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Efremov S, Zagatina A, Filippov A, Ryadinskiy M, Novikov M, Shmatov D. Left Ventricular Diastolic Dysfunction in Cardiac Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2024; 38:2459-2470. [PMID: 39069379 DOI: 10.1053/j.jvca.2024.06.042] [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: 05/04/2024] [Revised: 06/19/2024] [Accepted: 06/27/2024] [Indexed: 07/30/2024]
Abstract
Cardiac relaxation is a complex process that involves various interconnected characteristics and, along with contractile properties, determines stroke volume. Perioperative ischemia-reperfusion injury and left ventricular diastolic dysfunction (DD) are characterized by the left ventricle's inability to receive a sufficient blood volume under adequate preload. Baseline DD and perioperative DD have an impact on postoperative complications, length of hospital stay, and major clinical outcomes in a variety of cardiac pathologies. Several baseline and perioperative factors, such as age, female sex, hypertension, left ventricle hypertrophy, diabetes, and perioperative ischemia-reperfusion injury, contribute to the risk of DD. The recommended diagnostic criteria available in guidelines have not been validated in the perioperative settings and still need clarification. Timely diagnosis of DD might be crucial for effectively treating postoperative low cardiac output syndrome. This implies the need for an individualized approach to fluid infusion strategy, cardiac rate and rhythm control, identification of extrinsic causes, and administration of drugs with lusitropic effects. The purpose of this review is to consolidate scattered information on various aspects of diastolic dysfunction in cardiac surgery and provide readers with well-organized and clinically applicable information.
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Affiliation(s)
- Sergey Efremov
- Saint-Petersburg State University Hospital, Saint-Petersburg, Russian Federation.
| | - Angela Zagatina
- Cardiology Department, Research Cardiology Center "Medika", Saint Petersburg, Russian Federation
| | - Alexey Filippov
- Saint-Petersburg State University Hospital, Saint-Petersburg, Russian Federation
| | - Mikhail Ryadinskiy
- Saint-Petersburg State University Hospital, Saint-Petersburg, Russian Federation
| | - Maxim Novikov
- Saint-Petersburg State University Hospital, Saint-Petersburg, Russian Federation
| | - Dmitry Shmatov
- Saint-Petersburg State University Hospital, Saint-Petersburg, Russian Federation
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Sanfilippo F, Messina A, Scolletta S, Bignami E, Morelli A, Cecconi M, Landoni G, Romagnoli S. The "CHEOPS" bundle for the management of Left Ventricular Diastolic Dysfunction in critically ill patients: an experts' opinion. Anaesth Crit Care Pain Med 2023; 42:101283. [PMID: 37516408 DOI: 10.1016/j.accpm.2023.101283] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
The impact of left ventricular (LV) diastolic dysfunction (DD) on the outcome of patients with heart failure was established over three decades ago. Nevertheless, the relevance of LVDD for critically ill patients admitted to the intensive care unit has seen growing interest recently, and LVDD is associated with poor prognosis. Whilst an assessment of LV diastolic function is desirable in critically ill patients, treatment options for LVDD are very limited, and pharmacological possibilities to rapidly optimize diastolic function have not been found yet. Hence, a proactive approach might have a substantial role in improving the outcomes of these patients. Recalling historical Egyptian parallelism suggesting that Doppler echocardiography has been the "Rosetta stone" to decipher the study of LV diastolic function, we developed a potentially useful acronym for physicians at the bedside to optimize the management of critically ill patients with LVDD with the application of the bundle. We summarized the bundle under the acronym of the famous ancient Egyptian pharaoh CHEOPS: Chest Ultrasound, combining information from echocardiography and lung ultrasound; HEmodynamics assessment, with careful evaluation of heart rate and rhythm, as well as afterload and vasoactive drugs; OPtimization of mechanical ventilation and pulmonary circulation, considering the effects of positive end-expiratory pressure on both right and left heart function; Stabilization, with cautious fluid administration and prompt fluid removal whenever judged safe and valuable. Notably, the CHEOPS bundle represents experts' opinion and are not targeted at the initial resuscitation phase but rather for the optimization and subsequent period of critical illness.
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Affiliation(s)
- Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Catania, Italy; Department of General Surgery and Medico-Surgical Specialties, School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy.
| | - Antonio Messina
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, 20089, Rozzano, Milan, Italy.
| | - Sabino Scolletta
- Anesthesia and Intensive Care Unit, University Hospital of Siena, University of Siena, Siena, Italy.
