer mechanical ventilation (p = .010), higher primary graft dysfunction (PGD) grade at 72 h (PGD grade > 0 65% vs. 31%, p = .004, OR 4.2 [1.54-11.2]), longer ICU (p < .001) and hospital stay (p = .013). Levosimendan as a second-line inodilator appeared safe. CONCLUSIONS Vasoactive support is frequently necessary after LUTX, especially in recipients of grafts of lesser quality. Postoperative hemodynamic dysfunction requiring vasopressor support and graft dysfunction may represent a clinical continuum with immediate and long-term consequences. Further studies may elucidate if this represents a possible treatable condition.
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Affiliation(s)
- Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan(MI), Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan(MI), Italy
| | - Amedeo Guzzardella
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Fabiana Madotto
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Letizia Corinna Morlacchi
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
- Department of Internal Medicine, Respiratory Unit and Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan(MI), Italy
| | - Marco Bosone
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Claudia Bonetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Valeria Musso
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Valeria Rossetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
- Department of Internal Medicine, Respiratory Unit and Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan(MI), Italy
| | - Filippo Maria Russo
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan(MI), Italy
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
- Department of Internal Medicine, Respiratory Unit and Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan(MI), Italy
| | - Mario Nosotti
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
- Department of Cardio-thoraco-vascular diseases, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan(MI), Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan(MI), Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan(MI), Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan(MI), Italy
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12
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Cholley B, Bojan M, Guillon B, Besnier E, Mattei M, Levy B, Ouattara A, Tafer N, Delmas C, Tonon D, Rozec B, Fellahi JL, Lim P, Labaste F, Roubille F, Caruba T, Mauriat P. Overview of the current use of levosimendan in France: a prospective observational cohort study. Ann Intensive Care 2023; 13:69. [PMID: 37552372 PMCID: PMC10409690 DOI: 10.1186/s13613-023-01164-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/11/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Following the results of randomized controlled trials on levosimendan, French health authorities requested an update of the current use and side-effects of this medication on a national scale. METHOD The France-LEVO registry was a prospective observational cohort study reflecting the indications, dosing regimens, and side-effects of levosimendan, as well as patient outcomes over a year. RESULTS The patients included (n = 602) represented 29.6% of the national yearly use of levosimendan in France. They were treated for cardiogenic shock (n = 250, 41.5%), decompensated heart failure (n = 127, 21.1%), cardiac surgery-related low cardiac output prophylaxis and/or treatment (n = 86, 14.3%), and weaning from veno-arterial extracorporeal membrane oxygenation (n = 82, 13.6%). They received 0.18 ± 0.07 µg/kg/min levosimendan over 26 ± 8 h. An initial bolus was administered in 45 patients (7.5%), 103 (17.1%) received repeated infusions, and 461 (76.6%) received inotropes and or vasoactive agents concomitantly. Hypotension was reported in 218 patients (36.2%), atrial fibrillation in 85 (14.1%), and serious adverse events in 17 (2.8%). 136 patients (22.6%) died in hospital, and 26 (4.3%) during the 90-day follow-up. CONCLUSIONS We observed that levosimendan was used in accordance with recent recommendations by French physicians. Hypotension and atrial fibrillation remained the most frequent side-effects, while serious adverse event potentially attributable to levosimendan were infrequent. The results suggest that this medication was safe and potentially associated with some benefit in the population studied.
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Affiliation(s)
- Bernard Cholley
- Department of Anaesthesiology and Intensive Care Medicine, Hôpital Européen Georges Pompidou, AP-HP, 75015, Paris, France.
- Université Paris Cité, INSERM, UMR_S 1140 "Innovations Thérapeutiques en Hémostase", 75006, Paris, France.
| | - Mirela Bojan
- Pôle Cardiopathies Congénitales, Hôpital Marie Lannelongue, Groupe Hospitalier Paris-Saint Joseph, 92350, Le Plessis-Robinson, France
| | - Benoit Guillon
- Department of Cardiology, University Hospital Besancon, Besançon, France
| | - Emmanuel Besnier
- Department of Anaesthesiology and Critical Care, Normandie Univ, UNIROUEN, INSERM U1096, CHU Rouen, 76000, Rouen, France
| | - Mathieu Mattei
- Department of Cardiology and Cardiac Surgery, CHRU de Nancy, Hôpital de Brabois, Vandoeuvre-les Nancy, France
| | - Bruno Levy
- CHRU Nancy, Critical Care, CHRU de Nancy, Hôpital de Brabois, Vandoeuvre-Les Nancy, France
| | - Alexandre Ouattara
- Department of Cardiovascular Anesthesia and Critical Care, CHU Bordeaux, CHU de Bordeaux, 33000, Bordeaux, France
- Biology of Cardiovascular Diseases, Université de Bordeaux, INSERM, U1034, 33600, Pessac, France
| | - Nadir Tafer
- Department of Cardiovascular Anesthesia and Critical Care, CHU Bordeaux, CHU de Bordeaux, 33000, Bordeaux, France
- Biology of Cardiovascular Diseases, Université de Bordeaux, INSERM, U1034, 33600, Pessac, France
| | - Clément Delmas
- Cardiology Department, Rangueil University Hospital, Toulouse, France
| | - David Tonon
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, AP-HM, Aix-Marseille University, 13385, Marseille CEDEX 05, France
| | - Bertrand Rozec
- Department of Anaesthesiology and Critical Care, Institut du Thorax, Laennec Hospital, CHU de Nantes, and Nantes Université, CHU Nantes*, CNRS, INSERM, 44000, Nantes, France
| | - Jean-Luc Fellahi
- Department of Cardiothoracic Anaesthesiology and Critical Care, Louis Pradel University Hospital, Lyon, France
| | - Pascal Lim
- Cardiology department, Henri-Mondor University Hospital, AP-HP, Créteil, France
| | - François Labaste
- Department of Anaesthesiology and Critical Care Medicine, Rangueil University Hospital, Toulouse, France
| | - François Roubille
- Cardiology Department INI-CRT PhyMedExp INSERM, CNRS CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Thibaut Caruba
- Department of Pharmacy, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Philippe Mauriat
- Department of Cardiovascular Anesthesia and Critical Care, CHU Bordeaux, CHU de Bordeaux, 33000, Bordeaux, France
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13
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Gaisendrees C, Schlachtenberger G, Gerfer S, Krasivskyi I, Djordjevic I, Sabashnikov A, Kosmopoulos M, Jaeger D, Luehr M, Kuhn E, Deppe AC, Wahlers T. The impact of levosimendan on survival and weaning from ECMO after extracorporeal cardiopulmonary resuscitation. Artif Organs 2023; 47:1351-1360. [PMID: 37032531 DOI: 10.1111/aor.14540] [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] [Received: 05/12/2022] [Revised: 03/20/2023] [Accepted: 04/06/2023] [Indexed: 04/11/2023]
Abstract
OBJECTIVES Extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly used due to its beneficial outcomes and results compared to conventional CPR. After cardiac arrest, the overall ejection fraction is severely impaired; thus, weaning from ECMO is often prolonged or impossible. We hypothesized that early application of levosimendan in these patients facilitates ECMO weaning and survival. METHODS From 2016 until 2020, patients who underwent eCPR after cardiac arrest at our institution were analyzed retrospectively and divided into two groups: patients who received levosimendan during ICU stay (n = 24) and those who did not receive levosimendan (n = 84) and analyzed for outcome parameters. Furthermore, we used propensity-score matching and multinomial regression analysis to show the effect of levosimendan on outcome parameters. RESULTS Overall, in-hospital mortality was significantly lower in the group which received levosimendan (28% vs. 88%, p ≤ 0.01), and ECMO weaning was more feasible in patients who received levosimendan (88% vs. 20%, p ≤ 0.01). CPR duration until ECMO cannulation was significantly shorter in the levosimendan group (44 + 26 vs. 65 + 28, p = 0.002); interestingly, the rate of mechanical chest compressions before ECMO cannulation was lower in the levosimendan group (50% vs. 69%, p = 0.005). CONCLUSION In patients after cardiac arrest treated with eCPR, levosimendan seems to contribute to higher success rates of ECMO weaning, potentially due to a short to mid-term increase in inotropy. Also, the survival after levosimendan application was higher than patients who did not receive levosimendan.
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Affiliation(s)
| | | | - Stephen Gerfer
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Ihor Krasivskyi
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Deborah Jaeger
- Department of Emergency Medicine, INSERM U 1116, University of Lorraine, Vandœuvre-lès-Nancy, France, Nancy, France
| | - Maximilian Luehr
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Antje-Christin Deppe
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
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14
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Schiefenhövel F, Berger C, Penkova L, Grubitzsch H, Haller B, Meyer A, Heringlake M, Sander M, Erb JM, Balzer F, Treskatsch S. Influence of timing of Levosimendan administration on outcomes in cardiac surgery. Front Cardiovasc Med 2023; 10:1213696. [PMID: 37564910 PMCID: PMC10410848 DOI: 10.3389/fcvm.2023.1213696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/06/2023] [Indexed: 08/12/2023] Open
Abstract
Purpose Though a subgroup analysis has shown improved survival for patients suffering severely reduced ventricular function undergoing coronary artery bypass grafting, RCTs were not able to demonstrate overall beneficial effects of perioperative Levosimendan in cardiac surgery. This might be due to Levosimendan's pharmacokinetics reaching a steady-state concentration only 4-8 h after administration. Thus, this study now analysed the influence of timing of Levosimendan administration on perioperative outcome in cardiac surgery patients preoperatively presenting with severely reduced ventricular function and therefore considered at high-risk for intra- or postoperative low cardiac output syndrome. We hypothesized that prolonged preoperative Levosimendan administration ("preconditioning") would reduce mortality. Methods All adult patients undergoing cardiac surgery between 2006 and 2018 perioperatively receiving Levosimendan were included in this retrospective, observational cohort study (n = 498). Patients were stratified into 3 groups: Levosimendan started on the day prior to surgery ("preop"), Levosimendan started on the day of surgery ("intraop") or post ICU admission ("postop"). After propensity score matching (PSM) was performed, outcomes defined according to proposed standard definitions for perioperative outcome research were compared between groups. Results After PSM, there were no significant differences in patients' characteristics, comorbidities and type/priority of surgery between groups. Compared to intraop or postop Levosimendan treatment, preop treated patients had significantly lower in-hospital-mortality (preop vs. intraop. vs. postop = 16,7% vs. 33,3% vs. 42,3%), duration of mechanical ventilation and rate of continuous renal replacement therapy. Conclusions Prolonged preoperative treatment with Levosimendan of cardiac surgery patients preoperatively presenting with severely reduced left ventricular function might be beneficial in terms of postoperative outcome. Our results are in line with recent experts' recommendations concerning the prolonged perioperative use of Levosimendan. We strongly recommend that future randomized trials include this "preconditioning" treatment as an experimental arm.
