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Comprehensive Comparisons among Inotropic Agents on Mortality and Risk of Renal Dysfunction in Patients Who Underwent Cardiac Surgery: A Network Meta-Analysis of Randomized Controlled Trials. J Clin Med 2021; 10:jcm10051032. [PMID: 33802296 PMCID: PMC7959132 DOI: 10.3390/jcm10051032] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 02/23/2021] [Accepted: 02/26/2021] [Indexed: 02/07/2023] Open
Abstract
Several kinds of inotropes have been used in critically ill patients to improve hemodynamics and renal dysfunction after cardiac surgery; however, the treatment strategies for reducing mortality and increasing renal protection in patients who underwent cardiac surgery remain controversial. Therefore, we performed a comprehensive network meta-analysis to overcome the lack of head-to-head comparisons. A systematic database was searched up to 31 December 2020, for randomized controlled trials that compared different inotropes on mortality outcomes and renal protective effects after cardiac surgery. A total of 29 trials were included and a frequentist network meta-analysis was performed. Inconsistency analyses, publication bias, and subgroup analyses were also conducted. Compared with placebo, use of levosimendan significantly decreased the risks of mortality (odds ratio (OR): 0.74; 95% confidence interval (CI): 0.56–0.97) and risk of acute renal injury (OR: 0.61; 95% CI: 0.45–0.82), especially in low systolic function patients. Use of levosimendan also ranked the best treatment based on the P-score (90.1%), followed by placebo (64.5%), milrinone (49.6%), dopamine (49.5%), dobutamine (29.1%), and fenoldopam (17.0%). Taking all the available data into consideration, levosimendan was a safe renal-protective choice for the treatment of patients undergoing cardiac surgery, especially for those with low systolic function.
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Amin SW, Abd-Elgalil SM, Mohamed SA, Ahmed MM, Hamawy TY, Fathi LM. Levosimendan Versus Milrinone in the Management of Impaired Left Ventricular Function in Patients Undergoing Coronary Artery Bypass Graft Surgery. THE OPEN ANESTHESIA JOURNAL 2019; 13:59-67. [DOI: 10.2174/2589645801913010059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/17/2019] [Accepted: 06/26/2019] [Indexed: 09/02/2023]
Abstract
Background:
Patients undergoing cardiac surgery are at risk of postcardiotomy myocardial dysfunction. This condition causes delayed recovery, organ failure, prolonged intensive care unit and hospital stays, and an increased risk of mortality; these patients often require inotropic agent support. Levosimendan is a calcium sensitizer with a unique mechanism of action, binding to cardiac troponin C and enhancing myofilament responsiveness to calcium, increasing myocardial contraction without increasing myocardial oxygen consumption. Phosphodiesterase III inhibitors such as milrinone provide an alternative means of inotropic support by increasing the concentration of cyclic AMP and intracellular calcium. They also have vasodilatory effects.
Objective:
The aim of this study was the comparison between levosimendan versus milrinone regarding their effects on the hemodynamics, need for additional mechanical (intra aortic balloon pump) or pharmacological support to the heart, weaning from mechanical ventilation and duration of intensive care unit stay for patients after Off-Pump Coronary Artery Bypass Graft (OPCABG) surgery suffering from impaired left ventricular function (preoperative ejection fraction ≤ 40%).
Methods:
60 patients between 40 and 70 years of both sexes with impaired left ventricular function (ejection fraction ≤ 40%), New York Heart Association (NYHA III & IV), undergoing elective Off-Pump Coronary Artery Bypass Graft (OPCABG) surgery were selected for this study. After induction of anesthesia, patients were randomly assigned to one of two equal groups each containing 30 patients:
Group L (Levosimendan group) included patients who received levosimendan 0.1- 0.2 µg/kg/min. Started immediately with the induction of anesthesia.
Group M (Milrinone group) included patients who received milrinone 0.4-0.6 µg/kg/min. Started immediately with the induction of anesthesia.
In both groups, norepinephrine was titrated (8 mg norepinephrine in 50 ml saline) to keep mean arterial pressure MAP ≥ 70 mmHg.
Hemodynamic findings included Preoperative and post ICU discharge ejection fraction, systemic and pulmonary artery pressures, systemic and pulmonary vascular resistance, cardiac output and stroke volume. Also laboratory findings included Serum lactate and Troponin I., in addition, to post operative findings were: Need for intra aortic balloon pump, time of weaning from the ventilator, days of ICU stay and appearance of drug allergy compared in both groups.
Results:
There was a significant increase in the ejection fraction in both groups that was greater in the levosimendan group. The decrease in pulmonary pressure in the levosimendan group was more significant than milrinone group. There was a gradual decrease in pulmonary and systemic vascular resistance in both groups with a more significant decrease in the levosimendan group. There was a gradual increase in cardiac output and stroke volume in both groups that was greater in the levosimendan group. Serum lactate gradually decreased in both groups with an insignificant difference; there was an increase in serum troponin I level in both groups which was more significant in the milrinone group. Weaning from mechanical ventilation and length of ICU stay was shown to be significantly shorter in time in the levosimendan group.