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Andrea Morelli
- Department Clinical Internal, Anesthesiological and Cardiovascular Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Roma, Italy.
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, 20089, Rozzano, Milan, Italy.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| | - Stefano Romagnoli
- Department of Health Science, Section of Anaesthesia and Intensive Care, University of Florence, Department of Anetshesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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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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Yao YT, He LX, Zhao YY. The effect of levosimendan on postoperative bleeding and blood transfusion in cardiac surgical patients: a PRISMA-compliant systematic review and meta-analysis. Perfusion 2020; 36:694-703. [PMID: 33070760 DOI: 10.1177/0267659120963909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Levosimendan (LEVO), is an inotropic agent which has been shown to be associated with better myocardial performance, and higher survival rate in cardiac surgical patients. However, preliminary clinical evidence suggested that LEVO increased the risk of post-operative bleeding in patients undergoing valve surgery. Currently, there has been no randomized controlled trials (RCTs) designed specifically on this issue. Therefore, we performed present systemic review and meta-analysis. METHODS Electronic databases were searched to identify all RCTs comparing LEVO with Control (placebo, blank, dobutamine, milrinone, etc). Primary outcomes include post-operative blood loss and re-operation for bleeding. Secondary outcomes included post-operative transfusion of red blood cells (RBC), fresh frozen plasma (FFP) and platelet concentrates (PC). For continuous variables, treatment effects were calculated as weighted mean difference (WMD) and 95% confidential interval (CI). For dichotomous data, treatment effects were calculated as odds ratio (OR) and 95% CI. RESULTS Search yielded 15 studies including 1,528 patients. Meta-analysis suggested that, LEVO administration was not associated with increased risk of reoperation for bleeding post-operatively (OR = 1.01; 95%CI: 0.57 to 1.79; p = 0.97) and more blood loss volume (WMD = 28.25; 95%CI: -19.21 to 75.72; p = 0.24). Meta-analysis also demonstrated that, LEVO administration did not increase post-operative transfusion requirement for RBC (rate: OR = 0.97; 95%CI: 0.72 to 1.30; p = 0.83 and volume: WMD = 0.34; 95%CI: -0.55 to 1.22; p = 0.46), FFP (volume: WMD = 0.00; 95%CI: -0.10 to 0.10; p = 1.00) and PC (rate: OR = 1.01; 95%CI: 0.41 to 2.50; p = 0.98 and volume: WMD = 0.00; 95%CI: -0.05 to 0.04; p = 0.95). CONCLUSION This meta-analysis suggested that, peri-operative administration of LEVO was not associated with increased risks of post-operative bleeding and blood transfusion requirement in cardiac surgical patients.
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Affiliation(s)
- Yun-Tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Li-Xian He
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuan-Yuan Zhao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Yan SB, Wang XY, Shang GK, Wang ZH, Deng QM, Song JW, Sai WW, Song M, Zhong M, Zhang W. Impact of Perioperative Levosimendan Administration on Risk of Bleeding After Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials. Am J Cardiovasc Drugs 2020; 20:149-160. [PMID: 31523760 DOI: 10.1007/s40256-019-00372-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Levosimendan, a calcium sensitizer and potassium channel opener, has been demonstrated to improve myocardial function without increasing oxygen consumption and to show protective effects in other organs. Recently, a prospective, randomized controlled trial (RCT) revealed an association between levosimendan use and a possible increased risk of bleeding postoperatively. Levosimendan's anti-platelet effects have been shown in in vitro studies. Current studies do not provide sufficient data to support a relation between perioperative levosimendan administration and increased bleeding risk. PURPOSE Our goal was to investigate the relation between perioperative levosimendan administration and increased bleeding risk using a meta-analysis study design. METHODS The PubMed, Ovid, EMBASE and Cochrane Library databases were searched for relevant RCTs before July 1, 2019. The outcome parameters included reoperation secondary to increased bleeding in the postoperative period, the amount of postoperative recorded blood loss, and the need for transfusion of packed red blood cells (RBCs) and other blood products. RESULTS A total of 1160 patients in nine RCTs (576 in the levosimendan group and 584 in the control group) were included according to our inclusion criteria. Analysis showed that perioperative levosimendan administration neither increased the rate of reoperation secondary to bleeding nor increased the amount of postoperative chest tube drainage when compared with the control group. In terms of blood product transfusion, levosimendan did not influence the requirement for RBC transfusion, platelet transfusion nor fresh frozen plasma (FFP) transfusion. Levosimendan also did not shorten or prolong the aortic cross-clamp time or the cardiopulmonary bypass time. CONCLUSION The analyzed parameters, including reoperations due to bleeding, postoperative chest drainage and the requirement for blood products, revealed that levosimendan did not increase postoperative bleeding risk. More studies with a larger sample size are needed to address a more reliable conclusion due to study limitations.