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Affiliation(s)
- Fridtjof Schiefenhövel
- Department of Anaesthesiology and Intensive Care (AINS), Medical Center Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- Institute for Artificial Intelligence and Informatics in Medicine (AIIM), Chair of Medical Informatics, Medical Center Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Medical Informatics, Berlin, Germany
| | - Christian Berger
- Department of Anaesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Berlin, Germany
| | - Liubov Penkova
- Department of Anaesthesiology and Intensive Care Medicine, Charité Campus Mitte and Charité Campus Virchow, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Berlin, Germany
| | - Herko Grubitzsch
- Klinik für Kardiovaskuläre Chirurgie, Campus Virchow Klinikum, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Berlin, Germany
| | - Bernhard Haller
- Institute for Artificial Intelligence and Informatics in Medicine (AIIM), Chair of Medical Informatics, Medical Center Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Alexander Meyer
- Klinik für Kardiovaskuläre Chirurgie, Campus Virchow Klinikum, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Berlin, Germany
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Matthias Heringlake
- Department of Anaesthesia, Heart and Diabetes Center, Klinikum Karlsburg, Karlsburg, Germany
| | - Michael Sander
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Gießen UKGM, Justus-Liebig University Gießen, Gießen, Germany
| | - Joachim M. Erb
- Clinic for Anaesthesiology, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Felix Balzer
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Institute of Medical Informatics, Berlin, Germany
| | - Sascha Treskatsch
- Department of Anaesthesiology and Intensive Care Medicine, Charité Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Berlin, Germany
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15
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Milojevic M, Milosevic G, Nikolic A, Petrovic M, Petrovic I, Bojic M, Jagodic S. Mastering the Best Practices: A Comprehensive Look at the European Guidelines for Cardiopulmonary Bypass in Adult Cardiac Surgery. J Cardiovasc Dev Dis 2023; 10:296. [PMID: 37504552 PMCID: PMC10380276 DOI: 10.3390/jcdd10070296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/29/2023] Open
Abstract
The successful outcome of a cardiac surgery procedure is significantly dependent on the management of cardiopulmonary bypass (CPB). Even if a cardiac operation is technically well-conducted, a patient may suffer CPB-related complications that could result in severe comorbidities, reduced quality of life, or even death. However, the role of clinical perfusionists in perioperative patient care, which is critical, is often overlooked. Therefore, the European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Cardiothoracic Anaesthesiology (EACTA), and the European Board of Cardiovascular Perfusion (EBCP) have agreed to develop joint clinical practice guidelines (CPGs) for CPB due to its significant impact on patient care and significant variations in practice patterns between countries. The European guidelines, based on the EACTS standardized framework for the development of CPGs, cover the entire spectrum of CPB management in adult cardiac surgery. This includes training and education of clinical perfusionists, machine hardware, disposables, preparation for initiation of CPB, a complete set of procedures during CPB to help maintain end-organ function and anticoagulation, weaning from CPB, and the gaps in evidence and future research directions. This comprehensive coverage ensures that all aspects of CPB management are addressed, providing clinicians with a standardized approach to CPB management based on the latest evidence and best practices. To ensure better integration of these evidence-based recommendations into daily practice, this review aims to provide a general understanding of guideline development and an overview of essential treatment recommendations for CPB management.
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Affiliation(s)
- Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
- Erasmus University Medical Center, Department of Cardiothoracic Surgery, 3015 GD Rotterdam, The Netherlands
| | - Goran Milosevic
- Department of Perfusion Technology, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
| | - Aleksandar Nikolic
- Department of Cardiac Surgery, Acibadem-Sistina Hospital, 1000 Skopje, North Macedonia
| | - Masa Petrovic
- Center of Excellence, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Ivana Petrovic
- Center of Excellence, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
| | - Milovan Bojic
- Center of Excellence, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
| | - Sinisa Jagodic
- Department of Perfusion Technology, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
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Ftikos P, Falara A, Rellia P, Leontiadis E, Samanidis G, Kamperi N, Piperakis A, Tamvakopoulos C, Antoniou T, Theodoraki K. Monitoring of Levosimendan Administration in Patients with Pulmonary Hypertension Undergoing Cardiac Surgery and Effect of Two Different Dosing Schemes on Hemodynamic and Echocardiographic Parameters. Pharmaceuticals (Basel) 2023; 16:815. [PMID: 37375762 DOI: 10.3390/ph16060815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/17/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION The perioperative management of patients with pulmonary hypertension (PH) undergoing cardiac surgery represents one of the most challenging clinical scenarios. This fact mainly depends on the relationship existing between PH and right ventricular failure (RVF). Levosimendan (LS) is an inodilator that might be an effective agent in the treatment of PH and RVF. The aim of this study was to examine the impact of the duration of cardiopulmonary bypass (CPB) on the therapeutic drug monitoring of LS and to evaluate the effect of preemptive administration of LS on perioperative hemodynamic and echocardiographic parameters in cardiac surgical patients with preexisting PH. MATERIALS AND METHODS In this study, LS was administered in adult patients undergoing cardiac surgery before CPB in order to prevent exacerbation of preexisting PH and subsequent right ventricular dysfunction. Thirty cardiac surgical patients with preoperatively confirmed PH were randomized to receive either 6 μg/kg or 12 μg/kg of LS after the induction of anesthesia. The plasma concentration of LS was measured after CPB. In this study, a low sample volume was used combined with a simple sample preparation protocol. The plasma sample was extracted by protein precipitation and evaporated; then, the analyte was reconstituted and detected using specific and sensitive bioanalytical liquid chromatography with mass spectrometry (LC-MS/MS) methodology. The clinical, hemodynamic, and echocardiographic parameters were registered and evaluated before and after the administration of the drug. RESULTS A fast bioanalytical LC-MS/MS methodology (a run time of 5.5 min) was developed for the simultaneous determination of LS and OR-1896, its main metabolite in human plasma. The LC-MS/MS method was linear over a range of 0.1-50 ng/mL for LS and 1-50 ng/mL for its metabolite OR-1896. Measured plasma concentrations of LS were inversely related to the duration of CPB. LS administration before CPB during cardiac surgery was effective in reducing pulmonary artery pressure and improving hemodynamic parameters after CPB, with a more pronounced and durable effect of the drug at the dose of 12 μg/kg. Additionally, administration of LS at a dose of 12 μg/kg in cardiac surgical patients with PH before CPB improved right ventricular function. CONCLUSION LS administration decreases pulmonary artery pressure and may improve right ventricular function in patients with PH undergoing cardiac surgery.
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Affiliation(s)
- Panagiotis Ftikos
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece
| | - Areti Falara
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece
| | - Panagiota Rellia
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece
| | | | - George Samanidis
- Department of Cardiac Surgery, Onassis Cardiac Surgery Center, 176 74 Athens, Greece
| | - Natalia Kamperi
- Center of Clinical Research, Experimental Surgery and Translational Research, Division of Pharmacology-Pharmacotechnology, Biomedical Research Foundation, Academy of Athens, 115 27 Athens, Greece
| | - Artemios Piperakis
- Center of Clinical Research, Experimental Surgery and Translational Research, Division of Pharmacology-Pharmacotechnology, Biomedical Research Foundation, Academy of Athens, 115 27 Athens, Greece
| | - Constantin Tamvakopoulos
- Center of Clinical Research, Experimental Surgery and Translational Research, Division of Pharmacology-Pharmacotechnology, Biomedical Research Foundation, Academy of Athens, 115 27 Athens, Greece
| | - Theofani Antoniou
- Department of Anesthesiology, Onassis Cardiac Surgery Center, 176 74 Athens, Greece
| | - Kassiani Theodoraki
- Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece
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17
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Demailly Z, Besnier E, Tamion F, Lesur O. Ventriculo-arterial (un)coupling in septic shock: Impact of current and upcoming hemodynamic drugs. Front Cardiovasc Med 2023; 10:1172703. [PMID: 37324631 PMCID: PMC10266274 DOI: 10.3389/fcvm.2023.1172703] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/08/2023] [Indexed: 06/17/2023] Open
Abstract
Sepsis is an archetype of distributive shock and combines different levels of alterations in preload, afterload, and often cardiac contractility. The use of hemodynamic drugs has evolved over the past few years, along with the invasive and non-invasive tools used to measure these components in real time. However, none of them is impeccable, which is why the mortality of septic shock remains too high. The concept of ventriculo-arterial coupling (VAC) allows for the integration of these three fundamental macroscopic hemodynamic components. In this mini review, we discuss the knowledge, tools, and limitations of VAC measurement, along with the evidence supporting ventriculo-arterial uncoupling in septic shock. Finally, the impact of recommended hemodynamic drugs and molecules on VAC is detailed.
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Affiliation(s)
- Zoé Demailly
- Medical Intensive Care Unit, UNIROUEN, INSERM U1096, CHU Rouen, Normandie Université, Rouen, France
- Department of Anesthesiology and Critical Care, UNIROUEN, INSERM U1096, CHU Rouen, Normandie Université, Rouen, France
| | - Emmanuel Besnier
- Department of Anesthesiology and Critical Care, UNIROUEN, INSERM U1096, CHU Rouen, Normandie Université, Rouen, France
| | - Fabienne Tamion
- Medical Intensive Care Unit, UNIROUEN, INSERM U1096, CHU Rouen, Normandie Université, Rouen, France
| | - Olivier Lesur
- Centre de Recherche Clinique du CHU Sherbrooke, Sherbrooke, QC, Canada
- Départements de Soins Intensifs et de Médecine et Service de Pneumologie, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
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18
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Wang Q, Zuurbier CJ, Huhn R, Torregroza C, Hollmann MW, Preckel B, van den Brom CE, Weber NC. Pharmacological Cardioprotection against Ischemia Reperfusion Injury-The Search for a Clinical Effective Therapy. Cells 2023; 12:1432. [PMID: 37408266 DOI: 10.3390/cells12101432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/10/2023] [Accepted: 05/17/2023] [Indexed: 07/07/2023] Open
Abstract
Pharmacological conditioning aims to protect the heart from myocardial ischemia-reperfusion injury (IRI). Despite extensive research in this area, today, a significant gap remains between experimental findings and clinical practice. This review provides an update on recent developments in pharmacological conditioning in the experimental setting and summarizes the clinical evidence of these cardioprotective strategies in the perioperative setting. We start describing the crucial cellular processes during ischemia and reperfusion that drive acute IRI through changes in critical compounds (∆GATP, Na+, Ca2+, pH, glycogen, succinate, glucose-6-phosphate, mitoHKII, acylcarnitines, BH4, and NAD+). These compounds all precipitate common end-effector mechanisms of IRI, such as reactive oxygen species (ROS) generation, Ca2+ overload, and mitochondrial permeability transition pore opening (mPTP). We further discuss novel promising interventions targeting these processes, with emphasis on cardiomyocytes and the endothelium. The limited translatability from basic research to clinical practice is likely due to the lack of comorbidities, comedications, and peri-operative treatments in preclinical animal models, employing only monotherapy/monointervention, and the use of no-flow (always in preclinical models) versus low-flow ischemia (often in humans). Future research should focus on improved matching between preclinical models and clinical reality, and on aligning multitarget therapy with optimized dosing and timing towards the human condition.