Conclusion:
Both levosimendan and milrinone caused a significant increase in cardiac output, stroke volume and ejection fraction, with a decrease in pulmonary and systemic vascular resistance. These effects improved cardiac performance by decreasing afterload and increasing cardiac inotropism. It was noticed that these effects were more significant with levosimendan than milrinone. Also, there was a decrease in ICU stay, mechanical ventilation timing and hospital stay with levosimendan than milrinone which decreased the costs of treatment for the patients.
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Perioperative use of levosimendan in patients undergoing cardiac surgery. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2019. [DOI: 10.1097/cj9.0000000000000121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Alvarez J, Baluja A, Selas S, Otero P, Rial M, Veiras S, Caruezo V, Laboada M, Rodriguez I, Caslroagudin J, Lome S, Rodriguez A, Rodriguez J. A Comparison of Doubutamine and Levosimendan on Hepatic Blood Flow in Patients with a Low Cardiac Output State after Cardiac Surgery: A Randomised Controlled Study. Anaesth Intensive Care 2019; 41:719-27. [DOI: 10.1177/0310057x1304100606] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- J. Alvarez
- Department Anesthesia and Surgical ICU, University Hospital, University of Santiago de Compostela, Spain
| | - A. Baluja
- Department Anesthesia and Surgical ICU, University Hospital, University of Santiago de Compostela, Spain
| | - S. Selas
- Department Anesthesia and Surgical ICU, University Hospital, University of Santiago de Compostela, Spain
| | - P. Otero
- Department Anesthesia and Surgical ICU, University Hospital, University of Santiago de Compostela, Spain
| | - M. Rial
- Department Anesthesia and Surgical ICU, University Hospital, University of Santiago de Compostela, Spain
| | - S. Veiras
- Department Anesthesia and Surgical ICU, University Hospital, University of Santiago de Compostela, Spain
| | - V. Caruezo
- Department Anesthesia and Surgical ICU, University Hospital, University of Santiago de Compostela, Spain
| | - M. Laboada
- Department Anesthesia and Surgical ICU, University Hospital, University of Santiago de Compostela, Spain
| | - I. Rodriguez
- Department Anesthesia and Surgical ICU, University Hospital, University of Santiago de Compostela, Spain
| | - J. Caslroagudin
- Department Anesthesia and Surgical ICU, University Hospital, University of Santiago de Compostela, Spain
| | - S. Lome
- Department Anesthesia and Surgical ICU, University Hospital, University of Santiago de Compostela, Spain
| | - A. Rodriguez
- Department Anesthesia and Surgical ICU, University Hospital, University of Santiago de Compostela, Spain
| | - J. Rodriguez
- Department Anesthesia and Surgical ICU, University Hospital, University of Santiago de Compostela, Spain
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Roeleveld PP, de Klerk JCA. The Perspective of the Intensivist on Inotropes and Postoperative Care Following Pediatric Heart Surgery: An International Survey and Systematic Review of the Literature. World J Pediatr Congenit Heart Surg 2017; 9:10-21. [PMID: 29092664 PMCID: PMC5764149 DOI: 10.1177/2150135117731725] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: Inotropes are frequently being used in children undergoing heart surgery to prevent or treat low cardiac output syndrome (LCOS). There is only limited evidence that inotropes actually positively influence postoperative outcome. Our aim was to describe the current international practice variation in the use of inotropes following congenital heart surgery. Methods: We developed an online survey regarding the postoperative use of inotropes. We sent an invitation to all 197 registered members of the Pediatric Cardiac Intensive Care Society (PCICS) to participate in the survey. We also performed a systematic review of the literature. Results: Ninety-eight people (50%) responded, representing 62 international centers. Milrinone is routinely used perioperatively by 90 respondents (97%). Adrenaline/epinephrine is routinely used by 43%, dopamine by 36%, dobutamine by 11%, and levosimendan by 6%. Steroids are used routinely by 54% before initiating cardiopulmonary bypass. Vasopressin is used by 44% of respondents. The development of LCOS is monitored with lactate in 99% of respondents, physical examination (98%), intermittent mixed venous saturation (76%), continuous mixed venous saturation (13%), echocardiography (53%), core–peripheral temperature gap (29%), near-infrared spectrometry (25%), and 4% use cardiac output monitors (PiCCO, USCOM). To improve cardiac output, 42% add/increase milrinone, 37% add adrenaline, and 15% add dopamine. Rescue therapy is titrated individually, based on the patients’ pathophysiology. A systematic review of the literature failed to show compelling evidence with regard to the benefit of inotropes. Conclusions: Despite the lack of sufficient evidence, milrinone is used by the vast majority of caregivers following congenital heart surgery.