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Affiliation(s)
- Sen-Bo Yan
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China
| | - Xiao-Yan Wang
- Department of Pharmacy, Qilu Children's Hospital of Shandong University, Children's Hospital of Jinan, Jinan, Shandong, China
| | - Guo-Kai Shang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China
| | - Zhi-Hao Wang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Key Laboratory of Cardiovascular Proteomics of Shandong Province, Jinan, Shandong, China
| | - Qi-Ming Deng
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China
| | - Jia-Wen Song
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China
| | - Wen-Wen Sai
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China
| | - Ming Song
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China
| | - Ming Zhong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China
| | - Wei Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, China.
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Model-Based Quantification of Left Ventricular Diastolic Function in Critically Ill Patients with Atrial Fibrillation from Routine Data: A Feasibility Study. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2019; 2019:9682138. [PMID: 31223333 PMCID: PMC6541946 DOI: 10.1155/2019/9682138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 03/17/2019] [Indexed: 12/16/2022]
Abstract
Introduction Left ventricular diastolic dysfunction (LVDD) and atrial fibrillation (AF) are connected by pathophysiology and prevalence. LVDD remains underdiagnosed in critically ill patients despite potentially significant therapeutic implications since direct measurement cannot be performed in routine care at the bedside, and echocardiographic assessment of LVDD in AF is impaired. We propose a novel approach that allows us to infer the diastolic stiffness, β, a key quantitative parameter of diastolic function, from standard monitoring data by solving the nonlinear, ill-posed inverse problem of parameter estimation for a previously described mechanistic, physiological model of diastolic filling. The beat-to-beat variability in AF offers an advantageous setting for this. Methods By employing a global optimization algorithm, β is inferred from a simple six parameter and an expanded seven parameter model of left ventricular filling. Optimization of all parameters was limited to the interval ]0, 400[ and initialized randomly on large intervals encompassing the support of the likelihood function. Routine ECG and arterial pressure recordings of 17 AF and 3 sinus rhythm (SR) patients from the PhysioNet MGH/MF Database were used as inputs. Results Estimation was successful in 15 of 17 AF patients, while in the 3 SR patients, no reliable estimation was possible. For both models, the inferred β (0.065 ± 0.044 ml−1 vs. 0.038 ± 0.033 ml−1 (p=0.02) simple vs. expanded) was compatible with the previously described (patho) physiological range. Aortic compliance, α, inferred from the expanded model (1.46 ± 1.50 ml/mmHg) also compared well with literature values. Conclusion The proposed approach successfully inferred β within the physiological range. This is the first report of an approach quantifying LVDF from routine monitoring data in critically ill AF patients. Provided future successful external validation, this approach may offer a tool for minimally invasive online monitoring of this crucial parameter.
