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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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Wang LH, Wang XH, Tan JC, He LX, Fu RQ, Lin Y, Yao YT. Levosimendan administration is not associated with increased risk of bleeding and blood transfusion requirement in patients undergoing off-pump coronary artery bypass grafting: a retrospective study from single center. Perfusion 2023; 38:270-276. [PMID: 34619997 DOI: 10.1177/02676591211049022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Levosimendan (LEVO) is a positive inotropic drug which could increase myocardial contractility and reduce the mortality rate in cardiac surgical patients. However, Whether LEVO is associated with postoperative bleeding and blood transfusion in cardiac surgical patients is controversial. Therefore, the current study was designed to investigate the impact of LEVO administration on bleeding and blood transfusion requirement in off-pump coronary artery bypass grafting (OPCAB) patients. METHODS In a retrospective analysis, a total of 292 patients, aged 40-87 years, undergoing elective OPCAB between January 2019 and July 2019, were divided into LEVO group (n = 151) and Control group (n = 141). Patients in LEVO group continuously received LEVO at a rate of 0.1-0.2 μg kg-1 min-1 after anesthesia induction until 24 hours after OPCAB or patients in Control group received no LEVO. The primary outcome was postoperative chest drainage volume. The secondary outcomes were reoperation for postoperative bleeding, transfusion requirement of red blood cells (RBCs), fresh frozen plasma (FFP) and platelet concentrate (PC), etc. Comparisons of two groups were performed with the Student's t-test or Wilcoxon-Mann-Whitney test. RESULTS There was no significant difference with respect to chest drainage volume ((956.29 ± 555.45) ml vs (1003.19 ± 572.25) ml, p = 0.478) and the incidence of reoperation for postoperative bleeding (1.32% vs 1.42%, p = 0.945) between LEVO group and Control group. The transfusion incidence and volume of allogeneic RBCs, FFP, and PC were comparable between two groups. CONCLUSIONS LEVO administration was neither associated with more postoperative blood loss nor increased allogeneic blood transfusion requirement in OPCAB patients.
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Affiliation(s)
- Li-Hong Wang
- Department of Anesthesiology, Chuiyangliu Hospital of Tsinghua University, Beijing, China
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Hong Wang
- Department of Nutrition and Food, Tangshan City Center for Disease Control and Prevention, Tangshan, China
| | - Jie-Chao Tan
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Department of Anesthesiology, Shunde Hospital of Southern Medical University, Foshan, China
| | - Li-Xian He
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Run-Qiao Fu
- Department of Anesthesiology, Chuiyangliu Hospital of Tsinghua University, Beijing, China
| | - Yong Lin
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yun-Tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Levosimendan protects against ischemia – reperfusion injury in the human heart muscle. A pilot study. CURRENT ISSUES IN PHARMACY AND MEDICAL SCIENCES 2022. [DOI: 10.2478/cipms-2022-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Abstract
The consequences of myocardial infarction (MI) are an increasing problem worldwide. Despite spectacular progress in the invasive treatment of ischemic heart disease, the ability to limit the ischemia-reperfusion (I/R) injury remains largely unrealized. Recent studies have shown that stimulation of opioid receptors may confer a cardioprotective effect against I/R injury. Levosimendan, the inodilator, is indicated for the short-term treatment of acutely decompensated heart failure. We tested the hypothesis that levosimendan may provide cardioprotection in the opioid-like mechanism in the human myocardium.
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Aygun H, Olguner C, Koca U, Ergur BU, Sisman AR, Isguven D, Girgin P, Akkus M, Tulgar S. The effect of post-reperfusion levosimendan in an experimental intestinal ischemia-reperfusion model. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:45. [PMID: 37386547 DOI: 10.1186/s44158-022-00074-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/14/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND Levosimendan has been reported to have a positive effect on ischemia-reperfusion injury. Herein, we aimed to evaluate the effects of levosimendan applied after reperfusion in an experimental intestinal injury-reperfusion (IR) model. METHODS Twenty-one Wistar-albino male rats were separated into three groups: Sham group (n = 7): solely superior mesenteric artery (SMA) was dissected after laparotomy; intestinal ischemia-reperfusion group (IIR, n = 7): SMA was clamped for 60 min and unclamped for 120 min to cause ischemia-reperfusion; IIR + levosimendan group (IIR + L, n = 7): levosimendan was administered in ischemia-reperfusion model. The mean arterial pressures (MAP) were measured in all groups. MAP measurements were performed at the end of stabilization, at the 15th, 30th, and 60th minute of ischemia; at the 15th, 30th, 60th, and 120th minute of reperfusion; and at the end of levosimendan bolus application and when levosimendan infusion concluded. Reperfusion injury was evaluated with tissue malondialdehyde (MDA) and by Chiu score. RESULTS MAP at 15 min, 30 min, and 60 min of reperfusion was lower in IIR and IIR + L groups compared with basal inter-group measurements. Decline in MAP at 30 min after reperfusion was statistically significant in IIR and IIR + L groups when compared with the sham group. There was no significant difference between MDA levels in the groups. Chiu score was significantly lower in the sham group when compared to IIR and IIR + L groups and higher in IIR when compared to the IIR + L group. CONCLUSION Levosimendan leads to a decrease in intestinal damage although it did not affect lipid peroxidation and MAP when administered after reperfusion in an experimental intestinal IR model.
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Affiliation(s)
- Hakan Aygun
- Department of Anesthesiology, Bakircay University Cigli Training and Research Hospital, 8780/1 Sokak No:18 Yeni Mahalle Ata Sanayi, Izmir, Turkey.
| | - Cimen Olguner
- Department of Anesthesiology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Ugur Koca
- Department of Anesthesiology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Bekir Ugur Ergur
- Department of Histology and Embryology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Ali Rıza Sisman
- Department of Medical Biochemistry, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Duyguhan Isguven
- Department of Anesthesiology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Pelin Girgin
- Department of Anesthesiology, Bakircay University Cigli Training and Research Hospital, 8780/1 Sokak No:18 Yeni Mahalle Ata Sanayi, Izmir, Turkey
| | - Muhammed Akkus
- Department of Anesthesiology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
| | - Serkan Tulgar
- Department of Anesthesiology, Samsun University, Samsun Training and Research Hospital, Samsun, Turkey
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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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Leivaditis V, Koletsis E, Tsopanoglou N, Charokopos N, D’Alessandro C, Grapatsas K, Apostolakis E, Choleva E, Plota M, Emmanuil A, Dahm M, Dougenis D. The Coadministration of Levosimendan and Exenatide Offers a Significant Cardioprotective Effect to Isolated Rat Hearts against Ischemia/Reperfusion Injury. J Cardiovasc Dev Dis 2022; 9:jcdd9080263. [PMID: 36005427 PMCID: PMC9409795 DOI: 10.3390/jcdd9080263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/04/2022] [Accepted: 08/11/2022] [Indexed: 11/25/2022] Open
Abstract
(1) Background: The present study aims to investigate the effect of administration of Levosimendan and Exenatide in various concentrations, as well as of the coadministration of those agents in an ischemia–reperfusion injury isolated heart model. (2) Methods: After 30 min of perfusion, the hearts underwent a 30 min period of regional ischemia followed by a 120 min period of reperfusion. All animals were randomly divided into 12 experimental groups of nine animals in each group: (1) Control, (2) Sham, (3) Digox (Negative control, Digoxin 1.67 μg/min), (4) Levo 1 (Levosimendan 0.01 μg/min), (5) Levo 2 (Levosimendan 0.03 μg/mL), (6) Levo 3 (Levosimendan 0.1 μg/min), (7) Levo 4 (Levosimendan 0.3 μg/min), (8) Levo 5 (Levosimendan 1 μg/min), (9) Exen 1 (Exenatide 0.001 μg/min), (10) Exen 2 (Exenatide 0.01 μg/min), (11) Exen 3 (Exenatide 0.1 μg/min) and (12) Combi (Levosimendan 0.1 µg/mL + Exenatide 0.001 μg/min). The hemodynamic parameters were recorded throughout the experiment. Arrhythmias and coronary flow were also evaluated. After every experiment the heart was suitably prepared and infarct size was measured. Markers of myocardial injury were also measured. Finally, oxidative stress was evaluated measuring reactive oxygen species. (3) Results: A dose-dependent improvement of the haemodynamic response was observed after the administration of both Levosimendan and Exenatide. The coadministration of both agents presented an even greater effect, improving the haemodynamic parameters further than the two agents separately. Levosimendan offered an increase of the coronary flow and both agents offered a reduction of arrhythmias. A dose-dependent reduction of the size of myocardial infarction and myocardial injury was observed after administration of Levosimendan and Exenatide. The coadministration of both agents offered a further improving the above parameters. Levosimendan also offered a significant reduction of oxidative stress. (4) Conclusions: The administration of Levosimendan and Exenatide offers a significant benefit by improving the haemodynamic response, increasing the coronary flow and reducing the occurrence of arrhythmias, the size of myocardial injury and myocardial oxidative stress in isolated rat hearts.