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Affiliation(s)
- Qian Wang
- Department of Anesthesiology-L.E.I.C.A., Amsterdam University Medical Centers, Location AMC, Cardiovascular Science, Meibergdreef 11, 1105 AZ Amsterdam, The Netherlands
| | - Coert J Zuurbier
- Department of Anesthesiology-L.E.I.C.A., Amsterdam University Medical Centers, Location AMC, Cardiovascular Science, Meibergdreef 11, 1105 AZ Amsterdam, The Netherlands
| | - Ragnar Huhn
- Department of Anesthesiology, Kerckhoff-Clinic-Center for Heart, Lung, Vascular and Rheumatic Disease, Justus-Liebig-University Giessen, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Carolin Torregroza
- Department of Anesthesiology, Kerckhoff-Clinic-Center for Heart, Lung, Vascular and Rheumatic Disease, Justus-Liebig-University Giessen, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Markus W Hollmann
- Department of Anesthesiology-L.E.I.C.A., Amsterdam University Medical Centers, Location AMC, Cardiovascular Science, Meibergdreef 11, 1105 AZ Amsterdam, The Netherlands
| | - Benedikt Preckel
- Department of Anesthesiology-L.E.I.C.A., Amsterdam University Medical Centers, Location AMC, Cardiovascular Science, Meibergdreef 11, 1105 AZ Amsterdam, The Netherlands
| | - Charissa E van den Brom
- Department of Anesthesiology-L.E.I.C.A., Amsterdam University Medical Centers, Location AMC, Cardiovascular Science, Meibergdreef 11, 1105 AZ Amsterdam, The Netherlands
| | - Nina C Weber
- Department of Anesthesiology-L.E.I.C.A., Amsterdam University Medical Centers, Location AMC, Cardiovascular Science, Meibergdreef 11, 1105 AZ Amsterdam, The Netherlands
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Kralev A, Kalisnik JM, Bauer A, Sirch J, Fittkau M, Fischlein T. Impact of prophylactic intra-aortic balloon pump on early outcomes in patients with severe left ventricular dysfunction undergoing elective coronary artery bypass grafting with cardiopulmonary bypass. Int J Cardiol 2023:S0167-5273(23)00725-8. [PMID: 37209782 DOI: 10.1016/j.ijcard.2023.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/14/2023] [Accepted: 05/17/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVE Our aim was to analyse whether prophylactic preoperative intraaortic balloon pump (IABP) improves outcomes in hemodynamically stable patients with low left ventricular ejection fraction (LVEF ≤30%) undergoing elective myocardial revascularization (CABG) using cardiopulmonary bypass (CPB). Secondary aim was to identify the predictors for low cardiac output syndrome (LCOS). METHODS Prospectively collected data of 207 consecutive patients with LVEF ≤30% undergoing elective isolated CABG with CPB from 01/2009 to 12/2019, 136 with and 71 patients without IABP, were retrieved retrospectively. Patients with prophylactic IABP were matched 1:1 with patients without IABP by a propensity score matching. Stepwise logistic regression was conducted to identify predictors of postoperative LCOS in the propensity-matched cohort. P value ≤0.05 was considered significant. RESULTS Reduced postoperative LCOS (9.9% vs. 26.8%, P = 0.017) was observed in patients receiving prophylactic IABP. Stepwise logistic regression identified preoperative IABP as preventive factor for postoperative LCOS [Odds Ratio (OR) 0.19,95% Confidence Interval (CI), 0.06-0.55, P = 0.004]. The need of vasoactive and inotropic support was lower in patients with prophylactic IABP at 24, 48 and 72 h after surgery (12.3 [8.2-18.6] vs. 22.2 [14.4-28.8], P < 0.001, 7.7 [3.3-12.3] vs.16.3 [8.9-27.8], P < 0.001 and 2.4 [0-7] vs. 11.5 [3.1-26], P < 0.001, respectively). The patients in both groups did not differ in terms of in-hospital mortality (7.0% vs. 9.9%, P = 0.763). There were no major IABP-related complications. CONCLUSIONS Elective patients with left ventricular ejection fraction ≤30% undergoing CABG with CPB and prophylactic IABP insertion had less low cardiac output syndrome and similar in-hospital mortality.
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Affiliation(s)
- Andrej Kralev
- Department of Cardiac Surgery, Klinikum Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nurernberg, Germany
| | - Jurij Matija Kalisnik
- Department of Cardiac Surgery, Klinikum Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nurernberg, Germany; Surgery, Medical School, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia.
| | - André Bauer
- Department of Computer Science, Julius Maximillian University of Wuerzburg. Am Hubland, 97074 Wuerzburg, Germany
| | - Joachim Sirch
- Department of Cardiac Surgery, Klinikum Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nurernberg, Germany
| | - Matthias Fittkau
- Department of Cardiac Surgery, Klinikum Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nurernberg, Germany
| | - Theodor Fischlein
- Department of Cardiac Surgery, Klinikum Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nurernberg, Germany
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20
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Moon MR, Kachroo P. Leveraging Innovation to Mitigate Risk During Heart Surgery. Tex Heart Inst J 2023; 50:e238214. [PMID: 37335123 DOI: 10.14503/thij-23-8214] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Affiliation(s)
- Marc R Moon
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
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21
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Lescroart M, Pequignot B, Janah D, Levy B. The medical treatment of cardiogenic shock. JOURNAL OF INTENSIVE MEDICINE 2023; 3:114-123. [PMID: 37188116 PMCID: PMC10175741 DOI: 10.1016/j.jointm.2022.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/21/2022] [Accepted: 12/04/2022] [Indexed: 05/17/2023]
Abstract
Cardiogenic shock (CS) is a leading cause of mortality worldwide. CS presentation and management in the current era have been widely depicted in epidemiological studies. Its treatment is codified and relies on medical care and extracorporeal life support (ECLS) in the bridge to recovery, chronic mechanical device therapy, or transplantation. Recent improvements have changed the landscape of CS. The present analysis aims to review current medical treatments of CS in light of recent literature, including addressing excitation-contraction coupling and specific physiology on applied hemodynamics. Inotropism, vasopressor use, and immunomodulation are discussed as pre-clinical and clinical studies have focused on new therapeutic options to improve patient outcomes. Certain underlying conditions of CS, such as hypertrophic or Takotsubo cardiomyopathy, warrant specifically tailored management that will be overviewed in this review.
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Affiliation(s)
- Mickael Lescroart
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy 54511, France
- INSERM U1116, Faculté de Médecine, Vandoeuvre-les-Nancy 54511, France
- Université de Lorraine, Vandoeuvre-les-Nancy 54000, France
| | - Benjamin Pequignot
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy 54511, France
- INSERM U1116, Faculté de Médecine, Vandoeuvre-les-Nancy 54511, France
- Université de Lorraine, Vandoeuvre-les-Nancy 54000, France
| | - Dany Janah
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy 54511, France
- INSERM U1116, Faculté de Médecine, Vandoeuvre-les-Nancy 54511, France
- Université de Lorraine, Vandoeuvre-les-Nancy 54000, France
| | - Bruno Levy
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy 54511, France
- INSERM U1116, Faculté de Médecine, Vandoeuvre-les-Nancy 54511, France
- Université de Lorraine, Vandoeuvre-les-Nancy 54000, France
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22
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Kipka H, Schaflinger R, Tomasi R, Pogoda K, Mannell H. The Effects of the Levosimendan Metabolites OR-1855 and OR-1896 on Endothelial Pro-Inflammatory Responses. Biomedicines 2023; 11:biomedicines11030918. [PMID: 36979897 PMCID: PMC10045601 DOI: 10.3390/biomedicines11030918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/03/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023] Open
Abstract
The calcium sensitizer levosimendan is used for the treatment of acute decompensated heart failure. A small portion (4–7%) of levosimendan is metabolized to the pharmacologically active metabolite OR-1896 via the inactive intermediate OR-1855. In addition, levosimendan has been shown to exert positive effects on the endothelium in vitro antagonizing vascular dysfunction and inflammation. However, the function of the levosimendan metabolites within this context is still unknown. In this study, we thus investigated the impact of the metabolites OR-1896 and OR-1855 on endothelial inflammatory processes in vitro. We observed a reduction of IL-1β-dependent endothelial adhesion molecule ICAM-1 and VCAM-1 as well as interleukin (IL) -6 expression upon levosimendan treatment but not after treatment with OR-1855 or OR-1896, as assessed by western blotting, flow cytometry, and qRT-PCR. Instead, the metabolites impaired IL-1β-induced ROS formation via inactivation of the MAPK p38, ERK1/2, and JNK. Our results suggest that the levosimendan metabolites OR-1896 and OR-1855 have certain anti-inflammatory properties, partly other than levosimendan. Importantly, they additionally show that the intermediate metabolite OR-1855 does, in fact, have pharmacological effects in the endothelium. This is interesting, as the metabolites are responsible for the long-term therapeutic effects of levosimendan, and heart failure is associated with vascular dysfunction and inflammation.
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Affiliation(s)
- Hannah Kipka
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, 81377 Munich, Germany
- Institute of Cardiovascular Physiology and Pathophysiology, Biomedical Center, LMU Munich, 82152 Planegg, Germany
| | - Rebecca Schaflinger
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, 81377 Munich, Germany
- Institute of Cardiovascular Physiology and Pathophysiology, Biomedical Center, LMU Munich, 82152 Planegg, Germany
| | - Roland Tomasi
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Kristin Pogoda
- Institute of Cardiovascular Physiology and Pathophysiology, Biomedical Center, LMU Munich, 82152 Planegg, Germany
- Physiology, Institute for Theoretical Medicine, University of Augsburg, 86159 Augsburg, Germany
| | - Hanna Mannell
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, 81377 Munich, Germany
- Institute of Cardiovascular Physiology and Pathophysiology, Biomedical Center, LMU Munich, 82152 Planegg, Germany
- Physiology, Institute for Theoretical Medicine, University of Augsburg, 86159 Augsburg, Germany
- Correspondence:
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23
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Welker CC, Mielke JAR, Ramakrishna H. Levosimendan and Low Cardiac Output After Cardiac Surgery: Analysis of Trial Data. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00182-9. [PMID: 37028989 DOI: 10.1053/j.jvca.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/08/2023] [Indexed: 04/09/2023]
Affiliation(s)
- Carson C Welker
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jr Arthur R Mielke
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.