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Oldach MS, Ueda Y, Ontiveros ES, Fousse SL, Harris SP, Stern JA. Cardiac Effects of a Single Dose of Pimobendan in Cats With Hypertrophic Cardiomyopathy; A Randomized, Placebo-Controlled, Crossover Study. Front Vet Sci 2019. [PMID: 30778391 DOI: 10.3389/fvets.2019.00015.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Pimobendan has been shown to impart a significant survival benefit in cardiomyopathic cats who receive it as part of heart failure therapy. However, use of pimobendan remains controversial in cats with hypertrophic cardiomyopathy (HCM) due to lack of pharmacodynamic data for pimobendan in cats with HCM and due to theoretical concerns for exacerbating left ventricular outflow tract obstructions. Hypothesis/Objectives: Our objective was to investigate the cardiac effects of pimobendan in cats with HCM. We hypothesized that pimobendan would not exacerbate left ventricular outflow tract obstructions and that it would improve echocardiographic measures of diastolic function. Animals: Thirteen purpose-bred cats were studied from a research colony with naturally-occurring HCM due to a variant in myosin binding protein C. Methods: Cats underwent two examinations 24 h apart with complete standard echocardiography. On their first day of evaluation, they were randomized to receive oral placebo or 1.25 mg pimobendan 1 h prior to exam. On their second examination, they were crossed over and received the remaining treatment. Investigators were blinded to all treatments. Results: The pimobendan group had a significant increase in left atrial fractional shortening (pimobendan group 41.7% ± 5.9; placebo group 36.1% ± 6.0; p = 0.04). There was no significant difference in left ventricular outflow tract (LVOT) velocities between the groups (pimobendan group 2.8 m/s ± 0.8; placebo group 2.6 m/s ± 1.0). There were no significant differences between the number of cats with LVOT obstructions between groups (12 in pimobendan group; 11 in placebo group; p = 1.00). There were no detectable differences in any systolic measures, including left ventricular fractional shortening, mitral annular plane systolic excursion, and tricuspid annular plane systolic excursion. Doppler-based diastolic function assessment was precluded by persistent tachycardia. Conclusions: Improved left atrial function in the pimobendan group could explain some of the reported survival benefit for HCM cats in CHF. Pimobendan did not exacerbate LVOT obstructions and thus may not be contraindicated in HCM cats with LVOT obstructions. Future studies are needed to better characterize other physiologic effects, particularly regarding diastolic function assessment, and to better assess safety of pimobendan over a longer time-course.
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Affiliation(s)
- Maureen S Oldach
- William R. Prichard Veterinary Medical Teaching Hospital, University of California, Davis, Davis, CA, United States
| | - Yu Ueda
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Eric S Ontiveros
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Samantha L Fousse
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Samantha P Harris
- Department of Cellular and Molecular Medicine, Sarver Heart Center, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Joshua A Stern
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
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Oldach MS, Ueda Y, Ontiveros ES, Fousse SL, Harris SP, Stern JA. Cardiac Effects of a Single Dose of Pimobendan in Cats With Hypertrophic Cardiomyopathy; A Randomized, Placebo-Controlled, Crossover Study. Front Vet Sci 2019; 6:15. [PMID: 30778391 PMCID: PMC6369151 DOI: 10.3389/fvets.2019.00015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 01/16/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Pimobendan has been shown to impart a significant survival benefit in cardiomyopathic cats who receive it as part of heart failure therapy. However, use of pimobendan remains controversial in cats with hypertrophic cardiomyopathy (HCM) due to lack of pharmacodynamic data for pimobendan in cats with HCM and due to theoretical concerns for exacerbating left ventricular outflow tract obstructions. Hypothesis/Objectives: Our objective was to investigate the cardiac effects of pimobendan in cats with HCM. We hypothesized that pimobendan would not exacerbate left ventricular outflow tract obstructions and that it would improve echocardiographic measures of diastolic function. Animals: Thirteen purpose-bred cats were studied from a research colony with naturally-occurring HCM due to a variant in myosin binding protein C. Methods: Cats underwent two examinations 24 h apart with complete standard echocardiography. On their first day of evaluation, they were randomized to receive oral placebo or 1.25 mg pimobendan 1 h prior to exam. On their second examination, they were crossed over and received the remaining treatment. Investigators were blinded to all treatments. Results: The pimobendan group had a significant increase in left atrial fractional shortening (pimobendan group 41.7% ± 5.9; placebo group 36.1% ± 6.0; p = 0.04). There was no significant difference in left ventricular outflow tract (LVOT) velocities between the groups (pimobendan group 2.8 m/s ± 0.8; placebo group 2.6 m/s ± 1.0). There were no significant differences between the number of cats with LVOT obstructions between groups (12 in pimobendan group; 11 in placebo group; p = 1.00). There were no detectable differences in any systolic measures, including left ventricular fractional shortening, mitral annular plane systolic excursion, and tricuspid annular plane systolic excursion. Doppler-based diastolic function assessment was precluded by persistent tachycardia. Conclusions: Improved left atrial function in the pimobendan group could explain some of the reported survival benefit for HCM cats in CHF. Pimobendan did not exacerbate LVOT obstructions and thus may not be contraindicated in HCM cats with LVOT obstructions. Future studies are needed to better characterize other physiologic effects, particularly regarding diastolic function assessment, and to better assess safety of pimobendan over a longer time-course.