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Affiliation(s)
- Vasileios Leivaditis
- Department of Cardiothoracic and Vascular Surgery, Westpfalz-Klinikum, Hellmut-Hartert-Strasse 1, 67655 Kaiserslautern, Germany
- Department of Cardiothoracic Surgery, University Hospital of Patras, 26504 Patras, Greece
- Correspondence: ; Tel.: +49-151-50225145
| | - Efstratios Koletsis
- Department of Cardiothoracic Surgery, University Hospital of Patras, 26504 Patras, Greece
| | - Nikolaos Tsopanoglou
- Department of Pharmacology, School of Medicine, University of Patras, 26504 Patras, Greece
| | - Nikolaos Charokopos
- Department of Cardiothoracic Surgery, University Hospital of Patras, 26504 Patras, Greece
| | - Cristian D’Alessandro
- Laboratory of Biomechanics & Biomedical Engineering, Department of Mechanical Engineering & Aeronautics, University of Patras, 26504 Patras, Greece
| | - Konstantinos Grapatsas
- Department of Thoracic Surgery, Medical Center-University of Freiburg, Faculty of Medicine, 79106 Freiburg, Germany
| | - Efstratios Apostolakis
- Department of Cardiothoracic Surgery, University Hospital of Ioannina, 45500 Ioannina, Greece
| | - Effrosyni Choleva
- Laboratory of Molecular Pharmacology, Department of Pharmacy, University of Patras, 26504 Patras, Greece
| | - Maria Plota
- Department of Microbiology, School of Medicine, University of Patras, 26504 Patras, Greece
| | - Andreas Emmanuil
- Laboratory of Hematology, University Hospital of Patras, 26504 Patras, Greece
| | - Manfred Dahm
- Department of Cardiothoracic and Vascular Surgery, Westpfalz-Klinikum, Hellmut-Hartert-Strasse 1, 67655 Kaiserslautern, Germany
| | - Dimitrios Dougenis
- Department of Cardiothoracic Surgery, Attikon University Hospital of Athens, 12462 Athens, Greece
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Rysz S, Fagerlund MJ, Lundberg J, Ringh M, Hollenberg J, Lindgren M, Jonsson M, Djärv T, Nordberg P. The Use of Levosimendan after Out-of-Hospital Cardiac Arrest and Its Association with Outcome-An Observational Study. J Clin Med 2022; 11:jcm11092621. [PMID: 35566747 PMCID: PMC9103888 DOI: 10.3390/jcm11092621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Levosimendan improves resuscitation rates and cardiac performance in animal cardiac arrest models. The aim of this study was to describe the use of levosimendan in out-of-hospital cardiac arrest (OHCA) patients and its association with outcome. Methods: A retrospective observational study of OHCA patients admitted to six intensive care units in Stockholm, Sweden, between 2010 and 2016. Patients treated with levosimendan within 24 h from admission were compared with those not treated with levosimendan. Propensity score matching and multivariable logistic regression analysis were used to assess the association between levosimendan treatment and 30-day mortality Results: Levosimendan treatment was initiated in 94/940 (10%) patients within 24 h. The proportion of men (81%, vs. 67%, p = 0.007), initial shockable rhythm (66% vs. 37%, p < 0.001), acute myocardial infarction, AMI (47% vs. 24%, p < 0.001) and need for vasoactive support (98% vs. 61%, p < 0.001) were higher among patients treated with levosimendan. After adjustment for age, sex, bystander cardiopulmonary resuscitation, witnessed status, initial rhythm and AMI, the odds ratio (OR) for 30-day mortality in the levosimendan group compared to the no-levosimendan group was 0.94 (95% Confidence interval [CI], 0.56−1.57, p = 0.82). Similar results were seen when using a propensity score analysis comparing patients with circulatory shock. Conclusions: In this observational study of OHCA patients, levosimendan was used in a limited patient group, most often in those with initial shockable rhythms, acute myocardial infarction and with a high need for vasopressors. In this limited patient cohort, levosimendan treatment was not associated with 30-day mortality. However, a better matching of patient factors and indications for use is required to derive conclusions on associations with outcome.
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Affiliation(s)
- Susanne Rysz
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76 Stockholm, Sweden; (S.R.); (M.J.F.)
- Department of Medicine Solna, Karolinska Institutet, 171 77 Stockholm, Sweden;
| | - Malin Jonsson Fagerlund
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76 Stockholm, Sweden; (S.R.); (M.J.F.)
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Johan Lundberg
- Department of Clinical Neuroscience, Karolinska Institutet, 171 77 Stockholm, Sweden;
- Department of Neuroradiology, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Mattias Ringh
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, 118 83 Stockholm, Sweden; (M.R.); (J.H.); (M.J.)
| | - Jacob Hollenberg
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, 118 83 Stockholm, Sweden; (M.R.); (J.H.); (M.J.)
| | - Marcus Lindgren
- Department of Medicine, Piteå Hospital, 941 50 Piteå, Sweden;
| | - Martin Jonsson
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, 118 83 Stockholm, Sweden; (M.R.); (J.H.); (M.J.)
| | - Therese Djärv
- Department of Medicine Solna, Karolinska Institutet, 171 77 Stockholm, Sweden;
- Function Emergency Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Per Nordberg
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76 Stockholm, Sweden; (S.R.); (M.J.F.)
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet Södersjukhuset, 118 83 Stockholm, Sweden; (M.R.); (J.H.); (M.J.)
- Correspondence:
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8
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Lebedeva NB, Chesnokova LY. The Use of Levosimendan for the Treatment of Heart Failure and its Potential Organoprotective Effects. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-04-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The review article is aimed at providing a recent update on the use of levosimendan, an inotropic drug in current use for the treatment of heart failure. The review discusses its mechanisms of action, main hemodynamic effects, clinical trials and obtained evidences that have formed the basis of the current guidelines on its use, as well as the latest clinical and experimental trials evaluating its organ-protective effects. Conclusion: levosimendan has a promising potential for treating heart failure, prescribed even in low doses, and may be regarded as a drug with cerebroprotective and possible nephroprotective effects, requiring further large randomized clinical trials.
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Affiliation(s)
- N. B. Lebedeva
- Research Institute for Complex Issues of Cardiovascular Diseases
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9
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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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10
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Burkhoff D, Rich S, Pollesello P, Papp Z. Levosimendan-induced venodilation is mediated by opening of potassium channels. ESC Heart Fail 2021; 8:4454-4464. [PMID: 34716759 PMCID: PMC8712848 DOI: 10.1002/ehf2.13669] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 09/27/2021] [Indexed: 02/01/2023] Open
Abstract
Unique vascular responses adhere to the cardiovascular efficacy of the inodilator levosimendan. In particular, selective venodilation appears to explain its clinical benefit during pulmonary hypertension complicated by heart failure with preserved ejection fraction. Vasodilators increase vessel diameter in various parts of the vascular system to different degrees and thereby influence blood pressure, its distribution, and organ perfusion depending on their mechanisms of action. Levosimendan and its long‐lived active metabolite OR‐1896 mobilize a set of vasodilatory mechanisms, that is, the opening of the ATP‐sensitive K+ channels and other K+ channels on top of a highly selective inhibition of the phosphodiesterase III enzyme. A vessel‐specific combination of the above vasodilator mechanisms—in concert with cardiac effects and cardiovascular reflex regulations—illustrates the pharmacological profile of levosimendan in various cardiovascular disorders. While levosimendan has been known to be an inotrope, its properties as an activator of ATP‐sensitive K+ channels have gone largely ignored with respect to clinical applications. Here, we provide a summary of what is known about the ATP‐sensitive K+ channel properties in preclinical studies and now for the first time, its ATP‐sensitive K+ channel properties in a clinical trial.
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Affiliation(s)
| | - Stuart Rich
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Zoltán Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, 22 Móricz Zsigmond Str., Debrecen, H-4032, Hungary.,HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Budapest, Hungary
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11
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García‐González MJ, Aldea Perona A, Lara Padron A, Morales Rull JL, Martínez‐Sellés M, de Mora Martin M, López Díaz J, López Fernandez S, Ortiz Oficialdegui P, Jiménez Sosa A. Efficacy and safety of intermittent repeated levosimendan infusions in advanced heart failure patients: the LAICA study. ESC Heart Fail 2021; 8:4820-4831. [PMID: 34716753 PMCID: PMC8712777 DOI: 10.1002/ehf2.13670] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 09/12/2021] [Accepted: 10/03/2021] [Indexed: 12/12/2022] Open
Abstract
Aims The aim of the LAICA study was to evaluate the long‐term effectiveness and safety of intermittent levosimendan infusion in patients with advanced heart failure (AdHF). Methods and results This was a multicentre, randomized, double‐blind, placebo‐controlled clinical trial of intermittent levosimendan 0.1 μg/kg/min as a continuous 24‐h intravenous infusion administered once monthly for 1 year in patients with AdHF. The primary endpoint [incidence of rehospitalization (admission to the emergency department or hospital ward for >12 h) for acute decompensated HF or clinical deterioration of the underlying HF] occurred in 23/70 (33%) of the levosimendan group (Group I) and 12/27 (44%) of the placebo group (Group II) (P = 0.286). The incidence of hospital readmissions for acute decompensated HF (Group I vs. Group II) at 1, 3, 6, and 12 months was 4.2% vs. 18.2% (P = 0.036); 12.8% vs. 33.3% (P = 0.02); 25.7% vs. 40.7% (P = 0.147); 32.8% vs. 44.4% (P = 0.28), respectively. In a secondary pre‐specified time‐to‐event analysis no differences were observed in admission for acute decompensated HF between patients treated with levosimendan compared with placebo (hazard ratio 0.66; 95% CI, 0.32–1.32; P = 0.24). Cumulative incidence for the aggregated endpoint of acute decompensation of HF and/or death at 1 and 3 months were significatively lower in the levosimendan group than in placebo group [5.7% vs. 25.9% (P = 0.004) and 17.1% vs. 48.1% (P = 0.001), respectively], but not at 6 and 12 months [34.2% vs. 59.2% (P = 0.025); 41.4% vs. 66.6% (P = 0.022), respectively]. Survival probability was significantly higher in patients who received levosimendan compared with those who received placebo (log rank: 4.06; P = 0.044). There were no clinically relevant differences in tolerability between levosimendan and placebo and no new safety signals were observed. Conclusions In our study, intermittent levosimendan in patients with AdHF produced a statistically non‐significant reduction in the incidence of hospital readmissions for acute decompensated HF, a significantly lower cumulative incidence of acute decompensation of HF and/or death at 1 and 3 month of treatment and a significant improvement in survival during 12 months of treatment.