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24
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Yang B, Zhao T, Guo B, Li Y. Short-term effects of levosimendan use for venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis. Perfusion 2023; 38:305-312. [PMID: 34689640 DOI: 10.1177/02676591211051860] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Levosimendan has been demonstrated to reduce the incidence of cardiogenic shock and facilitate weaning from cardiopulmonary bypass. However, the beneficial effects of levosimendan treatment on hospital outcomes in patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) are uncertain. We performed a systematic review and meta-analysis to evaluate the short-term effects of levosimendan use for patients undergoing VA-ECMO. METHODS We searched PubMed, Embase, and the Cochrane Library for English articles published from inception to July 15, 2021. Observational studies comparing levosimendan versus non- levosimendan for VA-ECMO were considered eligible for the current study. RESULTS Nine observational studies with 1058 patients were included. In-hospital mortality was 46.3% in the levosimendan group as compared with 50.7% in the control group. Levosimendan significantly reduced in-hospital mortality in patients undergoing VA-ECMO compared with the control group (RR, 0.80; 95% CI, 0.67-0.95; p = 0.013). The incidence of weaning from VA-ECMO was 79.3% in the levosimendan group as compared with 63.4% in the control group. Levosimendan significantly increase the incidence of weaning from VA-ECMO in patients as compared with the control group (RR, 1.20; 95% CI, 1.07-1.34; p = 0.002). In the one-way sensitivity analysis for estimating the effect of each study on mortality or weaning from VA-ECMO, omission of each study did not make a significant difference. CONCLUSIONS Our study indicates that levosimendan use significantly reduced in-hospital mortality and increase the incidence of weaning in patients undergoing VA-ECMO.
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Affiliation(s)
- Boyu Yang
- The 4th Department of Cardiology, The Sceond Hospital of Hebei Medical University, Shijiazhuang, China
| | - Tong Zhao
- Department of Neurology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Bingyan Guo
- The 4th Department of Cardiology, The Sceond Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yongjun Li
- The 4th Department of Cardiology, The Sceond Hospital of Hebei Medical University, Shijiazhuang, China
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25
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Acute Kidney Injury and Renal Replacement Therapy: A Review and Update for the Perioperative Physician. Anesthesiol Clin 2023; 41:211-230. [PMID: 36872000 DOI: 10.1016/j.anclin.2022.10.004] [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: 03/06/2023]
Abstract
Post-operative acute kidney injury is a devastating complication with significant morbidity and mortality associated with it. The perioperative anesthesiologist is in a unique position to potentially mitigate the risk of postoperative AKI, however, understanding the pathophysiology, risk factors and preventative strategies is paramount. There are also certain clinical scenarios, where renal replacement therapy may be indicated intraoperatively including severe electrolyte abnormalities, metabolic acidosis and massive volume overload. A multidisciplinary approach including the nephrologist, critical care physician, surgeon and anesthesiologist is necessary to determine the optimal management of these critically ill patients.
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26
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Yu Y, Li C, Zhu S, Jin L, Hu Y, Ling X, Miao C, Guo K. Diagnosis, pathophysiology and preventive strategies for cardiac surgery-associated acute kidney injury: a narrative review. Eur J Med Res 2023; 28:45. [PMID: 36694233 PMCID: PMC9872411 DOI: 10.1186/s40001-023-00990-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/03/2023] [Indexed: 01/25/2023] Open
Abstract
Acute kidney injury (AKI) is a common and serious complication of cardiac surgery and is associated with increased mortality and morbidity, accompanied by a substantial economic burden. The pathogenesis of cardiac surgery-associated acute kidney injury (CSA-AKI) is multifactorial and complex, with a variety of pathophysiological theories. In addition to the existing diagnostic criteria, the exploration and validation of biomarkers is the focus of research in the field of CSA-AKI diagnosis. Prevention remains the key to the management of CSA-AKI, and common strategies include maintenance of renal perfusion, individualized blood pressure targets, balanced fluid management, goal-directed oxygen delivery, and avoidance of nephrotoxins. This article reviews the pathogenesis, definition and diagnosis, and pharmacological and nonpharmacological prevention strategies of AKI in cardiac surgical patients.
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Affiliation(s)
- Ying Yu
- grid.8547.e0000 0001 0125 2443Department of Anaesthesiology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road, Xuhui District, Shanghai, 20032 China
| | - Chenning Li
- grid.8547.e0000 0001 0125 2443Department of Anaesthesiology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road, Xuhui District, Shanghai, 20032 China
| | - Shuainan Zhu
- grid.8547.e0000 0001 0125 2443Department of Anaesthesiology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road, Xuhui District, Shanghai, 20032 China
| | - Lin Jin
- grid.8547.e0000 0001 0125 2443Department of Anaesthesiology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road, Xuhui District, Shanghai, 20032 China
| | - Yan Hu
- grid.8547.e0000 0001 0125 2443Department of Anaesthesiology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road, Xuhui District, Shanghai, 20032 China
| | - Xiaomin Ling
- grid.8547.e0000 0001 0125 2443Department of Anaesthesiology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road, Xuhui District, Shanghai, 20032 China
| | - Changhong Miao
- grid.8547.e0000 0001 0125 2443Department of Anaesthesiology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road, Xuhui District, Shanghai, 20032 China
| | - Kefang Guo
- grid.8547.e0000 0001 0125 2443Department of Anaesthesiology, Zhongshan Hospital, Fudan University, No 180 Fenglin Road, Xuhui District, Shanghai, 20032 China
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Sugimura Y, Kalampokas N, Arikan M, Rellecke P, Dalyanoglu H, Tudorache I, Westenfeld R, Boeken U, Lichtenberg A, Akhyari P, Aubin H. Preoperative Levosimendan therapy reduces postoperative right ventricular failure in patients undergoing left ventricular assist device implantation. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 36:6978238. [PMID: 36802258 PMCID: PMC9931070 DOI: 10.1093/icvts/ivac289] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/12/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Perioperative mortality and complications still remain high after left ventricular assist device (LVAD) implantation, especially in highly compromised patient cohorts. Here, we evaluate the effects of preoperative Levosimendan therapy on peri- and postoperative outcomes after LVAD implantation. METHODS We retrospectively analysed 224 consecutive patients with LVAD implantation for end-stage heart failure between November 2010 and December 2019 in our centre with regard to short- and longer-term mortality as well as incidence of postoperative right ventricular failure (RV-F). Out of these, 117 (52.2%) received preoperative i.v. Levosimendan therapy within 7 days before LVAD implantation (Levo group). RESULTS In-hospital, 30-day and 5-year mortality was comparable (in-hospital mortality: 18.8% vs 23.4%, P = 0.40; 30-day mortality: 12.0% vs 14.0%, P = 0.65; Levo vs control group). However, in the multivariate analysis, preoperative Levosimendan therapy significantly reduced postoperative RV-F but increased postoperative vasoactive inotropic score ([RV-F: odds ratio 2.153, confidence interval 1.146-4.047, P = 0.017; vasoactive inotropic score 24 h post-surgery: odds ratio 1.023, confidence interval 1.008-1.038, P = 0.002). These results were further confirmed by 1:1 propensity score matching of 74 patients in each group. Especially in the subgroup of patients with normal preoperative RV function, the prevalence of postoperative RV-F was significantly lower in the Levo- group as compared to the control group (17.6% vs 31.1%, P = 0.03; respectively). CONCLUSIONS Preoperative Levosimendan therapy reduces the risk of postoperative RV-F, especially in patients with normal preoperative RV function without effects on mortality up to 5 years after LVAD implantation.
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Affiliation(s)
| | | | - Metin Arikan
- Department of Cardiac Surgery, Medical Faculty and University Hospital, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Phillip Rellecke
- Department of Cardiac Surgery, Medical Faculty and University Hospital, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Hannan Dalyanoglu
- Department of Cardiac Surgery, Medical Faculty and University Hospital, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, Medical Faculty and University Hospital, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Duesseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty and University Hospital, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Payam Akhyari
- Corresponding author. Department of Cardiac Surgery, Medical Faculty and RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany. Tel: +49-241-8012345; fax: +49-241-80-33-12345; e-mail: (P. Akhyari)
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty and University Hospital, Heinrich-Heine-University Medical School, Duesseldorf, Germany
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Kochar A, Zheng Y, van Diepen S, Mehta RH, Westerhout CM, Mazer DC, Duncan AI, Whitlock R, Lopes RD, Argenziano M, de Varennes B, Alexander JH, Goodman SG, Fremes S. Predictors and associated clinical outcomes of low cardiac output syndrome following cardiac surgery: insights from the LEVO-CTS trial. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:818-825. [PMID: 36156131 DOI: 10.1093/ehjacc/zuac114] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 08/23/2022] [Accepted: 09/19/2022] [Indexed: 06/16/2023]
Abstract
AIMS High-risk cardiac surgery is commonly complicated by low cardiac output syndrome (LCOS), which is associated with high mortality. There are limited data derived from multi-centre studies with adjudicated endpoints describing factors associated with LCOS and its downstream clinical outcomes. METHODS AND RESULTS The Levosimendan in Patients with Left Ventricular Systolic Dysfunction Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass (LEVO-CTS) trial evaluated prophylactic levosimendan vs. placebo in patients with a reduced ejection fraction undergoing coronary artery bypass grafting (CABG) and/or valve surgery. We conducted a pre-specified analysis on LCOS, which was characterized by a four-part definition. We constructed a multivariable logistical regression model to evaluate risk factors associated with LCOS and performed Cox proportional hazards modelling to determine the association of LCOS with 90-day mortality. A total of 186 (22%) of 849 patients in the LEVO-CTS trial developed LCOS. The factors most associated with a higher adjusted risk of LCOS were pre-operative ejection fraction [odds ratio (OR) 1.26; 95% confidence interval (CI): 1.08-1.46 per 5% decrease] and age (OR 1.13; 95% CI: 1.04-1.24 per 5-year increase), whereas isolated CABG surgery (OR 0.44, 95% CI: 0.31-0.64) and levosimendan use (OR 0.65; 95% CI: 0.46-0.92) were associated with a lower risk of LCOS. Patients with LCOS had worse outcomes, including renal replacement therapy at 30-day (10 vs. 1%) and 90-day mortality (16 vs. 3%, adjusted hazard ratio of 5.04, 95% CI: 2.66-9.55). CONCLUSION Low cardiac output syndrome is associated with a high risk of post-operative mortality in high-risk cardiac surgery.