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Affiliation(s)
- Maureen S Oldach
- William R. Prichard Veterinary Medical Teaching Hospital, University of California, Davis, Davis, CA, United States
| | - Yu Ueda
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Eric S Ontiveros
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Samantha L Fousse
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Samantha P Harris
- Department of Cellular and Molecular Medicine, Sarver Heart Center, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Joshua A Stern
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
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Sanfilippo F, Scolletta S, Morelli A, Vieillard-Baron A. Practical approach to diastolic dysfunction in light of the new guidelines and clinical applications in the operating room and in the intensive care. Ann Intensive Care 2018; 8:100. [PMID: 30374644 PMCID: PMC6206316 DOI: 10.1186/s13613-018-0447-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 10/20/2018] [Indexed: 12/26/2022] Open
Abstract
There is growing evidence both in the perioperative period and in the field of intensive care (ICU) on the association between left ventricular diastolic dysfunction (LVDD) and worse outcomes in patients. The recent American Society of Echocardiography and European Association of Cardiovascular Imaging joint recommendations have tried to simplify the diagnosis and the grading of LVDD. However, both an often unknown pre-morbid LV diastolic function and the presence of several confounders-i.e., use of vasopressors, positive pressure ventilation, volume loading-make the proposed parameters difficult to interpret, especially in the ICU. Among the proposed parameters for diagnosis and grading of LVDD, the two tissue Doppler imaging-derived variables e' and E/e' seem most reliable. However, these are not devoid of limitations. In the present review, we aim at rationalizing the applicability of the recent recommendations to the perioperative and ICU areas, discussing the clinical meaning and echocardiographic findings of different grades of LVDD, describing the impact of LVDD on patients' outcomes and providing some hints on the management of patients with LVDD.
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Affiliation(s)
- F. Sanfilippo
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - S. Scolletta
- Unit of Intensive Care Medicine, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - A. Morelli
- Department of Anaesthesiology and Intensive Care, University of Rome, “La Sapienza”, Rome, Italy
| | - A. Vieillard-Baron
- Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne, France
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Fredholm M, Jörgensen K, Houltz E, Ricksten SE. Inotropic and lusitropic effects of levosimendan and milrinone assessed by strain echocardiography-A randomised trial. Acta Anaesthesiol Scand 2018; 62:1246-1254. [PMID: 29926912 DOI: 10.1111/aas.13170] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/14/2018] [Accepted: 05/15/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND We compared the direct inotropic and lusitropic effects of two inodilators, milrinone and levosimendan in patients after aortic valve replacement for aortic stenosis. METHODS In this randomised, blinded study, 31 patients with normal LV function, were randomised to either levosimendan (0.1 and 0.2 μg/kg/min, n = 15) or milrinone (0.4 and 0.8 μg/kg/min, n = 16) after aortic valve replacement. The effects on LV performance, LV strain, systolic (SR-S) and early diastolic (SR-E) strain rate were assessed by a pulmonary artery catheter and transoesophageal two-dimensional speckle tracking echocardiography of the LV inferior wall. To circumvent the inodilator-induced hemodynamic changes on LV systolic and diastolic deformation, central venous pressure (CVP), systolic artery pressure (SAP), and heart rate were maintained constant by colloid infusion, phenylephrine-induced vasoconstriction and atrial pacing, respectively, during drug infusion. RESULTS Both inotropic agents induced a dose-dependent increase in cardiac index and stroke volume index by approximately 20% at the highest infusion rates with no differences between groups (P = .139 and .249, respectively). CVP, pulmonary capillary wedge pressure, SAP and heart rate were maintained constant in both groups. LV strain and SR-S increased with both agents, dose-dependently, by 17%-18% and 25%-30%, respectively, at the highest infusion rates, with no difference between groups (P = .434 and .284, respectively). Both agents improved early LV relaxation with no differences between groups (P = .637). At the higher doses, both agents increased SR-E by 30%. CONCLUSIONS At clinically relevant infusion rates and a certain increase in LV performance the direct inotropic and lusitropic of milrinone and levosimendan were comparable.