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Affiliation(s)
- Martín J. García‐González
- Acute Cardiac Care Unit, Department of CardiologyHospital Universitario de CanariasCtra. La Cuesta—Taco, Ofra s/n, 38320 San Cristóbal de La LagunaTenerifeSpain
| | - Ana Aldea Perona
- Institut Municipal d'Investigacions Mèdiques (IMIM)BarcelonaSpain
| | - Antonio Lara Padron
- Acute Cardiac Care Unit, Department of CardiologyHospital Universitario de CanariasCtra. La Cuesta—Taco, Ofra s/n, 38320 San Cristóbal de La LagunaTenerifeSpain
| | - José Luis Morales Rull
- Heart Failure Unit, Department of Internal MedicineHospital Arnau de Vilanova, Institut de Recerca Biomédica de Lleida (IRBLleida)LleidaSpain
| | - Manuel Martínez‐Sellés
- Department of CardiologyHospital Universitario Gregorio Marañon, CIBERCV, Universidad Europea, Universidad ComplutenseMadridSpain
| | | | - Javier López Díaz
- Department of CardiologyHospital Clínico Universitario de Valladolid, CIBERCVValladolidSpain
| | - Silvia López Fernandez
- Heart Failure Unit, Department of CardiologyHospital Universitario Virgen de las NievesGranadaSpain
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12
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Zhou Q, Li P, Zhao H, Xu X, Li S, Zhao J, Xu D, Zeng Q. Heart Failure With Mid-range Ejection Fraction: A Distinctive Subtype or a Transitional Stage? Front Cardiovasc Med 2021; 8:678121. [PMID: 34113665 PMCID: PMC8185203 DOI: 10.3389/fcvm.2021.678121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/29/2021] [Indexed: 12/11/2022] Open
Abstract
Heart failure with mid-range ejection fraction (HFmrEF) was first proposed by Lam and Solomon in 2014, and was listed as a new subtype of heart failure (HF) in 2016 European Society of Cardiology guidelines. Since then, HFmrEF has attracted an increasing amount of attention, and the number of related studies on this topic has grown rapidly. The diagnostic criteria on the basis of left ventricular ejection fraction (LVEF) are straightforward; however, LVEF is not a static parameter, and it changes dynamically during the course of HF. Thus, HFmrEF may not be an independent disease with a uniform pathophysiological process, but rather a collection of patients with different characteristics. HFmrEF is often associated with various cardiovascular and non-cardiovascular diseases. Thus, the pathophysiological mechanisms of HFmrEF are particularly complex, and its clinical phenotypes are diverse. The complexity and heterogeneity of HFmrEF may be one reason for inconsistent results between clinical studies. In fact, whether HFmrEF is a distinctive subtype or a transitional stage between HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF) is controversial. In this review, we discuss the clinical characteristics, treatment and prognosis of patients with HFmrEF, as well as the differences among HFmrEF, HFrEF, and HFpEF.
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Affiliation(s)
- Qing Zhou
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Shock and Microcirculation, Southern Medical University, Guangzhou, China.,Bioland Laboratory (Guangzhou Regenerative Medicine and Health Guangdong Laboratory), Guangzhou, China.,Department of Cardiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Peixin Li
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Shock and Microcirculation, Southern Medical University, Guangzhou, China.,Bioland Laboratory (Guangzhou Regenerative Medicine and Health Guangdong Laboratory), Guangzhou, China
| | - Hengli Zhao
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Shock and Microcirculation, Southern Medical University, Guangzhou, China.,Bioland Laboratory (Guangzhou Regenerative Medicine and Health Guangdong Laboratory), Guangzhou, China
| | - Xingbo Xu
- Department of Cardiology and Pneumology, University Medical Center of Göttingen, Georg-August-University, Göttingen, Germany
| | - Shaoping Li
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China
| | - Jing Zhao
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China
| | - Dingli Xu
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Shock and Microcirculation, Southern Medical University, Guangzhou, China.,Bioland Laboratory (Guangzhou Regenerative Medicine and Health Guangdong Laboratory), Guangzhou, China
| | - Qingchun Zeng
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Shock and Microcirculation, Southern Medical University, Guangzhou, China.,Bioland Laboratory (Guangzhou Regenerative Medicine and Health Guangdong Laboratory), Guangzhou, China
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13
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Efficacy and safety of levosimendan and dobutamine in heart failure: A systematic review and meta-analysis. Cardiol J 2021; 28:492-493. [PMID: 33843036 DOI: 10.5603/cj.a2021.0037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/14/2021] [Indexed: 11/25/2022] Open
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14
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Potential of the Cardiovascular Drug Levosimendan in the Management of Amyotrophic Lateral Sclerosis: An Overview of a Working Hypothesis. J Cardiovasc Pharmacol 2020; 74:389-399. [PMID: 31730560 DOI: 10.1097/fjc.0000000000000728] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Levosimendan is a calcium sensitizer that promotes myocyte contractility through its calcium-dependent interaction with cardiac troponin C. Administered intravenously, it has been used for nearly 2 decades to treat acute and advanced heart failure and to support the heart function in various therapy settings characterized by low cardiac output. Effects of levosimendan on noncardiac muscle suggest a possible new application in the treatment of people with amyotrophic lateral sclerosis (ALS), a neuromuscular disorder characterized by progressive weakness, and eventual paralysis. Previous attempts to improve the muscle response in ALS patients and thereby maintain respiratory function and delay progression of disability have produced some mixed results. Continuing this line of investigation, levosimendan has been shown to enhance in vitro the contractility of the diaphragm muscle fibers of non-ALS patients and to improve in vivo diaphragm neuromuscular efficiency in healthy subjects. Possible positive effects on respiratory function in people with ALS were seen in an exploratory phase 2 study, and a phase 3 clinical trial is now underway to evaluate the potential benefit of an oral form of levosimendan on both respiratory and overall functions in patients with ALS. Here, we will review the various known pharmacologic effects of levosimendan, considering their relevance to people living with ALS.
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15
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Mamalyga ML, Mamalyga LM. Experimental Study of Heart Functionality during Treatment of Chronic Heart Failure in Rats of Different Age Groups with Levosimendan (Experimental Study). Bull Exp Biol Med 2020; 169:18-23. [PMID: 32474670 DOI: 10.1007/s10517-020-04815-8] [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: 02/26/2019] [Indexed: 10/24/2022]
Abstract
Levosimendan is effective in the therapy of chronic heart failure in both mature and old rats, but the duration of its therapeutic effect differs in these age groups. In 15 days after treatment, the myocardium in old rats maintained augmented functionality, whereas in old animals, functional potencies returned to the levels observed prior to the therapy. Stimulation of tissue respiration with combined administration of L-carnitine and α-lipoic acid against the background of levosimendan treatment prolonged its therapeutic effect in mature, but not in old rats.
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Affiliation(s)
- M L Mamalyga
- Department of Anatomy and Physiology of Humans and Animals, Institute of Biology and Chemistry, Moscow State Pedagogical University, Moscow, Russia.
| | - L M Mamalyga
- Department of Anatomy and Physiology of Humans and Animals, Institute of Biology and Chemistry, Moscow State Pedagogical University, Moscow, Russia
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16
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Abstract
Levosimendan is an inodilator that promotes cardiac contractility primarily through calcium sensitization of cardiac troponin C and vasodilatation via opening of adenosine triphosphate–sensitive potassium (KATP) channels in vascular smooth muscle cells; the drug also exerts organ-protective effects through a similar effect on mitochondrial KATP channels. This pharmacological profile identifies levosimendan as a drug that may have applications in a wide range of critical illness situations encountered in intensive care unit medicine: hemodynamic support in cardiogenic or septic shock; weaning from mechanical ventilation or from extracorporeal membrane oxygenation; and in the context of cardiorenal syndrome. This review, authored by experts from 9 European countries (Austria, Belgium, Czech republic, Finland, France, Germany, Italy, Sweden, and Switzerland), examines the clinical and experimental data for levosimendan in these situations and concludes that, in most instances, the evidence is encouraging, which is not the case with other cardioactive and vasoactive drugs routinely used in the intensive care unit. The size of the available studies is, however, limited and the data are in need of verification in larger controlled trials. Some proposals are offered for the aims and designs of these additional studies.
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17
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Reddy GMK, Singamsetti JM, Kaliyaperumal M, Doddipalla R, Ivaturi R, Rumalla CS, Korupolu RB, Babu BK. Degradation studies of levosimendan isolation, identification, and structure confirmation of stress degradation products using LCMS, mass mediated Prep-HPLC, NMR, HRMS, SFC and FTIR. J LIQ CHROMATOGR R T 2019. [DOI: 10.1080/10826076.2019.1613429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- G. Mahesh Kumar Reddy
- Department of Medicinal Chemistry, GVK Biosciences Pvt. Ltd, Hyderabad, India
- Department of Engineering Chemistry, Andhra University, Visakhapatnam, India
| | | | | | - Raju Doddipalla
- Department of Medicinal Chemistry, GVK Biosciences Pvt. Ltd, Hyderabad, India
| | - Ramu Ivaturi
- Department of Medicinal Chemistry, GVK Biosciences Pvt. Ltd, Hyderabad, India
| | | | - Raghu Babu Korupolu
- Department of Engineering Chemistry, Andhra University, Visakhapatnam, India
| | - B. Kishore Babu
- Department of Engineering Chemistry, Andhra University, Visakhapatnam, India
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18
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Alves ML, Warren CM, Simon JN, Gaffin RD, Montminy EM, Wieczorek DF, Solaro RJ, Wolska BM. Early sensitization of myofilaments to Ca2+ prevents genetically linked dilated cardiomyopathy in mice. Cardiovasc Res 2018; 113:915-925. [PMID: 28379313 DOI: 10.1093/cvr/cvx068] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 03/31/2017] [Indexed: 12/14/2022] Open
Abstract
Background Dilated cardiomoypathies (DCM) are a heterogeneous group of inherited and acquired diseases characterized by decreased contractility and enlargement of cardiac chambers and a major cause of morbidity and mortality. Mice with Glu54Lys mutation in α-tropomyosin (Tm54) demonstrate typical DCM phenotype with reduced myofilament Ca2+ sensitivity. We tested the hypothesis that early sensitization of the myofilaments to Ca2+ in DCM can prevent the DCM phenotype. Methods and results To sensitize Tm54 myofilaments, we used a genetic approach and crossbred Tm54 mice with mice expressing slow skeletal troponin I (ssTnI) that sensitizes myofilaments to Ca2+. Four groups of mice were used: non-transgenic (NTG), Tm54, ssTnI and Tm54/ssTnI (DTG). Systolic function was significantly reduced in the Tm54 mice compared to NTG, but restored in DTG mice. Tm54 mice also showed increased diastolic LV dimensions and HW/BW ratios, when compared to NTG, which were improved in the DTG group. β-myosin heavy chain expression was increased in the Tm54 animals compared to NTG and was partially restored in DTG group. Analysis by 2D-DIGE indicated a significant decrease in two phosphorylated spots of cardiac troponin I (cTnI) in the DTG animals compared to NTG and Tm54. Analysis by 2D-DIGE also indicated no significant changes in troponin T, regulatory light chain, myosin binding protein C and tropomyosin phosphorylation. Conclusion Our data indicate that decreased myofilament Ca2+ sensitivity is an essential element in the pathophysiology of thin filament linked DCM. Sensitization of myofilaments to Ca2+ in the early stage of DCM may be a useful therapeutic strategy in thin filament linked DCM.