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Affiliation(s)
- Ajar Kochar
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, USA
| | - Yinggan Zheng
- Canadian VIGOUR Centre at the University of Alberta, 40129 Edmonton, AB T6G, Canada
| | - Sean van Diepen
- Canadian VIGOUR Centre at the University of Alberta, 40129 Edmonton, AB T6G, Canada
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Rajendra H Mehta
- Duke Clinical Research Institute, Duke University Medical Center, 300 W. Morgan Street, Durham, NC 27701, USA
| | - Cynthia M Westerhout
- Canadian VIGOUR Centre at the University of Alberta, 40129 Edmonton, AB T6G, Canada
| | - David Cyril Mazer
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, University of Toronto, 300 Bond Street, Toronto ON M5B 1W8, Canada
| | - Andra I Duncan
- Department of Cardiothoracic Anesthesia, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Richard Whitlock
- Division of Cardiac Surgery, Hamilton Health Sciences, 237 Barton Street East Hamilton, ON L8L 2X2, USA
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, 300 W. Morgan Street, Durham, NC 27701, USA
| | - Michael Argenziano
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University College of Physicians & Surgeons, 630 West 168th Street, New York, NY 10032, USA
| | - Benoit de Varennes
- Department of Cardiovascular Surgery, McGill University Health Centre, 1001 boul. Decarie, Montreal QC H4A 3J1, Canada
| | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, 300 W. Morgan Street, Durham, NC 27701, USA
| | - Shaun G Goodman
- Canadian VIGOUR Centre at the University of Alberta, 40129 Edmonton, AB T6G, Canada
- Division of Cardiology, St Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Stephen Fremes
- Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Avenue, Toronto, ON M4N 3M5, USA
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Zhao Z, Meng Z, Song G, Wang C, Shi S, Zhao J, Zhang H, Wang M, Niu G, Zhou Z, Wang J, Wu Y. The effects of levosimendan in patients undergoing transcatheter aortic valve replacement- a retrospective analysis. Front Pharmacol 2022; 13:969088. [PMID: 36408223 PMCID: PMC9669067 DOI: 10.3389/fphar.2022.969088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Aortic stenosis (AS) increases left ventricular afterload, leading to cardiac damage and heart failure (HF). Transcatheter aortic valve replacement (TAVR) is an effective therapy for AS. No inotropic agents including levosimendan have been evaluated in patients undergoing TAVR. Methods: A total of 285 patients underwent TAVR between 2014 and 2019; 210 were included in the matched analysis and 105 received 0.1 μg/kg body weight/min levosimendan immediately after the prosthesis had been successfully implanted. Medical history, laboratory tests, and echocardiography results were analyzed. Endpoints including 2-year all-cause mortality, stroke, or HF-related hospitalization, and a combination of the above were analyzed by Cox proportional hazard models. Results: The levosimendan group had no difference in 2-year mortality compared with the control group (hazard ratio [HR]: 0.603, 95% confidence interval [CI]: 0.197–1.844; p = 0.375). However, levosimendan reduced stroke or HF-related hospitalization (HR: 0.346; 95% CI: 0.135–0.884; p = 0.027) and the combined endpoint (HR: 0.459, 95% CI: 0.215–0.980; p = 0.044). After adjusting for multiple variants, levosimendan still reduced stroke or HF-related hospitalization (HR: 0.346, 95% CI: 0.134–0.944; p = 0.038). Conclusion: Prophylactic levosimendan administration immediately after valve implantation in patients undergoing TAVR can reduce stroke or HF-related hospitalization but does not lower all-cause mortality.
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Affiliation(s)
- Zhenyan Zhao
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhen Meng
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Guangyuan Song
- Interventional Center of Valvular Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Chunrong Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sheng Shi
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Zhao
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hongliang Zhang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Moyang Wang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Guannan Niu
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zheng Zhou
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jianhui Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Jianhui Wang, ; Yongjian Wu,
| | - Yongjian Wu
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Jianhui Wang, ; Yongjian Wu,
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Rodenas-Alesina E, Brahmbhatt DH, Rao V, Salvatori M, Billia F. Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: A comprehensive review. Front Cardiovasc Med 2022; 9:1040251. [PMID: 36407460 PMCID: PMC9671519 DOI: 10.3389/fcvm.2022.1040251] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/18/2022] [Indexed: 08/26/2023] Open
Abstract
Left ventricular assist devices (LVADs) are increasingly common across the heart failure population. Right ventricular failure (RVF) is a feared complication that can occur in the early post-operative phase or during the outpatient follow-up. Multiple tools are available to the clinician to carefully estimate the individual risk of developing RVF after LVAD implantation. This review will provide a comprehensive overview of available tools for RVF prognostication, including patient-specific and right ventricle (RV)-specific echocardiographic and hemodynamic parameters, to provide guidance in patient selection during LVAD candidacy. We also offer a multidisciplinary approach to the management of early RVF, including indications and management of right ventricular assist devices in this setting to provide tools that help managing the failing RV.
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Affiliation(s)
- Eduard Rodenas-Alesina
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- Department of Cardiology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Darshan H. Brahmbhatt
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Vivek Rao
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
| | - Marcus Salvatori
- Department of Anesthesia, University Health Network, Toronto, ON, Canada
| | - Filio Billia
- Mechanical Circulatory Support Program, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
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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.
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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
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Chen JJ, Lee TH, Kuo G, Huang YT, Chen PR, Chen SW, Yang HY, Hsu HH, Hsiao CC, Yang CH, Lee CC, Chen YC, Chang CH. Strategies for post–cardiac surgery acute kidney injury prevention: A network meta-analysis of randomized controlled trials. Front Cardiovasc Med 2022; 9:960581. [PMID: 36247436 PMCID: PMC9555275 DOI: 10.3389/fcvm.2022.960581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/12/2022] [Indexed: 12/05/2022] Open
Abstract
Objects Cardiac surgery is associated with acute kidney injury (AKI). However, the effects of various pharmacological and non-pharmacological strategies for AKI prevention have not been thoroughly investigated, and their effectiveness in preventing AKI-related adverse outcomes has not been systematically evaluated. Methods Studies from PubMed, Embase, and Medline and registered trials from published through December 2021 that evaluated strategies for preventing post–cardiac surgery AKI were identified. The effectiveness of these strategies was assessed through a network meta-analysis (NMA). The secondary outcomes were prevention of dialysis-requiring AKI, mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS. The interventions were ranked using the P-score method. Confidence in the results of the NMA was assessed using the Confidence in NMA (CINeMA) framework. Results A total of 161 trials (involving 46,619 participants) and 53 strategies were identified. Eight pharmacological strategies {natriuretic peptides [odds ratio (OR): 0.30, 95% confidence interval (CI): 0.19–0.47], nitroprusside [OR: 0.29, 95% CI: 0.12–0.68], fenoldopam [OR: 0.36, 95% CI: 0.17–0.76], tolvaptan [OR: 0.35, 95% CI: 0.14–0.90], N-acetyl cysteine with carvedilol [OR: 0.37, 95% CI: 0.16–0.85], dexmedetomidine [OR: 0.49, 95% CI: 0.32–0.76;], levosimendan [OR: 0.56, 95% CI: 0.37–0.84], and erythropoietin [OR: 0.62, 95% CI: 0.41–0.94]} and one non-pharmacological intervention (remote ischemic preconditioning, OR: 0.76, 95% CI: 0.63–0.92) were associated with a lower incidence of post–cardiac surgery AKI with moderate to low confidence. Among these nine strategies, five (fenoldopam, erythropoietin, natriuretic peptides, levosimendan, and remote ischemic preconditioning) were associated with a shorter ICU LOS, and two (natriuretic peptides [OR: 0.30, 95% CI: 0.15–0.60] and levosimendan [OR: 0.68, 95% CI: 0.49–0.95]) were associated with a lower incidence of dialysis-requiring AKI. Natriuretic peptides were also associated with a lower risk of mortality (OR: 0.50, 95% CI: 0.29–0.86). The results of a sensitivity analysis support the robustness and effectiveness of natriuretic peptides and dexmedetomidine. Conclusion Nine potentially effective strategies were identified. Natriuretic peptide therapy was the most effective pharmacological strategy, and remote ischemic preconditioning was the only effective non-pharmacological strategy. Preventive strategies might also help prevent AKI-related adverse outcomes. Additional studies are required to explore the optimal dosages and protocols for potentially effective AKI prevention strategies.
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Affiliation(s)
- Jia-Jin Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | | | - George Kuo
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yen-Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Rung Chen
- Department of Anesthesiology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shao-Wei Chen
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Huang-Yu Yang
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsiang-Hao Hsu
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ching-Chung Hsiao
- Department of Nephrology, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Chia-Hung Yang
- Department of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Chang Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- *Correspondence: Chih-Hsiang Chang,
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The importance of pharmacokinetics, pharmacodynamic and repetitive use of levosimendan. Biomed Pharmacother 2022; 153:113391. [DOI: 10.1016/j.biopha.2022.113391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 12/15/2022] Open
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Lee WC, Wu PJ, Fang HY, Fang YN, Chen HC, Tong MS, Sung PH, Lee CH, Chung WJ. Levosimendan Administration May Provide More Benefit for Survival in Patients with Non-Ischemic Cardiomyopathy Experiencing Acute Decompensated Heart Failure. J Clin Med 2022; 11:jcm11143997. [PMID: 35887759 PMCID: PMC9322737 DOI: 10.3390/jcm11143997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/23/2022] [Accepted: 07/08/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Acute decompensated heart failure (ADHF) is a life-threatening condition with a high mortality rate. Levosimendan is an effective inotropic agent used to maintain cardiac output and a long-lasting effect. However, only few studies have compared the clinical outcomes, after levosimendan therapy, among etiologies of ADHF. Methods: Between July 2014 and December 2019, 184 patients received levosimendan therapy for ADHF at our hospital. A total of 143 patients had ischemic cardiomyopathy (ICM), and 41 patients had non-ICM (NICM). Data on comorbidities, echocardiographic findings, laboratory findings, use of mechanical devices, consumption of other inotropic or vasopressor agents, frequency of HF hospitalization, cardiovascular (CV) mortality, and all-cause mortality were compared between the ICM and NICM groups. Results: Patients with ICM were older with higher prevalence of diabetes mellitus when compared to patients with NICM. Patients with NICM had a poorer left ventricular ejection fraction (LVEF) and higher left ventricular end-systolic volume when compared to patients with ICM. At the 30 day follow-up period, a lower CV mortality (ICM vs. NICM: 20.9% vs. 5.1%; log-rank p = 0.033) and lower all-cause mortality (ICM vs. NICM: 28.7% vs. 9.8%; log-rank p = 0.018) was observed in the NICM patients. A significantly lower all-cause mortality was noted at 180 day (ICM vs. NICM: 39.2% vs. 22.0%; log-rank p = 0.043) and 1 year (ICM vs. NICM: 41.3% vs. 24.4%; log-rank p = 0.046) follow up in the NICM subgroup. NICM (hazard ratio (HR): 0.303, 95% confidence interval (CI): 0.108–0.845; p = 0.023) and ECMO use (HR: 2.550, 95% CI: 1.385–4.693; p = 0.003) were significant predictors of 30 day all-cause mortality. Conclusions: In our study on levosimendan use for ADHF patients, better clinical outcomes were noted in the NICM population when compared to the ICM population. In the patients with cardiogenic shock or ventilator use, significantly lower incidence of 30 day mortality presented in the NICM population when compared with the ICM population.