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Affiliation(s)
- M. Fredholm
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - K. Jörgensen
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - E. Houltz
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - S.-E. Ricksten
- Department of Anesthesiology and Intensive Care Medicine at the Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
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Metkus TS, Suarez-Pierre A, Crawford TC, Lawton JS, Goeddel L, Dodd-O J, Mukherjee M, Abraham TP, Whitman GJ. Diastolic dysfunction is common and predicts outcome after cardiac surgery. J Cardiothorac Surg 2018; 13:67. [PMID: 29903030 PMCID: PMC6003153 DOI: 10.1186/s13019-018-0744-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 05/31/2018] [Indexed: 12/20/2022] Open
Abstract
Background Diastolic dysfunction (DD) identified on echocardiography predicts mortality after cardiac surgery, however the most useful diastolic parameters for assessment and the association of DD with prolonged mechanical ventilation, ICU re-admission, and hospital length of stay are not established. Methods We included patients that underwent coronary artery bypass grafting (CABG), aortic valve replacement (AVR) or a combined procedure (CAB-AVR) from 2010 to 2016, and who had preoperative transthoracic echocardiography (TTE) at our institution within 6 months of the operation. Diastolic function was graded using the transmitral E and A waves and the septal tissue Doppler velocity. We performed logistic regression to assess the association of grade of DD with a composite endpoint of death, prolonged mechanical ventilation, ICU readmission during hospitalization, and hospital length of stay longer than 14 days. Results Between 2010 and 2016, 577 patients were eligible for inclusion. DD was common, with 42% of the cohort manifesting grade II or grade III DD. Rates of death and prolonged ventilation increased across grades of DD and across quartiles of increasing LV filling pressure, assessed by the E/e’ ratio. Adjusting for age, sex, procedure, systolic and diastolic function, both systolic (odds ratio 0.68 95% CI 0.55–0.85 per inter-quartile increase in LVEF) and diastolic function (odds ratio 1.31 95% CI 1.04–1.66 per increasing DD grade) both independently predicted outcome. Conclusion Diastolic dysfunction is common among patients undergoing cardiac surgery and is associated with death, prolonged mechanical ventilation, and prolonged hospital and ICU length of stay independent of systolic dysfunction.
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Affiliation(s)
- Thomas S Metkus
- Division of Cardiology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 524 D2, Baltimore, MD, 21287, USA.
| | - Alejandro Suarez-Pierre
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Todd C Crawford
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lee Goeddel
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeffrey Dodd-O
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Monica Mukherjee
- Division of Cardiology, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 524 D2, Baltimore, MD, 21287, USA
| | - Theodore P Abraham
- Division of Cardiology, Department of Medicine, University of California, San Francisco, 505 Parnassus Ave., Suite M344 San Francisco, San Francisco, CA, USA
| | - Glenn J Whitman
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Levosimendan: new indications and evidence for reduction in perioperative mortality? Curr Opin Anaesthesiol 2018; 29:454-61. [PMID: 27168089 DOI: 10.1097/aco.0000000000000357] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW In the last years, the perioperative use of levosimendan in cardiac surgery patients is spreading. Moreover, newer indications have been suggested such as the treatment of sepsis-associated myocardial dysfunction. In the present review, we discuss the most recent evidences in these settings. RECENT FINDINGS Levosimendan has been seemingly confirmed to reduce mortality in patients undergoing cardiac surgery. In particular, it appears to be the only inotropic drug to have a favorable effect on survival in any clinical setting. Moreover, levosimendan has been shown to exert a cardioprotective action and to reduce acute kidney injury, renal replacement therapy, and ICU stay in cardiac surgery patients. Finally, levosimendan has been suggested to reduce mortality in patients with severe sepsis and to improve renal outcomes in critically ill patients. SUMMARY Although a strong rationale likely exists to use levosimendan in the setting of perioperative and critical care medicine, evidence mainly comes from small and often poor-quality randomized clinical trials, whose results acquire significance only when pooled in meta-analyses. Moreover, some aspects related to which subgroups of patients may derive the most benefits from receiving levosimendan, to the optimal timing of administration, and to the potential adverse effects need to be further clarified. Important insights will be hopefully provided soon by the several large multicenter investigations which are currently ongoing.