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Affiliation(s)
- Marco L Alves
- Department of Physiology and Biophysics, Center for Cardiovascular Research, University of Illinois, 835 S Wolcott Ave. (M/C 901), Chicago, IL 60612, USA.,Center for Research in Echocardiography and Cardiology, Heart Institute, University of Sao Paulo, Avenida Dr. Eneas de Carvalho Aguiar 44, 05403-900, Sao Paulo, Brazil
| | - Chad M Warren
- Department of Physiology and Biophysics, Center for Cardiovascular Research, University of Illinois, 835 S Wolcott Ave. (M/C 901), Chicago, IL 60612, USA
| | - Jillian N Simon
- Department of Physiology and Biophysics, Center for Cardiovascular Research, University of Illinois, 835 S Wolcott Ave. (M/C 901), Chicago, IL 60612, USA
| | - Robert D Gaffin
- Department of Physiology and Biophysics, Center for Cardiovascular Research, University of Illinois, 835 S Wolcott Ave. (M/C 901), Chicago, IL 60612, USA
| | - Eric M Montminy
- Department of Physiology and Biophysics, Center for Cardiovascular Research, University of Illinois, 835 S Wolcott Ave. (M/C 901), Chicago, IL 60612, USA
| | - David F Wieczorek
- Department of Molecular Genetics, Biochemistry and Microbiology, University of Cincinnati, College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA
| | - R John Solaro
- Department of Physiology and Biophysics, Center for Cardiovascular Research, University of Illinois, 835 S Wolcott Ave. (M/C 901), Chicago, IL 60612, USA
| | - Beata M Wolska
- Department of Physiology and Biophysics, Center for Cardiovascular Research, University of Illinois, 835 S Wolcott Ave. (M/C 901), Chicago, IL 60612, USA.,Department of Medicine, Division of Cardiology, University of Illinois, 840 S Wood St. (M/C 715), Chicago, IL 60612, USA
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19
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Prajapati PB, Bhayani DR, Mehta PJ. Accelerated stability testing of levosimendan: isolation and characterization of degradation impurities utilizing preparative HPLC, LC–MS, NMR, and IR. J LIQ CHROMATOGR R T 2018. [DOI: 10.1080/10826076.2018.1470982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Pintu B. Prajapati
- Department of Pharmaceutical Analysis, Institute of Pharmacy, Nirma University, Ahmedabad, India
| | - Dhara R. Bhayani
- Department of Pharmaceutical Analysis, Institute of Pharmacy, Nirma University, Ahmedabad, India
| | - Priti J. Mehta
- Department of Pharmaceutical Analysis, Institute of Pharmacy, Nirma University, Ahmedabad, India
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20
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Comín-Colet J, Manito N, Segovia-Cubero J, Delgado J, García Pinilla JM, Almenar L, Crespo-Leiro MG, Sionis A, Blasco T, Pascual-Figal D, Gonzalez-Vilchez F, Lambert-Rodríguez JL, Grau M, Bruguera J. Efficacy and safety of intermittent intravenous outpatient administration of levosimendan in patients with advanced heart failure: the LION-HEART multicentre randomised trial. Eur J Heart Fail 2018; 20:1128-1136. [PMID: 29405611 DOI: 10.1002/ejhf.1145] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/04/2018] [Accepted: 01/05/2018] [Indexed: 11/07/2022] Open
Abstract
AIMS The LION-HEART study was a multicentre, double-blind, randomised, parallel-group, placebo-controlled trial evaluating the efficacy and safety of intravenous administration of intermittent doses of levosimendan in outpatients with advanced chronic heart failure. METHODS AND RESULTS Sixty-nine patients from 12 centres were randomly assigned at a 2:1 ratio to levosimendan or placebo groups, receiving treatment by a 6-hour intravenous infusion (0.2 μg/kg/min without bolus) every 2 weeks for 12 weeks. The primary endpoint was the effect on serum concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP) throughout the treatment period in comparison with placebo. Secondary endpoints included evaluation of safety, clinical events and health-related quality of life (HRQoL). The area under the curve (AUC, pg.day/mL) of the levels of NT-proBNP over time for patients who received levosimendan was significantly lower than for the placebo group (344 × 103 [95% Confidence Interval (CI) 283 × 103 -404 × 103 ] vs. 535 × 103 [443 × 103 -626 × 103 ], p = 0.003). In comparison with the placebo group, the patients on levosimendan experienced a reduction in the rate of heart failure hospitalisation (hazard ratio 0.25; 95% CI 0.11-0.56; P = 0.001). Patients on levosimendan were less likely to experience a clinically significant decline in HRQoL over time (P = 0.022). Adverse event rates were similar in the two treatment groups. CONCLUSIONS In this small pilot study, intermittent administration of levosimendan to ambulatory patients with advanced systolic heart failure reduced plasma concentrations of NT-proBNP, worsening of HRQoL and hospitalisation for heart failure. The efficacy and safety of this intervention should be confirmed in larger trials.
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Affiliation(s)
- Josep Comín-Colet
- Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), and Universitat Autònoma de Barcelona, Barcelona, Spain.,Heart Diseases Institute, Hospital Universitari de Bellvitge, IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Nicolás Manito
- Heart Diseases Institute, Hospital Universitari de Bellvitge, IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | | | - Juan Delgado
- Unidad de Insuficiencia Cardiaca y Trasplante, Servicio de Cardiología, Hospital 12 de Octubre, Madrid, Spain
| | | | - Luis Almenar
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - María G Crespo-Leiro
- Complexo Hospitalario Universitario de A Coruña (CHUAC) e Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidad de A Coruña (UDC), A Coruña, Spain
| | - Alessandro Sionis
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Teresa Blasco
- Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | | | - José Luis Lambert-Rodríguez
- Unidad de Trasplante Cardiaco e Insuficiencia Cardiaca Avanzada, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - María Grau
- Cardiovascular Epidemiology & Genetics, IMIM (Hospital del Mar Medical Research Institute) and University of Barcelona, Barcelona, Spain
| | - Jordi Bruguera
- Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), and Universitat Autònoma de Barcelona, Barcelona, Spain
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21
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Lin PMF, Chow SCY, Ng SWY, Ho AMH, Wan S. Acute liver failure with extreme hyperbilirubinemia secondary to endocarditis-related severe mitral and tricuspid regurgitation: a challenge and an opportunity for surgeons. J Thorac Dis 2018; 10:1067-1071. [PMID: 29607182 DOI: 10.21037/jtd.2018.01.138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Hyperbilirubinemia is a known risk factor in patients undergoing open heart operations. Infective endocarditis often leads to valvular injury, such as rupture of chordae tendineae or leaflet perforation, which can cause acute heart failure in association with pulmonary hypertension and liver dysfunction. Here we present a patient with massive liver congestion, reflected by extreme hyperbilirubinemia, secondary to acute heart failure following mitral valve endocarditis that was successfully treated by emergency mitral and tricuspid valve repair.
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Affiliation(s)
- Peter M F Lin
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Simon C Y Chow
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Sally W Y Ng
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Anthony M H Ho
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.,Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Song Wan
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
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22
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Kandasamy A, Simon HA, Murthy P, Annadurai M, Ali MM, Ramanathan G. Comparison of Levosimendan versus Dobutamine in Patients with Moderate to Severe Left Ventricular Dysfunction Undergoing Off-pump Coronary Artery Bypass Grafting: A Randomized Prospective Study. Ann Card Anaesth 2017; 20:200-206. [PMID: 28393781 PMCID: PMC5408526 DOI: 10.4103/aca.aca_195_16] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Context: Recent upsurge in referral of patients with compromised left ventricular (LV) function for cardiac surgery has led to an increasing use inotropes to achieve improvement of tissue perfusion in the perioperative period. Aims and Objectives: To compare the hemodynamic effects and immediate postoperative outcomes with levosimendan and dobutamine in patients with moderate to severe LV dysfunction undergoing off-pump coronary artery bypass grafting (OPCAB). Settings and Design: University teaching hospital, randomized control study. Materials and Methods: Eighty patients were randomly divided into two groups of 40 each. Group I received levosimendan at 0.1 μg/kg/min and Group II received dobutamine at 5 μg/kg/min. Hemodynamic data were noted at 30 min, during obtuse marginal grafting, 1, 6, 12, and 24 h after surgery. Heart rate (HR), mean arterial pressure (MAP), pulmonary capillary wedge pressure (PCWP), cardiac index (CI), systemic vascular resistance index (SVRI) and pulmonary vascular resistance index (PVRI), left ventricular stroke work index (LVSWI) and right ventricular stroke work index (RVSWI), mixed venous oximetry (SvO2), and lactate were measured. Statistical Analysis Used: Chi-square and Student's t-test. Results: The HR, MAP, PCWP, SVRI, and PVRI were lower in Group I when compared to Group II. Group I patients showed a statistically significant increase in LVSWI, RVSWI, and CI, when compared to Group II. Comparatively, Group I patients maintained higher SvO2 and lower lactate levels. Duration of ventilation, Intensive Care Unit (ICU), and hospital stay were lower in Group I. Conclusions: Levosimendan was associated with statistically significant increase in indices of contractility (CI, LVSWI, and RVSWI) and decrease in PCWP during and after OPCAB. Levosimendan group had lower incidence of atrial fibrillation, shorter length of ICU, and hospital stay.
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Affiliation(s)
- Ashok Kandasamy
- Department of Cardiothoracic Anesthesia, SRM Medical College Hospital and Research Centre, SRM University, Kattankulathur, Chennai, Tamil Nadu, India
| | - Hariharan Antony Simon
- Department of Cardiothoracic Anesthesia, SRM Medical College Hospital and Research Centre, SRM University, Kattankulathur, Chennai, Tamil Nadu, India
| | - P Murthy
- Department of Cardiothoracic Anesthesia, SRM Medical College Hospital and Research Centre, SRM University, Kattankulathur, Chennai, Tamil Nadu, India
| | - Mahalakshmi Annadurai
- Department of Cardiothoracic Anesthesia, SRM Medical College Hospital and Research Centre, SRM University, Kattankulathur, Chennai, Tamil Nadu, India
| | - Mushkath Mohamed Ali
- Department of Cardiothoracic Anesthesia, SRM Medical College Hospital and Research Centre, SRM University, Kattankulathur, Chennai, Tamil Nadu, India
| | - Gayathri Ramanathan
- Department of Cardiothoracic Anesthesia, SRM Medical College Hospital and Research Centre, SRM University, Kattankulathur, Chennai, Tamil Nadu, India
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23
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Impact of levosimendan on platelet function. Thromb Res 2017; 159:76-81. [PMID: 28987709 DOI: 10.1016/j.thromres.2017.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/22/2017] [Accepted: 10/01/2017] [Indexed: 11/22/2022]
Abstract
Levosimendan has been developed for treatment of severe heart failure. The favorable hemodynamic effect of levosimendan is related to its unique dual mechanism of action - increase of the contractile force of the myocardium caused by enhanced sensitivity of myofilaments to calcium combined with vasodilatation caused by the opening of adenosine triphosphate - dependent potassium channels. Due to the structural similarities to phosphodiesterase inhibitors it may partly exert its action via inhibition of phosphodiesterase inhibitors III. Inhibition of the phosphodiesterase inhibitors III leads to an increase of intracellular concentration of cyclic adenosine monophosphate causing an anti-aggregatory effect. There are some contradictory or indirect and inconclusive reports related to the impact of levosimendan on platelet function. The aim of this systematic review was to critically discuss the impact of levosimendan on platelet function according to currently available knowledge based on the findings of experimental as well as observational and randomized clinical studies.