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Affiliation(s)
- Wei-Chieh Lee
- Division of Cardiovascular Medicine, Chi-Mei Medical Center, Tainan 71004, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Correspondence: ; Tel.: +886-6-281-2811; Fax: +886-6-282-8928
| | - Po-Jui Wu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (H.-Y.F.); (Y.-N.F.); (H.-C.C.); (M.-S.T.); (P.-H.S.); (C.-H.L.); (W.-J.C.)
| | - Hsiu-Yu Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (H.-Y.F.); (Y.-N.F.); (H.-C.C.); (M.-S.T.); (P.-H.S.); (C.-H.L.); (W.-J.C.)
| | - Yen-Nan Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (H.-Y.F.); (Y.-N.F.); (H.-C.C.); (M.-S.T.); (P.-H.S.); (C.-H.L.); (W.-J.C.)
| | - Huang-Chung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (H.-Y.F.); (Y.-N.F.); (H.-C.C.); (M.-S.T.); (P.-H.S.); (C.-H.L.); (W.-J.C.)
| | - Meng-Shen Tong
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (H.-Y.F.); (Y.-N.F.); (H.-C.C.); (M.-S.T.); (P.-H.S.); (C.-H.L.); (W.-J.C.)
| | - Pei-Hsun Sung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (H.-Y.F.); (Y.-N.F.); (H.-C.C.); (M.-S.T.); (P.-H.S.); (C.-H.L.); (W.-J.C.)
| | - Chieh-Ho Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (H.-Y.F.); (Y.-N.F.); (H.-C.C.); (M.-S.T.); (P.-H.S.); (C.-H.L.); (W.-J.C.)
| | - Wen-Jung Chung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (P.-J.W.); (H.-Y.F.); (Y.-N.F.); (H.-C.C.); (M.-S.T.); (P.-H.S.); (C.-H.L.); (W.-J.C.)
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Levosimendan in paediatric cardiac anaesthesiology. Eur J Anaesthesiol 2022; 39:646-655. [DOI: 10.1097/eja.0000000000001711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Segev A, Lavee J, Kassif Y, Shemesh Y, Kogan A, Freimark D, Morgan A, Lotan D, Itelman E, Grupper A. Effect of levosimendan infusion prior to left ventricular assist device implantation on right ventricular failure. J Cardiothorac Surg 2022; 17:158. [PMID: 35710438 PMCID: PMC9205013 DOI: 10.1186/s13019-022-01915-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
Objective Investigate the safety and efficacy of preoperative levosimendan in patients undergoing left ventricular assist device (LVAD) implantation.
Methods Consecutive patients who received LVADs (HeartMate-2, 3, HVAD) in a single tertiary medical center (2012–2018). INTERMACS profile 1 patients were excluded. The primary outcome was post-LVAD right ventricular failure (RVF) and inhospital mortality rates. The secondary outcomes included other clinical, echocardiographic and hemodynamic parameters at follow-up. Results Final cohort consisted of 62 patients (40[65%] in the levosimendan group and 22[35%] in the no-levosimendan group). Post-operative RVF rate and inotrope or ventilation support time were similar in the levosimendan and no-levosimendan groups (7.5% vs. 13.6%; P = 0.43, median of 51 vs. 72 h; P = 0.41 and 24 vs. 27 h; P = 0.19, respectively). Length of hospitalization, both total and in the intensive care unit, was not statistically significant (median days of 13 vs. 16; P = 0.34, and 3 vs. 4; P = 0.44, respectively). Post-operative laboratory and echocardiographic parameters and in-hospital complication rate did not differ between the groups, despite worse baseline clinical parameters in the Levosimendan group. There was no significant difference in the in-hospital and long term mortality rate (2.5% vs. 4.5%; P > 0.999 and 10% vs. 27.3% respectively; P = 0.64). Conclusions Levosimendan infusion prior to LVAD implantation was safe and associated with comparable results without significant improved post-operative outcomes, including RVF. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-022-01915-6.
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Affiliation(s)
- Amitai Segev
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Jacob Lavee
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yigal Kassif
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel
| | - Yedida Shemesh
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel
| | - Alexander Kogan
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel
| | - Dov Freimark
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Morgan
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel
| | - Dor Lotan
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Edward Itelman
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel
| | - Avishay Grupper
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Verma S, Rathwell S, Fremes S, Zheng Y, Mehta R, Lopes RD, Alexander JH, Goodman SG, Diepen SV. Associated factors and clinical outcomes in mechanical circulatory support use in patients undergoing high risk on-pump cardiac surgery: Insights from the LEVO-CTS trial. Am Heart J 2022; 248:35-41. [PMID: 35263653 DOI: 10.1016/j.ahj.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND We describe variables and outcomes associated with peri-operative mechanical circulatory support (MCS) utilization among patients enrolled in the Levosimendan in patients with Left Ventricular Systolic Dysfunction Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass (LEVO-CTS) trial. METHODS In the LEVO-CTS trial, MCS utilization (defined as intra-aortic balloon pump, extracorporeal membrane oxygenation, or surgical ventricular assist device) within 5 days of surgery was examined. The association between MCS use and outcomes including 90-day mortality, 30-day renal-replacement therapy, and hospital and critical stay length of stay were determined. RESULTS Among the 849 patients from 70 centers randomized to levosimendan or placebo, 85 (10.0%) patients were treated with MCS (71 intra-aortic balloon pump, 7 extracorporeal membrane oxygenation, 7 ventricular assist device); with 89.4% started on post-operative day 0. Inter-institutional use ranged from 0% to 100%. Variables independently associated with MCS utilization included combined coronary artery bypass grafting and valve surgery (adjusted odds ratio [OR] 2.73, 95% confidence interval [CI] 1.70-4.37, P < .001), history of lung disease (OR 1.70, 95% CI 1.06-2.70, P = .029), and history of heart failure (OR 2.44, 95% CI 1.10-5.45, P = .027). Adjusted 90-day mortality (22.4% vs 4.1%, hazard ratio 6.11, 95% CI 3.95-9.44, P < .001) was higher, and median critical care length of stay (8.0 vs 4.0 days, P < .001) was longer in patients managed with MCS. CONCLUSIONS In a randomized controlled trial of high-risk cardiac surgical patients in North America, we observed patient, and surgical variables associated with MCS utilization. MCS use was associated with a higher risk of post-operative mortality.
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Caruba T, Charles-Nelson A, Alexander JH, Mehta RH, Heringlake M, Toller W, Yavchitz A, Sabatier B, Chatellier G, Cholley B. Prophylactic levosimendan in patients with low ejection fraction undergoing coronary artery bypass grafting: A pooled analysis of two multicentre randomised controlled trials. Anaesth Crit Care Pain Med 2022; 41:101107. [PMID: 35643391 DOI: 10.1016/j.accpm.2022.101107] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To assess the effect of preoperative levosimendan on mortality at Day-90 in patients with left ventricular ejection fraction (LVEF) ≤ 40%, and to investigate a possible differential effect between patients undergoing isolated coronary artery bypass grafting (CABG) versus CABG combined with valve replacement surgery. DESIGN Pooled analysis of two multicentre randomised controlled trials (RCT) investigating prophylactic levosimendan versus placebo prior to CABG surgery on mortality at Day-90 in patients with LVEF ≤ 40%. A meta-analysis of all RCT investigating the same issue was also conducted. RESULTS A cohort of 1084 patients (809 isolated CABG, and 275 combined surgery) resulted from the merging of LEVO-CTS and LICORN databases. Seventy-two patients were dead at day 90. The mortality at day 90 was not different between levosimendan and placebo (Hazard Ratio (HR): 0.73, 95% CI: 0.41-1.28, p = 0.27). However, there was a significant interaction between the type of surgery and the study drug (p = 0.004). We observed a decrease in mortality at day 90 in the isolated CABG subgroup (HR: 0.39, 95% CI: 0.19-0.82, p = 0.013), but not in the combined surgery subgroup (HR: 1.73, 95% CI: 0.77-3.92, p = 0.19). The meta-analysis of 6 RCT involving 1441 patients confirmed the differential effect on mortality at day 30 between the 2 subgroups. CONCLUSIONS Preoperative levosimendan did not reduce mortality in a mixed surgical population with LV dysfunction. However, the subgroup of patients undergoing isolated CABG had a reduction in mortality at day 90, whereas there was no significant effect in combined surgery patients. This finding requires confirmation with a specific prospective trial.
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Affiliation(s)
- Thibaut Caruba
- AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France
| | | | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Rajendra H Mehta
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Matthias Heringlake
- Dept. of Anaesthesiology and Intensive Care Medicine, Heart- and Diabetes Center, Karlsburg, Germany
| | | | - Amelie Yavchitz
- AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France
| | - Brigitte Sabatier
- AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France; Inserm UMR_1138, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris Cité, F-75006 Paris, France and Inria, HeKA, PariSantéCampus, Paris, France
| | - Gilles Chatellier
- AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France; Université de Paris, F-75006 Paris, France
| | - Bernard Cholley
- AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France; Université de Paris, INSERM UMR_S 1140 "Innovations Thérapeutiques en Hémostase", F-75006 Paris, France.
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Fakher M, Aboelghet M, Moharam A, Khaled M, Abdelaziz A. The Role of Perioperative Levosimendan in Patients with Reduced Ejection Fraction undergoing Cardiac surgery in Reducing Post-operative Hemodynamic Support. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Acute perioperative left ventricular dysfunction is a major complication affecting patients subjected to cardiac surgery and is associated with increased mortality. Levosimendan as a “calcium sensitizers” with inodilator effect improves myocardial contractility by sensitizing troponin C to calcium without increasing myocardial oxygen consumption and without impairing relaxation and diastolic function.
AIM: The aim of this study was to evaluate the effect of perioperative levosimendan compared to the conventional management used in the patient with poor left ventricular function undergoing cardiac surgery to reduce the need of post-operative pharmacological and mechanical circulatory support.
METHODS: It is prospective observational studies were patients undergoing cardiac surgery divided into two groups of 25 patients each. The first group received conventional management while the other group received levosimendan additionally duration and type of post-operative pharmacological support, duration of mechanical ventilation, durations of ICU and hospital stays, and major outcomes, and data about the need of mechanical support were collected.
RESULTS: In the levosimendan, fewer patients required vasoactive agents post-surgery (Noradrenaline) compared to the conventional group, yet the use of inotropic support (adrenaline) in the 2nd day and the need of mechanical circulatory support was equal in both groups. The mortality was equal in both groups.
CONCLUSION: Perioperative levosimendan may reduce the need of vasoactive agents postoperatively, but it does not reduce the need of inotropic nor mechanical support.