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Sanfilippo F, Knight JB, Scolletta S, Santonocito C, Pastore F, Lorini FL, Tritapepe L, Morelli A, Arcadipane A. Levosimendan for patients with severely reduced left ventricular systolic function and/or low cardiac output syndrome undergoing cardiac surgery: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:252. [PMID: 29047417 PMCID: PMC5648477 DOI: 10.1186/s13054-017-1849-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 09/28/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Previous studies have shown beneficial effects of levosimendan in high-risk patients undergoing cardiac surgery. Two large randomized controlled trials (RCTs), however, showed no advantages of levosimendan. METHODS We performed a systematic review and meta-analysis (MEDLINE and Embase from inception until March 30, 2017), investigating whether levosimendan offers advantages compared with placebo in high-risk cardiac surgery patients, as defined by preoperative left ventricular ejection fraction (LVEF) ≤ 35% and/or low cardiac output syndrome (LCOS). The primary outcomes were mortality at longest follow-up and need for postoperative renal replacement therapy (RRT). Secondary postoperative outcomes investigated included myocardial injury, supraventricular arrhythmias, development of LCOS, acute kidney injury (AKI), duration of mechanical ventilation, intensive care unit and hospital lengths of stay, and incidence of hypotension during drug infusion. RESULTS Six RCTs were included in the meta-analysis, five of which investigated only patients with LVEF ≤ 35% and one of which included predominantly patients with LCOS. Mortality was similar overall (OR 0.64 [0.37, 1.11], p = 0.11) but lower in the subgroup with LVEF < 35% (OR 0.51 [0.32, 0.82], p = 0.005). Need for RRT was reduced by levosimendan both overall (OR 0.63 [0.42, 0.94], p = 0.02) and in patients with LVEF < 35% (OR 0.55 [0.31, 0.97], p = 0.04). Among secondary outcomes, we found lower postoperative LCOS in patients with LVEF < 35% receiving levosimendan (OR 0.49 [0.27, 0.89], p = 0.02), lower overall AKI (OR 0.62 [0.42, 0.92], p = 0.02), and a trend toward lower mechanical support, both overall (p = 0.07) and in patients with LVEF < 35% (p = 0.05). CONCLUSIONS Levosimendan reduces mortality in patients with preoperative severely reduced LVEF but does not affect overall mortality. Levosimendan reduces the need for RRT after high-risk cardiac surgery.
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Affiliation(s)
- Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Via Tricomi 5, 90127, Palermo, Italy.
| | - Joshua B Knight
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Via Tricomi 5, 90127, Palermo, Italy.,Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sabino Scolletta
- Unit of Anesthesia and Critical Care Medicine, Department of Medical Biotechnologies, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Cristina Santonocito
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Via Tricomi 5, 90127, Palermo, Italy
| | - Federico Pastore
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Via Tricomi 5, 90127, Palermo, Italy
| | - Ferdinando L Lorini
- Department of Anaesthesia and Intensive Care, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Luigi Tritapepe
- Department of Cardiovascular, Respiratory, Nephrological, Anaesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Andrea Morelli
- Department of Anesthesiology and Intensive Care, Policlinico Umberto 1, Sapienza University of Rome, Rome, Italy
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Via Tricomi 5, 90127, Palermo, Italy
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Levosimendan beyond inotropy and acute heart failure: Evidence of pleiotropic effects on the heart and other organs: An expert panel position paper. Int J Cardiol 2016; 222:303-312. [PMID: 27498374 DOI: 10.1016/j.ijcard.2016.07.202] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/28/2016] [Indexed: 02/04/2023]
Abstract
Levosimendan is a positive inotrope with vasodilating properties (inodilator) indicated for decompensated heart failure (HF) patients with low cardiac output. Accumulated evidence supports several pleiotropic effects of levosimendan beyond inotropy, the heart and decompensated HF. Those effects are not readily explained by cardiac function enhancement and seem to be related to additional properties of the drug such as anti-inflammatory, anti-oxidative and anti-apoptotic ones. Mechanistic and proof-of-concept studies are still required to clarify the underlying mechanisms involved, while properly designed clinical trials are warranted to translate preclinical or early-phase clinical data into more robust clinical evidence. The present position paper, derived by a panel of 35 experts in the field of cardiology, cardiac anesthesiology, intensive care medicine, cardiac physiology, and cardiovascular pharmacology from 22 European countries, compiles the existing evidence on the pleiotropic effects of levosimendan, identifies potential novel areas of clinical application and defines the corresponding gaps in evidence and the required research efforts to address those gaps.
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