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García-Canales A, Peña-Juárez RA, Sandoval-Franco LDM. [Vasopressors and inotropes: use in paediatrics]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2017; 88:39-50. [PMID: 28336302 DOI: 10.1016/j.acmx.2017.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 02/14/2017] [Accepted: 02/15/2017] [Indexed: 11/16/2022] Open
Abstract
The cardiovascular system is a dynamic system, which is required to ensure adequate delivery of oxygen, nutrients, and hormones to the tissues that are necessary for cell metabolism. It also synthesises and modifies the vasoactive components that regulate vascular tone and myocardial function. These vasoactive components have demonstrated their beneficial effects in the management of paediatric patients in a critical condition with heart failure and shock. However, their use and abuse brings harmful effects, increases mortality, and is associated with arrhythmias. An increase in myocardial oxygen consumption favours the presence of ischaemia, therefore it is necessary to know the mechanism of action and indications of these drugs to minimise their harmful effects. The purpose of this review is to describe the pharmacology and clinical applications of inotropic and vasopressor agents in the paediatric patient in acritical condition.
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Affiliation(s)
- Adrián García-Canales
- Departamento de Terapia Intensiva Pediátrica, Hospital Regional Valentín Gómez Farías, ISSSTE, Zapopan, Jalisco, México.
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Gustafsson F, Guarracino F, Schwinger RHG. The inodilator levosimendan as a treatment for acute heart failure in various settings. Eur Heart J Suppl 2017; 19:C2-C7. [PMID: 29249904 PMCID: PMC5932561 DOI: 10.1093/eurheartj/sux001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Levosimendan is an inodilator developed for treatment of acute heart failure. It was shown to enhance cardiac contractility, and to exert a vasodilatory effect in all vascular beds. In some trials, the use of levosimendan was associated with cardioprotective effects. These distinctive qualities may be relevant to its use in a range of acute heart failure settings and/or complications, including acute coronary syndromes and cardiogenic shock. It is conjectured that part of the benefit of levosimendan may arise from restoration of ventriculo-arterial coupling via optimization of the ratio of arterial to ventricular elastance and the transfer of mechanical energy. Full confirmation of the effectiveness of levosimendan is still awaited in many of these scenarios; however, the range of potential applications highlights both the versatility of levosimendan and the relative lack of proven interventions in many of these situations.
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Affiliation(s)
- Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Fabio Guarracino
- Department of Cardiothoracic Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
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Krychtiuk KA, Kaun C, Hohensinner PJ, Stojkovic S, Seigner J, Kastl SP, Zuckermann A, Eppel W, Rauscher S, de Martin R, Maurer G, Huber K, Wojta J, Speidl WS. Anti-thrombotic and pro-fibrinolytic effects of levosimendan in human endothelial cells in vitro. Vascul Pharmacol 2017; 90:44-50. [PMID: 28192257 DOI: 10.1016/j.vph.2017.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 12/16/2016] [Accepted: 02/05/2017] [Indexed: 11/25/2022]
Abstract
AIMS Levosimendan is an inodilator for the treatment of acute decompensated heart failure (HF). Data from clinical studies suggest that levosimendan is particularly effective in HF due to myocardial infarction. After acute revascularization, no reflow-phenomenon is a common complication that may lead to pump failure and cardiogenic shock. Our aim was to examine whether levosimendan interferes with the pro-thrombotic phenotype of activated endothelial cells in vitro. METHODS Human heart microvascular endothelial cells (HHMEC) and human umbilical vein endothelial cells (HUVEC) were treated with interleukin-1β (IL-1β) (200U/mL) or thrombin (5U/mL) and co-treated with or without levosimendan (0.1-10μM) for 2-24h. In addition, flow experiments were performed. Effects on plasminogen activator inhibitor-1 (PAI-1) and tissue factor (TF) expression and activity were measured by rt-PCR, specific ELISA and flow cytometry. RESULTS Treatment with IL-1β or thrombin significantly increased the expression of PAI-1 and TF in endothelial cells. Co-treatment with levosimendan strongly attenuated the effects of IL-1β and thrombin on PAI-1 and TF mRNA by up to 50% and 45%, in a dose- and time-dependent manner. Similar results were obtained under flow conditions. Furthermore, co-treatment with levosimendan dampened the antigen production of PAI-1 and the surface expression of TF by 35% and 45%, respectively. Additionally, levosimendan diminished both TF and PAI-1 activity. CONCLUSION Levosimendan down-regulates the expression of the pro-thrombotic and anti-fibrinolytic biomolecules TF and PAI-1 in activated human endothelial cells. Our findings may, at least in part, explain some of the beneficial effects of levosimendan after myocardial reperfusion.
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Affiliation(s)
- Konstantin A Krychtiuk
- Department of Internal Medicine II, Medical University of Vienna, Austria; Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria
| | - Christoph Kaun
- Department of Internal Medicine II, Medical University of Vienna, Austria
| | | | - Stefan Stojkovic
- Department of Internal Medicine II, Medical University of Vienna, Austria
| | - Jacqueline Seigner
- Department of Vascular Biology and Thrombosis Research, Medical University of Vienna, Austria
| | - Stefan P Kastl
- Department of Internal Medicine II, Medical University of Vienna, Austria
| | | | - Wolfgang Eppel
- Department of Obstetrics and Gynecology, Medical University of Vienna, Austria
| | | | - Rainer de Martin
- Department of Vascular Biology and Thrombosis Research, Medical University of Vienna, Austria
| | - Gerald Maurer
- Department of Internal Medicine II, Medical University of Vienna, Austria
| | - Kurt Huber
- 3rd Medical Department for Cardiology and Emergency Medicine, Wilhelminenhospital, Vienna, Austria
| | - Johann Wojta
- Department of Internal Medicine II, Medical University of Vienna, Austria; Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria; Core Facilities, Medical University of Vienna, Austria
| | - Walter S Speidl
- Department of Internal Medicine II, Medical University of Vienna, Austria.
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Sahu MK, Das A, Malik V, Subramanian A, Singh SP, Hote M. Comparison of levosimendan and nitroglycerine in patients undergoing coronary artery bypass graft surgery. Ann Card Anaesth 2016; 19:52-8. [PMID: 26750674 PMCID: PMC4900377 DOI: 10.4103/0971-9784.173020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Levosimendan a calcium ion sensitizer improves both systolic and diastolic functions. This novel lusitropic drug has predictable antiischemic properties which are mediated via the opening of mitochondrial adenosine triphosphate-sensitive potassium channels. This action of levosimendan is beneficial in cardiac surgical patients as it improves myocardial contractility, decreases systemic vascular resistance (SVR), and increases cardiac index (CI) and is thought to be cardioprotective. We decided to study whether levosimendan has any impact on the outcomes such as the duration of ventilation, the length of Intensive Care Unit (ICU) stay, and the hospital stay when compared with the nitroglycerine (NTG), which is the current standard of care at our center. Materials and Methods: Forty-seven patients undergoing elective coronary artery bypass surgery were randomly assigned to two groups receiving either levosimendan or NTG. The medications were started before starting surgery and continued until 24 h in the postoperative period. Baseline hemodynamic parameters were evaluated before beginning of the operation and then postoperatively at 3 different time intervals. N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) levels were also measured in both groups. Results: In comparison to the NTG group, the duration of ventilation and length of ICU stay were significantly less in levosimendan group (P < 0.05, P = 0.02). NT-proBNP level analysis showed a slow rising pattern in both groups and a statistically significant rise in the levels was observed in NTG group (P = 0.03, P = 0.02) in postoperative period when compared to levosimendan group of patients. Conclusion: Levosimendan treatment in patients undergoing surgical revascularization resulted in improved CI, decreased SVR and lower heart rate. And, thereby the duration of ventilation and length of ICU stay were significantly less in this group of patients when compared with NTG group.
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Affiliation(s)
- Manoj K Sahu
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
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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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Zangrillo A, Alvaro G, Pisano A, Guarracino F, Lobreglio R, Bradic N, Lembo R, Gianni S, Calabrò MG, Likhvantsev V, Grigoryev E, Buscaglia G, Pala G, Auci E, Amantea B, Monaco F, De Vuono G, Corcione A, Galdieri N, Cariello C, Bove T, Fominskiy E, Auriemma S, Baiocchi M, Bianchi A, Frontini M, Paternoster G, Sangalli F, Wang CY, Zucchetti MC, Biondi-Zoccai G, Gemma M, Lipinski MJ, Lomivorotov VV, Landoni G. A randomized controlled trial of levosimendan to reduce mortality in high-risk cardiac surgery patients (CHEETAH): Rationale and design. Am Heart J 2016; 177:66-73. [PMID: 27297851 DOI: 10.1016/j.ahj.2016.03.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 03/30/2016] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Patients undergoing cardiac surgery are at risk of perioperative low cardiac output syndrome due to postoperative myocardial dysfunction. Myocardial dysfunction in patients undergoing cardiac surgery is a potential indication for the use of levosimendan, a calcium sensitizer with 3 beneficial cardiovascular effects (inotropic, vasodilatory, and anti-inflammatory), which appears effective in improving clinically relevant outcomes. DESIGN Double-blind, placebo-controlled, multicenter randomized trial. SETTING Tertiary care hospitals. INTERVENTIONS Cardiac surgery patients (n = 1,000) with postoperative myocardial dysfunction (defined as patients with intraaortic balloon pump and/or high-dose standard inotropic support) will be randomized to receive a continuous infusion of either levosimendan (0.05-0.2 μg/[kg min]) or placebo for 24-48 hours. MEASUREMENTS AND MAIN RESULTS The primary end point will be 30-day mortality. Secondary end points will be mortality at 1 year, time on mechanical ventilation, acute kidney injury, decision to stop the study drug due to adverse events or to start open-label levosimendan, and length of intensive care unit and hospital stay. We will test the hypothesis that levosimendan reduces 30-day mortality in cardiac surgery patients with postoperative myocardial dysfunction. CONCLUSIONS This trial is planned to determine whether levosimendan could improve survival in patients with postoperative low cardiac output syndrome. The results of this double-blind, placebo-controlled randomized trial may provide important insights into the management of low cardiac output in cardiac surgery.