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Xie W, Li D, Shi Y, Yu N, Yan Y, Zhang Y, Yu Q, Li Y, Du J, Lin Z, Wu F. Serum FGF21 Levels Predict the MACE in Patients With Myocardial Infarction After Coronary Artery Bypass Graft Surgery. Front Cardiovasc Med 2022; 9:850517. [PMID: 35463746 PMCID: PMC9020287 DOI: 10.3389/fcvm.2022.850517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/09/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesPrognosis evaluation in myocardial infarction (MI) patients with major adverse clinical events (MACE) who have undergone coronary artery bypass graft (CABG) is greatly important to identify high-risk patients. Elevated metabolic hormone fibroblast growth factor 21 (FGF21) is associated with the risk of MI. The aim of this study is to assess the relationship between FGF21 and the incidence of MACE in patients with MI after CABG surgery.MethodsPatients with three-vessel disease who were scheduled for first-time isolated CABG were enrolled in this project and underwent to evaluate the incidence of MACE during 48 h after CABG surgery, as well as to collect serum samples for FGF21 levels in both preoperative- and postoperative-CABG (pre-CABG and post-CABG).ResultsA total of 265 patients with MI undergoing CABG were enrolled in this study, 21 patients experienced MACE during the 48 h after CAGB surgery. Serum FGF21 levels of patients with MACE at post-CABG were significantly higher than that in patients without MACE [553.7 (433.6) vs. 291.7 (334.4), p < 0.001]. Furthermore, among 81 individuals of these 265 patients, a lower level of FGF21 in preoperative-CABG (pre-CABG) and a higher level of FGF21 at postoperative-CABG (post-CABG) were observed in MI patients with MACE as compared to those without MACE respectively [ (275.0 (260.4) vs. 410.3 (420.7), p = 0.049; 550.7 (519.9) vs. 370.6 (441.2), p = 0.031]. In addition, serum FGF21 levels of MI patients with MACE at post-CABG were significantly increased compared with the baseline levels in pre-CABG [550.7 (519.9) vs.275.0 (260.4) p < 0.001]. However, these profiles were not observed in patients without MACE [410.3 (420.7) vs. 370.6 (441.2), p=0.2137]. Logistic regression analysis demonstrated that both serum FGF21 and CK-MB levels at post-CABG were independently associated with the incidence of MACE in patients with MI after CABG surgery. Finally, ROC analysis for FGF21 levels of 265 MI patients at post-CABG identified 455.4 pg/ml as an optimal cut-off value to predict MACE, with a sensitivity and specificity of 91.7 and 68.4% respectively.ConclusionSerum FGF21 levels at post-CABG are independently associated with the incidence of MACE in patients with MI who have undergone CABG. Measurement of FGF21 may help distinguish patients with MI at a high risk of MACE after CABG surgery.
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Affiliation(s)
- Wei Xie
- School of Pharmaceutical College, Wenzhou Medical University, Wenzhou, China
| | - Dan Li
- School of Pharmaceutical College, Wenzhou Medical University, Wenzhou, China
| | - Yaru Shi
- School of Pharmaceutical College, Wenzhou Medical University, Wenzhou, China
| | - Ning Yu
- School of Pharmaceutical College, Wenzhou Medical University, Wenzhou, China
| | - Yu Yan
- The 2nd Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yingchao Zhang
- School of Pharmaceutical College, Wenzhou Medical University, Wenzhou, China
| | - Qiongli Yu
- School of Pharmaceutical College, Wenzhou Medical University, Wenzhou, China
| | - Yulin Li
- Beijing Anzhen Hospital of Capital Medical University, Beijing, China
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Jie Du
- The 2nd Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
- Beijing Anzhen Hospital of Capital Medical University, Beijing, China
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
- Jie Du
| | - Zhuofeng Lin
- School of Pharmaceutical College, Wenzhou Medical University, Wenzhou, China
- Zhuofeng Lin
| | - Fan Wu
- School of Pharmaceutical College, Wenzhou Medical University, Wenzhou, China
- *Correspondence: Fan Wu
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Abstract
Variants in >12 genes encoding sarcomeric proteins can cause various cardiomyopathies. The two most common are hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM). Current therapeutics do not target the root causes of these diseases, but attempt to prevent disease progression and/or to manage symptoms. Accordingly, novel approaches are being developed to treat the cardiac muscle dysfunction directly. Challenges to developing therapeutics for these diseases include the diverse mechanisms of pathogenesis, some of which are still being debated and defined. Four small molecules that modulate the myosin motor protein in the cardiac sarcomere have shown great promise in the settings of HCM and DCM, regardless of the underlying genetic pathogenesis, and similar approaches are being developed to target other components of the sarcomere. In the setting of HCM, mavacamten and aficamten bind to the myosin motor and decrease the ATPase activity of myosin. In the setting of DCM, omecamtiv mecarbil and danicamtiv increase myosin activity in cardiac muscle (but omecamtiv mecarbil decreases myosin activity in vitro). In this Review, we discuss the therapeutic strategies to alter sarcomere contractile activity and summarize the data indicating that targeting one protein in the sarcomere can be effective in treating patients with genetic variants in other sarcomeric proteins, as well as in patients with non-sarcomere-based disease.
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Zhou S, Diehl R, Sessler DI, Liang C, Mascha EJ, Soltesz EG, Duncan AE. Procedure-Specific Relationships Between Postoperative Troponin T and a Composite of Mortality and Low Cardiac Output Syndrome: A Retrospective Cohort Analysis. Anesth Analg 2022; 134:1260-1269. [PMID: 35110515 DOI: 10.1213/ane.0000000000005850] [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]
Abstract
BACKGROUND Myocardial injury after coronary artery bypass grafting (CABG) is defined as troponin concentrations >10 times 99th percentile upper reference limit (URL) according to the Fourth Universal Definition. However, troponin concentrations after non-CABG cardiac surgery which indicate greater-than-expected myocardial injury and increased risk for complications remain unclear. Our goal was to assess procedure-specific relationships between troponin T and a composite outcome of low cardiac output syndrome and in-hospital mortality in cardiac surgical patients. METHODS Patients having cardiac surgery between January 2010 and December 2017 were categorized into 4 groups by procedure: (1) CABG; (2) mitral valve repair; (3) aortic valve repair/replacement (AVR); (4) mitral valve replacement (MVR) or CABG + valve surgeries. Exclusion criteria were elevated preoperative troponin T, preoperative kidney failure, circulatory arrest, or preoperative/planned mechanical circulatory support. Logistic regression was used to assess the association between troponin T and composite outcome, both overall and by procedure, including assessment of the interaction between procedure and troponin T on outcome. RESULTS Among 10,253 patients, 37 (0.4%) died and 393 (3.8%) developed the primary outcome. Troponin T concentrations differed by procedure (P < .001). Compared to CABG, AVR had 0.53 (99.2% confidence interval [CI], 0.50-0.56; unadjusted P < .001) times lower troponin T concentrations, while MVR/CABG + valve were 1.54 (99.2% CI, 1.45-1.62, unadjusted P < .001) times higher. There were linear relationships between log2 troponin T concentration and log odds mortality/low cardiac output syndrome. The (unadjusted) relationships were parallel for various types of surgery (interaction P = .59), but at different levels of the outcome. CONCLUSIONS The relative increase in odds for mortality/low cardiac output syndrome per a similar increase in troponin T concentrations did not differ among cardiac surgical procedures, but the absolute troponin T concentrations did. Troponin concentrations should thus be interpreted in context of surgical procedure.
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Affiliation(s)
- Shan Zhou
- From the Department of Cardiothoracic Anesthesiology
| | - Rachel Diehl
- From the Department of Cardiothoracic Anesthesiology
| | | | - Chen Liang
- Department of Outcomes Research.,Department of Quantitative Health Sciences
| | - Edward J Mascha
- Department of Outcomes Research.,Department of Quantitative Health Sciences
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Andra E Duncan
- From the Department of Cardiothoracic Anesthesiology.,Department of Outcomes Research
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Reiterer C, Kabon B, Taschner A, Adamowitsch N, Graf A, Fraunschiel M, Horvath K, Kuhrn M, Clement T, Treskatsch S, Berger C, Fleischmann E. Effect of perioperative levosimendan administration on postoperative N-terminal pro-B-type natriuretic peptide concentration in patients with increased cardiovascular risk factors undergoing non-cardiac surgery: protocol for the double-blind, randomised, placebo-controlled IMPROVE trial. BMJ Open 2022; 12:e058216. [PMID: 35063963 PMCID: PMC8785196 DOI: 10.1136/bmjopen-2021-058216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Elevated N-terminal pro-brain natriuretic peptide (NT-pro-BNP) after non-cardiac surgery is a strong predictor for cardiovascular complications and reflects increased myocardial strain. NT-pro-BNP concentrations significantly rise after non-cardiac surgery within the first 3 days. Levosimendan is a potent inotropic drug that increases calcium sensitivity to cardiac myocytes, which results in improved cardiac contractility that last for approximately 7 days. Thus, we will test the effect of a pre-emptive perioperative administration of levosimendan on postoperative NT-pro-BNP concentration as compared with the administration of a placebo in patients undergoing moderate-risk to high-risk major abdominal surgery. METHODS AND ANALYSIS We will conduct a double-blinded prospective randomised trial at the Medical University of Vienna, Vienna, Austria (and potentially a second centre in Germany), including 230 patients at-risk for cardiovascular complications undergoing moderate- to high-risk major abdominal surgery. Patients will be randomly assigned to receive a single dose of 12.5 mg levosimendan versus placebo after induction of anaesthesia. The primary outcome will be the postoperative maximum NT-pro-BNP concentration between both group within the first three postoperative days. Our secondary outcomes will be the incidence of myocardial ischaemia, myocardial injury after non-cardiac surgery and a composite of myocardial infarction and death within 30 days and 1 year after surgery between both groups. Our further secondary outcome will be stratification of NT-pro-BNP values according to previously thresholds to predict mortality of myocardial infarction after surgery. ETHICS AND DISSEMINATION The study was approved by the Ethics Committee of the Medical University of Vienna on 14 July 2020 (EK 2187/2019). Written informed consent will be obtained from all patients a day before surgery. Results of this study will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04329624.
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Affiliation(s)
- Christian Reiterer
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Outcome Research Consortium, Cleveland, Ohio, USA
| | - Barbara Kabon
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Alexander Taschner
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Nikolas Adamowitsch
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Alexandra Graf
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Wien, Austria
| | - Melanie Fraunschiel
- ITSC - IT Systems & Communications, Medical University of Vienna, Wien, Austria
| | - Katharina Horvath
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Melanie Kuhrn
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Theresa Clement
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Christian Berger
- Department of Anesthesiology and Intensive Care Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Edith Fleischmann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Outcome Research Consortium, Cleveland, Ohio, USA
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6548865. [DOI: 10.1093/ejcts/ezac168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 02/24/2022] [Accepted: 02/24/2022] [Indexed: 11/14/2022] Open
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Abstract
Rationale & Objective Adaptive design methods are intended to improve the efficiency of clinical trials and are relevant to evaluating interventions in dialysis populations. We sought to determine the use of adaptive designs in dialysis clinical trials and quantify trends in their use over time. Study Design We completed a novel full-text systematic review that used a machine learning classifier (RobotSearch) for filtering randomized controlled trials and adhered to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Setting & Study Populations We searched MEDLINE (PubMed) and ClinicalTrials.gov using sensitive dialysis search terms. Selection Criteria for Studies We included all randomized clinical trials with patients receiving dialysis or clinical trials with dialysis as a primary or secondary outcome. There was no restriction of disease type or intervention type. Data Extraction & Analytical Approach We performed a detailed data extraction of trial characteristics and a completed a narrative synthesis of the data. Results 57 studies, available as 68 articles and 7 ClinicalTrials.gov summaries, were included after full-text review (initial search, 209,033 PubMed abstracts and 6,002 ClinicalTrials.gov summaries). 31 studies were conducted in a dialysis population and 26 studies included dialysis as a primary or secondary outcome. Although the absolute number of adaptive design methods is increasing over time, the relative use of adaptive design methods in dialysis trials is decreasing over time (6.12% in 2009 to 0.43% in 2019, with a mean of 1.82%). Group sequential designs were the most common type of adaptive design method used. Adaptive design methods affected the conduct of 50.9% of trials, most commonly resulting in stopping early for futility (41.2%) and early stopping for safety (23.5%). Acute kidney injury was studied in 32 trials (56.1%), kidney failure requiring dialysis was studied in 24 trials (42.1%), and chronic kidney disease was studied in 1 trial (1.75%). 27 studies (47.4%) were supported by public funding. 44 studies (77.2%) did not report their adaptive design method in the title or abstract and would not be detected by a standard systematic review. Limitations We limited our search to 2 databases (PubMed and ClinicalTrials.gov) due to the scale of studies sourced (209,033 and 6,002 results, respectively). Conclusions Adaptive design methods are used in dialysis trials but there has been a decline in their relative use over time.