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García-González MJ, Jorge-Pérez P, Jiménez-Sosa A, Acea AB, Lacalzada Almeida JB, Ferrer Hita JJ. Levosimendan improves hemodynamic status in critically ill patients with severe aortic stenosis and left ventricular dysfunction: an interventional study. Cardiovasc Ther 2016; 33:193-9. [PMID: 25959786 DOI: 10.1111/1755-5922.12132] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
AIMS To study the hemodynamic effect of levosimendan administration in acute heart failure patients with severe aortic stenosis (AS) and reduced left ventricular ejection fraction (LVEF). METHODS Hemodynamic response to 24 h intravenous levosimendan infusion (0.1 μg/kg/min without a loading dose) in patients with severe AS (aortic valve area ≤1 cm(2) , time-velocity integral between left ventricular out-flow tract and aortic valve <0.25), reduced LVEF (≤40%), and a depressed cardiac index (CI) <2.2 L/min/m(2) was determined in a sequential group of nine patients aged 76 ± 10 years (5 men). RESULTS Baseline mean ejection fraction was 33 ± 0.7%; mean aortic valve area was 0.37 ±0.11 cm(2) /m(2) ; peak and mean gradients of 63.6 ± 20.53 and 36.7 ± 12.62 mmHg, respectively; and mean CI was 1.65 ± 0.20 L/min/m(2) . At 6 and 12 h of levosimendan therapy, mean CI had increased to 2.00 ± 0.41 L/min/m(2) (P = 0.02) and 2.17 ± 0.40 L/min/m(2) (P = 0.01), respectively. At 24 h, mean CI had increased further to 2.37 ± 0.49 L/min/m(2) (P = 0.01). A significant beneficial effect was also observed in pulmonary capillary wedge pressure, pulmonary artery mean pressure, central venous pressure, systemic vascular resistances, pulmonary vascular resistances, stroke volume index, left ventricular stroke work index. NTproBNP levels decreased at 24 h of levosimendan treatment. Levosimendan infusion was also well tolerated. Five patients subsequently underwent aortic valve surgery replacement. One died (of postoperative multiorgan failure). At 30 days, overall survival was 75%. CONCLUSIONS Levosimendan administration improves hemodynamic parameters in critically ill patients with severe AS and reduced LVEF. In our study, it provides a safe and effective bridge to aortic-valve replacement or oral vasodilator therapy in surgical contraindicated patients. A controlled study is needed to confirm these preliminary findings.
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Affiliation(s)
- Martín J García-González
- Acute Cardiac Care Unit, Department of Cardiology, Hospital Universitario de Canarias - Servicio Canario de la Salud, Tenerife, Spain
| | - Pablo Jorge-Pérez
- Acute Cardiac Care Unit, Department of Cardiology, Hospital Universitario de Canarias - Servicio Canario de la Salud, Tenerife, Spain
| | - Alejandro Jiménez-Sosa
- Research Unit, Hospital Universitario de Canarias, Ctra. La Cuesta - Taco, San Cristobal de La Laguna, Sta. Cruz de Tenerife, Spain
| | - Antonio Barragán Acea
- Acute Cardiac Care Unit, Department of Cardiology, Hospital Universitario de Canarias - Servicio Canario de la Salud, Tenerife, Spain
| | - Juan B Lacalzada Almeida
- Acute Cardiac Care Unit, Department of Cardiology, Hospital Universitario de Canarias - Servicio Canario de la Salud, Tenerife, Spain
| | - Julio J Ferrer Hita
- Acute Cardiac Care Unit, Department of Cardiology, Hospital Universitario de Canarias - Servicio Canario de la Salud, Tenerife, Spain
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Organ protection possibilities in acute heart failure. Rev Clin Esp 2016. [DOI: 10.1016/j.rceng.2016.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Calcium sensitizers: What have we learned over the last 25years? Int J Cardiol 2016; 203:543-8. [DOI: 10.1016/j.ijcard.2015.10.240] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 10/30/2015] [Accepted: 10/31/2015] [Indexed: 01/10/2023]
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Abstract
Acute heart failure (AHF) emerges as a major and growing epidemiological concern with high morbidity and mortality rates. Current therapies in patients with acute heart failure rely on different strategies. Patients with hypotension, hypoperfusion, or shock require inotropic support, whereas diuretics and vasodilators are recommended in patients with systemic or pulmonary congestion. Traditionally inotropic agents, referred to as Ca2+ mobilizers load the cardiomyocyte with Ca2+ and thereby increase oxygen consumption and risk for arrhythmias. These limitations of traditional inotropes may be avoided by sarcomere targeted agents. Direct activation of the cardiac sarcomere may be achieved by either sensitizing the cardiac myofilaments to Ca2+ or activating directly the cardiac myosin. In this review, we focus on sarcomere targeted inotropic agents, emphasizing their mechanisms of action and overview the most relevant clinical considerations.
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Treskatsch S, Balzer F, Geyer T, Spies CD, Kastrup M, Grubitzsch H, Wernecke KD, Erb JM, Braun JP, Sander M. Early levosimendan administration is associated with decreased mortality after cardiac surgery. J Crit Care 2015; 30:859.e1-6. [PMID: 25837801 DOI: 10.1016/j.jcrc.2015.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/04/2015] [Accepted: 03/07/2015] [Indexed: 12/29/2022]
Abstract
PURPOSE The aim of this study was to assess the effects on postoperative outcome of levosimendan with respect to timing of its administration in cardiac surgery patients. MATERIALS AND METHODS Levosimendan administration was triggered by a severely reduced left ventricular systolic function (left ventricular ejection fraction, <35%) and/or signs of a low cardiac output syndrome. A total of 159 patients were retrospectively assigned depending on an early (perioperatively up to the first hour after intensive care unit [ICU] admission) vs late (later than the first hour after ICU admission) start of treatment. RESULTS Patients receiving levosimendan after the first hour of ICU admission (n = 89) had a significantly increased inhospital (P = .004) and 1-year (P = .027) mortality. Duration of mechanical ventilation (P = .002), incidence of renal dysfunction (P = .002), and need of renal replacement therapy (P = .032) were significantly increased in the late start group. A late start of levosimendan treatment was associated with an odds ratio of 2.258 (95% confidence interval, 1.139-4.550; P = .021) for inhospital mortality and an adjusted hazard ratio of 1.827 (95% confidence interval, 1.155-2.890; P = .010) for 1-year survival. CONCLUSIONS Findings of this retrospective analysis favor an "early," that is, intraoperatively up to the first hour after ICU admission, start of perioperative levosimendan treatment to maximize its ability to reduce mortality and morbidity.
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Affiliation(s)
- Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
| | - Felix Balzer
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
| | - Torsten Geyer
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
| | - Claudia D Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
| | - Marc Kastrup
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
| | - Herko Grubitzsch
- Department of Cardiovascular Surgery, Campus Charité Mitte, Charité-Universitätsmedizin, Berlin, Germany.
| | | | - Joachim M Erb
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital of Basel, Basel, Switzerland.
| | - Jan P Braun
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Helios Klinikum Hildesheim GmbH, Hildesheim, Germany.
| | - Michael Sander
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
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Krychtiuk KA, Watzke L, Kaun C, Buchberger E, Hofer-Warbinek R, Demyanets S, Pisoni J, Kastl SP, Rauscher S, Gröger M, Aliabadi A, Zuckermann A, Maurer G, de Martin R, Huber K, Wojta J, Speidl WS. Levosimendan exerts anti-inflammatory effects on cardiac myocytes and endothelial cells in vitro. Thromb Haemost 2014; 113:350-62. [PMID: 25273157 DOI: 10.1160/th14-06-0549] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 08/25/2014] [Indexed: 01/09/2023]
Abstract
Levosimendan is a positive inotropic drug for the treatment of acute decompensated heart failure (HF). Clinical trials showed that levosimendan was particularly effective in HF due to myocardial infarction. Myocardial necrosis induces a strong inflammatory response, involving chemoattractants guiding polymorphonuclear neutrophils (PMN) into the infarcted myocardial tissue. Our aim was to examine whether levosimendan exhibits anti-inflammatory effects on human adult cardiac myocytes (HACM) and human heart microvascular endothelial cells (HHMEC). Cardiac myocytes and endothelial cells were stimulated with interleukin-1β (IL)-1β (200 U/ml) and treated with levosimendan (0.1-10 µM) for 2-48 hours. IL-1β strongly induced expression of IL-6 and IL-8 in HACM and E-selectin and intercellular adhesion molecule-1 (ICAM-1) in HHMEC and human umbilical vein endothelial cells (HUVEC). Treatment with levosimendan strongly attenuated IL-1β-induced expression of IL-6 and IL-8 in HACM as well as E-selectin and ICAM-1 in ECs. Levosimendan treatment further reduced adhesion of PMN to activated endothelial cells under both static and flow conditions by approximately 50 %. Incubation with 5-hydroxydecanoic acid, a selective blocker of mitochondrial ATP-dependent potassium channels, partly abolished the above seen anti-inflammatory effects. Additionally, levosimendan strongly diminished IL-1β-induced reactive oxygen species and nuclear factor-κB (NF-κB) activity through inhibition of S536 phosphorylation. In conclusion, levosimendan exhibits anti-inflammatory effects on cardiac myocytes and endothelial cells in vitro. These findings could explain, at least in part, the beneficial effects of levosimendan after myocardial infarction.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Johann Wojta
- Johann Wojta, PhD, Department of Internal Medicine II, Medical University of Vienna, Austria, Tel.: +43 1 4040073500, Fax: +43 1 4040073586, E-mail:
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Impact of levosimendan on brain injury patterns in a lamb model of infant cardiopulmonary bypass. Pediatr Res 2014; 76:64-71. [PMID: 24713816 DOI: 10.1038/pr.2014.51] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 01/10/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND The effects of levosimendan (Levo) on injury patterns in the immature brain following cardiopulmonary bypass (CPB) are unknown. METHODS Eighteen 3- to 4-wk-old anesthetized lambs, instrumented with vascular catheters and aortic and right carotid artery flow probes, were allocated to non-CPB, CPB, or CPB+Levo groups (each n = 6). After 120 min CPB with 90 min aortic cross-clamp, CPB animals received dopamine, and CPB+Levo animals both dopamine and Levo, for 4 h. All lambs then underwent brain magnetic resonance imaging, followed by postmortem brain perfusion fixation for immunohistochemical studies. RESULTS In CPB lambs, aortic (P < 0.05) and carotid artery (P < 0.01) blood flows fell by 29 and 30%, respectively, between 2 and 4 h after cross-clamp removal but were unchanged in the CPB+Levo group. No brain injury was detectable with magnetic resonance imaging in either CPB or CPB+Levo lambs. However, on immunohistochemical analysis, white matter astrocyte density of both groups was higher than in non-CPB lambs (P < 0.05), while white matter microglial density was higher (P < 0.05), but markers of cortical oxidative stress were less prevalent in CPB+Levo than CPB lambs. CONCLUSION While Levo prevented early postoperative falls in cardiac output and carotid artery blood flow in a lamb model of infant CPB, this was associated with heterogeneous neuroglial activation and manifestation of markers of oxidative stress.
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Varvarousi G, Stefaniotou A, Varvaroussis D, Aroni F, Xanthos T. The role of Levosimendan in cardiopulmonary resuscitation. Eur J Pharmacol 2014; 740:596-602. [PMID: 24972240 DOI: 10.1016/j.ejphar.2014.06.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Revised: 06/13/2014] [Accepted: 06/17/2014] [Indexed: 11/30/2022]
Abstract
Although initial resuscitation from cardiac arrest (CA) has increased over the past years, long term survival rates remain dismal. Epinephrine is the vasopressor of choice in the treatment of CA. However, its efficacy has been questioned, as it has no apparent benefits for long-term survival or favorable neurologic outcome. Levosimendan is an inodilator with cardioprotective and neuroprotective effects. Several studies suggest that it is associated with increased rates of return of spontaneous circulation as well as improved post-resuscitation myocardial function and neurological outcome. The purpose of this article is to review the properties of Levosimendan during cardiopulmonary resuscitation (CPR) and also to summarize existing evidence regarding the use of Levosimendan in the treatment of CA.
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Affiliation(s)
- Giolanda Varvarousi
- National and Kapodistrian University of Athens, Medical School, MSc Cardiopulmonary Resuscitation, 75 Mikras Asias Street, 11527 Athens, Greece
| | - Antonia Stefaniotou
- National and Kapodistrian University of Athens, Medical School, MSc Cardiopulmonary Resuscitation, 75 Mikras Asias Street, 11527 Athens, Greece
| | - Dimitrios Varvaroussis
- National and Kapodistrian University of Athens, Medical School, MSc Cardiopulmonary Resuscitation, 75 Mikras Asias Street, 11527 Athens, Greece
| | - Filippia Aroni
- National and Kapodistrian University of Athens, Medical School, MSc Cardiopulmonary Resuscitation, 75 Mikras Asias Street, 11527 Athens, Greece
| | - Theodoros Xanthos
- National and Kapodistrian University of Athens, Medical School, MSc Cardiopulmonary Resuscitation, 75 Mikras Asias Street, 11527 Athens, Greece; Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece.
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Abstract
The field of mitochondrial ion channels has recently seen substantial progress, including the molecular identification of some of the channels. An integrative approach using genetics, electrophysiology, pharmacology, and cell biology to clarify the roles of these channels has thus become possible. It is by now clear that many of these channels are important for energy supply by the mitochondria and have a major impact on the fate of the entire cell as well. The purpose of this review is to provide an up-to-date overview of the electrophysiological properties, molecular identity, and pathophysiological functions of the mitochondrial ion channels studied so far and to highlight possible therapeutic perspectives based on current information.
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Erb J, Beutlhauser T, Feldheiser A, Schuster B, Treskatsch S, Grubitzsch H, Spies C. Influence of levosimendan on organ dysfunction in patients with severely reduced left ventricular function undergoing cardiac surgery. J Int Med Res 2014; 42:750-64. [PMID: 24781725 DOI: 10.1177/0300060513516293] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 11/19/2013] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Levosimendan is an inotropic drug with organ-protective properties due to its activation of mitochondrial K(ATP) channels. This prospective, randomized, double-blind, placebo-controlled study investigated whether administration of levosimendan prior to cardiopulmonary bypass could reduce organ dysfunction and influence subsequent secondary endpoints. PATIENTS AND METHODS Patients with left ventricular ejection fraction <30% scheduled for elective coronary artery bypass surgery (with or without valve surgery) received either levosimendan (12.5 mg, 0.1 µg kg(-1) per min; n = 17) or placebo (n = 16) central venous infusion, immediately after anaesthesia induction, as add-on medication to a goal-orientated treatment algorithm. RESULTS A total of 33 patients completed the study. There were no statistically significant differences in Sequential Organ Failure Assessment scores, survival, haemodynamic parameters, time to extubation, time in intensive care unit, need for haemodialysis or health-related quality-of-life at 6 months post operation. The levosimendan group compared with the placebo group had significantly lower use of epinephrine (35% versus 81%) and nitroglycerine (6% versus 44%) 24 h postoperation, and significantly less frequent serious adverse events (13% versus 47%). CONCLUSIONS These preliminary results show that timely perioperative levosimendan treatment is feasible, has a favourable safety profile safe and may help to prevent low cardiac output syndrome. However, organ function was not preserved. Further studies, using larger sample sizes, are required.
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Affiliation(s)
- Joachim Erb
- Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital of Basel, Basel, Switzerland
| | - Torsten Beutlhauser
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Aarne Feldheiser
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Birgit Schuster
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sascha Treskatsch
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Herko Grubitzsch
- Department of Cardiovascular Surgery, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Onody P, Stangl R, Fulop A, Rosero O, Garbaisz D, Turoczi Z, Lotz G, Rakonczay Z, Balla Z, Hegedus V, Harsanyi L, Szijarto A. Levosimendan: a cardiovascular drug to prevent liver ischemia-reperfusion injury? PLoS One 2013; 8:e73758. [PMID: 24040056 PMCID: PMC3770697 DOI: 10.1371/journal.pone.0073758] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 07/22/2013] [Indexed: 01/19/2023] Open
Abstract
Introduction Temporary occlusion of the hepatoduodenal ligament leads to an ischemic-reperfusion (IR) injury in the liver. Levosimendan is a new positive inotropic drug, which induces preconditioning-like adaptive mechanisms due to opening of mitochondrial KATP channels. The aim of this study was to examine possible protective effects of levosimendan in a rat model of hepatic IR injury. Material and Methods Levosimendan was administered to male Wistar rats 1 hour (early pretreatment) or 24 hours (late pretreatment) before induction of 60-minute segmental liver ischemia. Microcirculation of the liver was monitored by laser Doppler flowmeter. After 24 hours of reperfusion, liver and blood samples were taken for histology, immuno- and enzyme-histochemistry (TUNEL; PARP; NADH-TR) as well as for laboratory tests. Furthermore, liver antioxidant status was assessed and HSP72 expression was measured. Results In both groups pretreated with levosimendan, significantly better hepatic microcirculation was observed compared to respective IR control groups. Similarly, histological damage was also reduced after levosimendan administration. This observation was supported by significantly lower activities of serum ALT (pearly = 0.02; plate = 0.005), AST (pearly = 0.02; plate = 0.004) and less DNA damage by TUNEL test (pearly = 0.05; plate = 0.034) and PAR positivity (pearly = 0.02; plate = 0.04). Levosimendan pretreatment resulted in significant improvement of liver redox homeostasis. Further, significantly better mitochondrial function was detected in animals receiving late pretreatment. Finally, HSP72 expression was increased by IR injury, but it was not affected by levosimendan pretreatment. Conclusion Levosimendan pretreatment can be hepatoprotective and it could be useful before extensive liver resection.
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Affiliation(s)
- Peter Onody
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
- * E-mail:
| | - Rita Stangl
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Andras Fulop
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Oliver Rosero
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - David Garbaisz
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Zsolt Turoczi
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Gabor Lotz
- 2 Department of Pathology, Semmelweis University, Budapest, Hungary
| | - Zoltan Rakonczay
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Zsolt Balla
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Viktor Hegedus
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Laszlo Harsanyi
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Attila Szijarto
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
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The effects of levosimendan exposure on oxidant/antioxidant status and trace element levels in the pulmonary artery of rats. J Membr Biol 2013; 246:473-8. [PMID: 23673724 PMCID: PMC3682096 DOI: 10.1007/s00232-013-9559-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 05/03/2013] [Indexed: 10/26/2022]
Abstract
We investigated both the effect of levosimendan and the role of oxidant/antioxidant status and trace element levels in the pulmonary artery of rats. Fourteen male Wistar albino rats were randomly divided into two groups of seven animals each. Group 1 was not exposed to levosimendan and served as a control. Levosimendan (12 μg/kg) diluted in 10 ml 0.9 % NaCl was administered intraperitoneally to group 2. Animals of both groups were killed after 3 days, and their pulmonary arteries were harvested to determine changes in tissue oxidant/antioxidant status and trace element levels. The animals in both groups were killed 72 h after the levosimendan exposure treatment, and pulmonary arteries were harvested to determine levels of the lipid peroxidation product MDA and the antioxidant GSH as well as the decreased activity of antioxidant enzymes such as SOD, GSH-Px and CAT. It was found that MDA levels increased in pulmonary artery tissues of rats after levosimendan administration. The GSH level decreased in the pulmonary artery of rats after levosimendan treatment. Co, Mn, Fe, Cd and Pb levels were significantly higher (P < 0.001) and Mg, Zn and Cu levels significantly lower (P < 0.001) in the levosimendan group compared to the control group. These results suggest that levosimendan treatment caused an increase in free radical production and a decrease in antioxidant enzyme activity in the pulmonary artery of levosimendan-treated rats. It also caused a decrease or increase in the levels of many minerals in the pulmonary artery, which is an undesirable condition for normal pharmacological function.