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CSA-AKI: Incidence, Epidemiology, Clinical Outcomes, and Economic Impact. J Clin Med 2021; 10:jcm10245746. [PMID: 34945041 PMCID: PMC8706363 DOI: 10.3390/jcm10245746] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/01/2021] [Accepted: 12/05/2021] [Indexed: 12/13/2022] Open
Abstract
Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication following cardiac surgery and reflects a complex biological combination of patient pathology, perioperative stress, and medical management. Current diagnostic criteria, though increasingly standardized, are predicated on loss of renal function (as measured by functional biomarkers of the kidney). The addition of new diagnostic injury biomarkers to clinical practice has shown promise in identifying patients at risk of renal injury earlier in their course. The accurate and timely identification of a high-risk population may allow for bundled interventions to prevent the development of CSA-AKI, but further validation of these interventions is necessary. Once the diagnosis of CSA-AKI is established, evidence-based treatment is limited to supportive care. The cost of CSA-AKI is difficult to accurately estimate, given the diverse ways in which it impacts patient outcomes, from ICU length of stay to post-hospital rehabilitation to progression to CKD and ESRD. However, with the global rise in cardiac surgery volume, these costs are large and growing.
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Sheng W, Qiao H, Niu Z, Wang T, Li H, Zhang W, Wu J, Lv X. Prospective Study on the Postoperative Use of Levosimendan After Conventional Heart Valve Replacement. Med Sci Monit 2021; 27:e932001. [PMID: 34588413 PMCID: PMC8491556 DOI: 10.12659/msm.932001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background The aim of this study was to explore the effect of levosimendan in patients after heart valve replacement and its influence on postoperative recovery. Material/Methods This prospective study included 185 patients with valvular diseases undergoing conventional valve replacement. Patients were divided into 2 groups using a random number table before surgery. Patients in the levosimendan group were administrated levosimendan intravenous infusion immediately after entering the Intensive Care Unit (ICU). The left ventricular ejection fraction (LVEF), cardiac output, and heart failure-related index, such as B-type natriuretic peptide (BNP) level, were recorded at 1, 3, and 7 days after surgery. The dosage and administration time of dopamine and epinephrine, mechanical ventilation time, ICU length of stay, and postoperative adverse events were recorded. Results Cardiac output and LVEF of patients in the levosimendan group were significantly higher than those in the control group at different time points (P<0.05), and BNP level was lower than that of the control group (P<0.0001). Dosage and administration time of dopamine and epinephrine in the levosimendan group were lower than those of the control group (P<0.0001, P<0.0001, respectively). ICU length of stay and total incidence of postoperative adverse events were lower than those of the control group (P<0.0001, P=0.002, respectively). Conclusions Levosimendan administration immediately after heart valve replacement effectively improved the heart function of patients, reduced administration of vasoactive drugs, shortened length of ICU stay, reduced incidence of postoperative adverse events, and promoted recovery of patients after surgery.
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Affiliation(s)
- Wei Sheng
- Department of Cardiovascular Surgery, Qingdao Municipal Hospital, Medical College of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Hui Qiao
- Department of Cardiovascular Surgery, Qingdao Municipal Hospital, Medical College of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Zhaozhuo Niu
- Department of Cardiovascular Surgery, Qingdao Municipal Hospital, Medical College of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Tianyi Wang
- Department of Cardiovascular Surgery, Qingdao Municipal Hospital, Medical College of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Haoyou Li
- Department of Cardiovascular Surgery, Qingdao Municipal Hospital, Medical College of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Wenfeng Zhang
- Department of Cardiovascular Surgery, Qingdao Municipal Hospital, Medical College of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Jiantao Wu
- Department of Cardiovascular Surgery, Qingdao Municipal Hospital, Medical College of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Xiao Lv
- Department of Cardiovascular Surgery, Qingdao Municipal Hospital, Medical College of Qingdao University, Qingdao, Shandong, China (mainland)
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Thiele H, de Waha-Thiele S, Freund A, Zeymer U, Desch S, Fitzgerald S. Management of cardiogenic shock. EUROINTERVENTION 2021; 17:451-465. [PMID: 34413010 PMCID: PMC9724885 DOI: 10.4244/eij-d-20-01296] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Despite the rapidly evolving evidence base in modern cardiology, progress in the area of cardiogenic shock remains slow, with short-term mortality still reaching 40-50%, relatively unchanged in recent years. Despite advances with an increase in the number of clinical trials taking place in this admittedly difficult-to-study area, the evidence base on which we make day-to-day decisions in clinical practice remains relatively sparse. With only definitive evidence for early revascularisation and the relative ineffectiveness of intra-aortic balloon pumping, most aspects of patient management are based on expert consensus, rather than randomised controlled trials. This updated 2020 review will outline the management of CS mainly after acute myocardial infarction with major focus on state-of-the-art treatment based on randomised clinical trials or matched comparisons if available.
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Affiliation(s)
- Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology, Strümpellstr. 39, 04289 Leipzig, Germany
| | | | - Anne Freund
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany,Leipzig Heart Institute, Leipzig, Germany
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Steffen Desch
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany,Leipzig Heart Institute, Leipzig, Germany
| | - Sean Fitzgerald
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
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Conti N, Gatti M, Raschi E, Diemberger I, Potena L. Evidence and Current Use of Levosimendan in the Treatment of Heart Failure: Filling the Gap. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:3391-3409. [PMID: 34376973 PMCID: PMC8350150 DOI: 10.2147/dddt.s295214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/22/2021] [Indexed: 12/14/2022]
Abstract
Levosimendan is a distinctive inodilator combing calcium sensitization, phosphodiesterase inhibition and vasodilating properties through the opening of adenosine triphosphate-dependent potassium channels. It was first approved in Sweden in 2000 for the short-term treatment of acutely decompensated severe chronic heart failure when conventional therapy is not sufficient, and in cases where inotropic support is considered appropriate. After more than 20 years, clinical applications have considerably expanded across critical care and emergency medicine, and levosimendan is now under investigation in different cardiac settings (eg, septic shock, pulmonary hypertension) and for non-cardiac applications (eg, amyotrophic lateral sclerosis). This narrative review outlines key milestones in levosimendan history, by addressing regulatory issues, pharmacological peculiarities and clinical aspects (efficacy and safety) of a drug that did not receive great attention in the heart failure guidelines. A brief outlook to the ongoing clinical trials is also offered.
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Affiliation(s)
- Nicolina Conti
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Milo Gatti
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy.,SSD Clinical Pharmacology, IRCSS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Igor Diemberger
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum - University of Bologna, Bologna, Italy.,Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luciano Potena
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Ellouze O, Soudry Faure A, Radhouani M, Abou‐Arab O, Besnier E, Moussa M, Cransac A, Ksiazek E, Fischer M, Mertes PM, Bouhemad B, Guinot PG. Levosimendan in venoarterial ECMO weaning. Rational and design of a randomized double blind multicentre trial. ESC Heart Fail 2021; 8:3339-3347. [PMID: 34145993 PMCID: PMC8318420 DOI: 10.1002/ehf2.13427] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 04/25/2021] [Accepted: 05/02/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used in circulatory failure. The main indications are cardiogenic shock, post-cardiotomy cardiac failure, and refractory cardiac arrest. However, VA-ECMO weaning is particularly challenging, and weaning failure is reported to be as high as 50%, with increased related mortality. Levosimendan is a novel long acting effect inodilator used in cardiogenic shock and terminal heart failure decompensation. Levosimendan use in VA-ECMO patients seems to reduce weaning failure regardless of the initial aetiology and to reduce mortality when administrated early after VA-ECMO initiation. However, studies are limited to retrospective analyses and reported case series. The aim of the WEANILEVO trial is to evaluate whether administration of levosimendan before VA-ECMO weaning is associated with a reduced rates of weaning failure and recourse to other temporary circulatory support. METHODS AND RESULTS WEANILEVO is a randomized, prospective, multicentre, double-blind, parallel-group, controlled trial. One hundred eighty patients will be enrolled if they had acute circulatory heart failure treated with VA-ECMO and for whom weaning is expected within 48 h. The study drugs are either levosimendan (0.2 μg/kg/min for 24 h) or a placebo. The primary endpoint of the trial is the absence of VA-ECMO weaning, recourse to another VA-ECMO, or other temporary circulatory assistance or death within 7 days of VA-ECMO weaning. CONCLUSIONS Levosimendan use in VA-ECMO appears to be beneficial for reducing weaning failure and mortality. The results of WEANILEVO should significantly influence decisions regarding the use of levosimendan for VA-ECMO weaning.
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Affiliation(s)
- Omar Ellouze
- Department of Anesthesia and Critical CareUniversity Hospital of DijonDijonFrance
| | | | - Mohamed Radhouani
- Department of Anesthesia and Critical CareUniversity Hospital of DijonDijonFrance
| | - Osama Abou‐Arab
- Department of Anesthesia and Critical CareUniversity Hospital of AmiensAmiensFrance
| | - Emmanuel Besnier
- Department of Anesthesia and Critical CareUniversity Hospital of RouenRouenFrance
| | - Mouhamed Moussa
- Department of Anesthesia and Critical CareUniversity Hospital of LilleLilleFrance
| | - Amélie Cransac
- Department of PharmacyUniversity Hospital of DijonDijonFrance
| | - Elea Ksiazek
- Direction of Clinical ResearchUniversity Hospital of DijonDijonFrance
| | | | - Paul Michel Mertes
- Department of Anesthesia and Critical CareUniversity Hospital of StrasbourgStrasbourgFrance
| | - Belaid Bouhemad
- Department of Anesthesia and Critical CareUniversity Hospital of DijonDijonFrance
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