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Pathak A, Lebrin M, Vaccaro A, Senard JM, Despas F. Pharmacology of levosimendan: inotropic, vasodilatory and cardioprotective effects. J Clin Pharm Ther 2013; 38:341-9. [PMID: 23594161 DOI: 10.1111/jcpt.12067] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 03/20/2013] [Indexed: 01/15/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Positive inotropic agents are frequently used in acute decompensated heart failure (ADHF) due to left ventricular systolic dysfunction. These agents are known to improve cardiac performance and peripheral perfusion in the short-term treatment. However, several preclinical and clinical studies emphasized detrimental effects of these drugs on myocardial oxygen demand and on sympathetic tone entailing arrhythmogenesis. Levosimendan is an inotropic agent with an original mechanism of action. This review focuses on major data available for levosimendan. METHODS A literature search was conducted in the PubMed database by including studies published in English using combinations of the following key words, levosimendan, inotropic drugs and acute heart failure. Furthermore, bibliographies of selected references were also evaluated for relevant articles. The collection for this review was limited to the most recently available human and animal data. RESULTS AND DISCUSSION Levosimendan's vasodilatory and cardioprotective effects are mediated by calcium sensitization of contractile proteins and opening of adenosine triphosphate (ATP)-dependent K+ channels in vascular smooth muscle cells and on mitochondrial ATP-sensitive potassium [mito.K(ATP)] channels. This inotropic agent has mild PDE inhibitory action. Unlike other inotropic agents, levosimendan improves cardiac performance without activating the sympathetic nervous system. Moreover, there are evidences that levosimendan has additional anti-inflammatory and anti-apoptotic properties that prevent cardiac toxicity and contributes to positive hemodynamic response of the drug. Four randomized trials evaluated the effects of levosimendan on mortality in patients with acute decompensated chronic heart failure; nevertheless, a clear benefit has not been demonstrated so far. Although levosimendan is indicated for the treatment of ADHF (class of recommendation IIa, level of evidence B), it is has not been approved in all countries. WHAT IS NEW AND CONCLUSION This review summarizes the characteristics and the current knowledge of the literature on levosimendan and its active metabolite OR-1896.
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Affiliation(s)
- A Pathak
- Institut National de Sante et de Recherche Médicale (INSERM), UMR-1048, Institut des maladies métaboliques et cardiovasculaires I2MC, Toulouse, France
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Kivikko M, Nieminen MS, Pollesello P, Pohjanjousi P, Colucci WS, Teerlink JR, Mebazaa A. The clinical effects of levosimendan are not attenuated by sulfonylureas. SCAND CARDIOVASC J 2012; 46:330-8. [DOI: 10.3109/14017431.2012.725206] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Aydin C, Ay Y, Basel H, Kavak S, İnan B, Bektaş H, Gümrükçüoğlu HA, Ekim H, Demir H. Analysis of the Influences of Short-Term Levosimendan Exposure on Oxidant/Antioxidant Status and Trace-Element Levels in the Physiological Status of the Thoracic Aorta of Rats. J Membr Biol 2012; 245:827-32. [DOI: 10.1007/s00232-012-9489-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Accepted: 07/07/2012] [Indexed: 11/29/2022]
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Abstract
Acute cardiac failure caused by myocardial infarction or inadequate cardioprotection during heart surgery is associated with increased mortality and morbidity. Levosimendan is a new drug used in heart failure though it is limited by the systemic hypotension, which develops with intravenous administration. Intracoronary (IC) administration however should affect systemic circulation less while maintaining the beneficial cardiac effects of the drug. We herewith report the results from the first such clinical series. Levosimendan was administered IC in 33 consecutive patients who developed cardiogenic shock during heart surgery and were unable to wean off cardiopulmonary bypass despite maximal support. Preadministration/postadministration coronary graft flows, hemodynamic parameters, left ventricular function, and metabolic requirements were measured and compared. Levosimendan significantly increased graft flows and improved hemodynamic parameters. Systolic blood pressure (93 ± 26.4 vs. 106 ± 18.2 mm Hg, P < 0.05) and cardiac index (2.0 ± 0.5 vs. 3.1 ± 0.2, P < 0.001) were increased, whereas systemic vascular resistance (1470.7 ± 114 vs. 1195.8 ± 112, P < 0.01) was reduced. Better myocardial perfusion improved metabolic requirements, with myocardial oxygen extraction and glucose uptake increasing by 72% and 74%, respectively, whereas lactate production was reduced by 64%. Echocardiography demonstrated additional ventricular segment recruitment. Therefore, IC Levosimendan administration in acute heart failure is safe and efficacious producing improved cardiac function without significant detrimental hypotension.
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Abstract
Levosimendan exerts cardioprotection through mitochondrial K(ATP) (mitoK(ATP)) channels opening. In addition, intracoronary levosimendan was found to modulate programmed forms of cell death by nitric oxide (NO) involvement. The aim of this study was to examine the role of mitoK(ATP) channels and NO in the effects of levosimendan on apoptosis/autophagy. In H9c2 cells treated with hydrogen peroxide apoptosis/autophagy, survival signaling, cell viability, mitochondrial membrane potential, and permeability transition pore opening were analyzed through Western blot and colorimetric and fluorescence assays. Pretreatment of H9c2 cells with levosimendan was able to counteract the oxidative injuries caused by hydrogen peroxide. The effects of levosimendan were potentiated by diazoxide and were similar to those elicited by the autophagic activator rapamycin. The autophagic inhibitor 3-methyladenine reduced the effects of levosimendan, whereas after the pan-caspases inhibitor N-Acetyl-Asp-Glu-Val-Asp-al (Z-VAD.FMK), cell survival and autophagy in response to levosimendan increased. Both the mitoK(ATP) channels inhibition and the NO synthase blocking attenuated the cardioprotection elicited by levosimendan. The results have shown that levosimendan protects H9c2 cells against oxidative injuries through the modulation of the interplay between autophagy and apoptosis and the activation of survival signaling. The mitoK(ATP) channels and NO may be involved in such cardioprotection through interference with mitochondrial functioning.
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Abstract
PURPOSE OF REVIEW ICU patients frequently develop low output syndromes due to cardiac dysfunction, myocardial injury, and inflammatory activation. Conventional inotropic agents seem to be useful in restoring hemodynamic parameters and improving peripheral organ perfusion, but can increase short-term and long-term mortality in these patients. Novel inotropes may be promising in the management of ICU patients, having no serious adverse effects. This review summarizes all the current knowledge about the use of conventional and new inotropic agents in various clinical entities of critically ill patients. RECENT FINDINGS In recent European Society of Cardiology guidelines, inotropic agents are administered in patients with low output syndrome due to impaired cardiac contractility, and signs and symptoms of congestion. The most recommended inotropes in this condition are levosimendan and dobutamine (both class of recommendation: IIa, level of evidence: B). Recent data indicate that levosimendan may be useful in postmyocardial infarction cardiac dysfunction and septic shock through increasing coronary flow and attenuating inflammatory activation, respectively. Furthermore, calcium sensitizing by levosimendan can be effectively used for weaning of mechanical ventilation in postcardiac surgery patients and has also cardioprotective effect as expressed by the absence of troponin release in this patient population. Finally, new agents, such as istaroxime and cardiac myosin activators may be safe and improve central hemodynamics in experimental models of heart failure and heart failure patients in phase II clinical trials; however, large-scale randomized clinical trials are required. SUMMARY In an acute cardiac care setting, short-term use of inotropic agents is crucial for the restoration of arterial blood pressure and peripheral tissue perfusion, as well as weaning of cardiosurgery. New promising agents should be tested in randomized clinical trials.
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Omerovic E, Råmunddal T, Albertsson P, Holmberg M, Hallgren P, Boren J, Grip L, Matejka G. Levosimendan neither improves nor worsens mortality in patients with cardiogenic shock due to ST-elevation myocardial infarction. Vasc Health Risk Manag 2010; 6:657-63. [PMID: 20859537 PMCID: PMC2941779 DOI: 10.2147/vhrm.s8856] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Indexed: 01/13/2023] Open
Abstract
Background: The aim of this study was to evaluate the effect of levosimendan on mortality in cardiogenic shock (CS) after ST elevation myocardial infarction (STEMI). Methods and results: Data were obtained prospectively from the SCAAR (Swedish Coronary Angiography and Angioplasty Register) and the RIKS-HIA (Register of Information and Knowledge about Swedish Heart Intensive Care Admissions) about 94 consecutive patients with CS due to STEMI. Patients were classified into levosimendan-mandatory and levosimendan-contraindicated cohorts. Inotropic support with levosimendan was mandatory in all patients between January 2004 and December 2005 (n = 46). After the SURVIVE and REVIVE II studies were presented, levosimendan was considered contraindicated and was not used in consecutive patients between December 2005 and December 2006 (n = 48). The cohorts were similar with respect to pre-treatment characteristics and concomitant medications. There was no difference in the incidence of new-onset atrial fibrillation, in-hospital cardiac arrest and length of stay at the coronary care unit. There was no difference in adjusted mortality at 30 days and at one year. Conclusion: The use of levosimendan neither improves nor worsens mortality in patients with CS due to STEMI. Well-designed randomized clinical trials are needed to define the role of inotropic therapy in the treatment of CS.
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Affiliation(s)
- Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Levosimendan as treatment option in severe verapamil intoxication: a case report and review of the literature. Case Rep Med 2010; 2010. [PMID: 20814559 PMCID: PMC2931406 DOI: 10.1155/2010/546904] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Revised: 05/09/2010] [Accepted: 07/08/2010] [Indexed: 11/17/2022] Open
Abstract
Cardiovascular shock due to verapamil intoxication is often refractory to standard resuscitation methods. Recommended therapy includes prevention of further absorption of the drug, inotropic therapy, calcium gluconate, and hyperinsulinemia/euglycemia therapy. Often further measures are needed such as ventricular pacing or mechanical circulatory support. Still, mortality remains high.
Levosimendan, an inotropic agent, that enhances myofilament response to calcium, increases myocardial contraction and could therefore be beneficial in verapamil intoxication. Here, we report the case of a 60-year-old patient with clinically severe verapamil poisoning who presented with shock, bradycardia, and sopor. Standard therapy including high-dose inotropes failed to ameliorate the signs of intoxication. But additional therapy with levosimendan led to rapid improvement. Based on this observation, the literature is reviewed focusing on utilization of levosimendan in the treatment of calcium channel blocker overdose. We suggest to consider levosimendan as additional treatment option in patients with cardiovascular shock due to verapamil intoxication that are refractory to standard management.
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