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Affiliation(s)
- Peter P Roeleveld
- 1 Department of Pediatric Intensive Care, Leiden University Medical center, Leiden, The Netherlands
| | - J C A de Klerk
- 2 Department of Neonatal Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Chen QH, Zheng RQ, Lin H, Shao J, Yu JQ, Wang HL. Effect of levosimendan on prognosis in adult patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:253. [PMID: 29041948 PMCID: PMC5645931 DOI: 10.1186/s13054-017-1848-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 09/28/2017] [Indexed: 01/24/2023]
Abstract
Background Small trials suggest that levosimendan is associated with a favorable outcome in patients undergoing cardiac surgery. However, recently published larger-scale trials did not provide evidence for a similar benefit from levosimendan. We performed a meta-analysis to assess the survival benefits of levosimendan in patients undergoing cardiac surgery and to investigate its effects in subgroups of patients with preoperative low-ejection fraction (EF). Methods We identified randomized clinical trials through 20 April 2017 that investigated levosimendan therapy versus control in patients undergoing cardiac surgery. Individual patient data from each study were compiled. Meta-analyses were performed for primary outcomes, secondary outcomes and serious adverse events, and subgroup analyses according to the preoperative EF of enrolled patients were also conducted. The risk of bias was assessed using the Cochrane risk-of-bias tool. Results Seventeen studies involving a total of 2756 patients were included. Levosimendan therapy was associated with a significant reduction in 30-day mortality (RR 0.67; 95% CI, 0.49 to 0.93; p = 0.02) and reduced the risk of death in single-center trials (RR 0.49; 95% CI, 0.30 to 0.79; p = 0.004) and in subgroup trials of inferior quality (RR 0.39; 95% CI, 0.17 to 0.92; p = 0.02); however, in multicenter and in high-quality subgroup-analysis trials, no significant difference in mortality was observed between patients who received levosimendan therapy and controls (p > 0.05). However, in high-quality subgroup trials, levosimendan therapy was associated with reduced mortality in patients in a preoperative low-EF subgroup (RR 0.58; 95% CI, 0.38 to 0.88; p = 0.01). Similarly, only patients in the preoperative low-EF subgroup benefited in terms of reduced risk of renal replacement therapy (RR 0.54; 95% CI, 0.34 to 0.85; p = 0.007). Furthermore, levosimendan therapy was associated with a significant reduction in intensive care unit (ICU) length of stay (MDR −17.19; 95% CI, −34.43 to −2.94; p = 0.02). Conclusions In patients undergoing cardiac surgery, the benefit of levosimendan in terms of survival was not shown in multicenter or in high-quality trials; however, levosimendan therapy was associated with reduced mortality in patients with preoperative ventricular systolic dysfunction. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1848-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Qi-Hong Chen
- Department of Critical Care Medicine, Subei People's Hospital, School of Medicine, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu, 225001, People's Republic of China
| | - Rui-Qiang Zheng
- Department of Critical Care Medicine, Subei People's Hospital, School of Medicine, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu, 225001, People's Republic of China
| | - Hua Lin
- Department of Critical Care Medicine, Subei People's Hospital, School of Medicine, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu, 225001, People's Republic of China
| | - Jun Shao
- Department of Critical Care Medicine, Subei People's Hospital, School of Medicine, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu, 225001, People's Republic of China
| | - Jiang-Quan Yu
- Department of Critical Care Medicine, Subei People's Hospital, School of Medicine, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu, 225001, People's Republic of China
| | - Hua-Ling Wang
- Department of Critical Care Medicine, Subei People's Hospital, School of Medicine, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu, 225001, People's Republic of China. .,Department of Cardiology, Subei People's Hospital, School of Medicine, Yangzhou University, 98 Nantong West Road, Yangzhou, 225001, People's Republic of China.
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Cornejo-Avendaño J, Azpiri-López J, Ramírez-Rosales A. Levosimendan in acute decompensated heart failure: Systematic review and meta-analysis. MEDICINA UNIVERSITARIA 2017. [DOI: 10.1016/j.rmu.2017.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Hinojosa FQ, Revelo M, Salazar A, Maggi G, Schiraldi R, Brogly N, Gilsanz F. Levosimendan as a treatment for acute renal failure associated with cardiogenic shock after hip fracture. Braz J Anesthesiol 2016; 67:89-91. [PMID: 28017176 DOI: 10.1016/j.bjane.2014.07.009] [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: 06/10/2014] [Accepted: 07/07/2014] [Indexed: 10/24/2022] Open
Abstract
Inotropic drugs are part of the treatment of heart failure; however, inotropic treatment has been largely debated due to the increased incidence of adverse effects and increased mortality. Recently levosimendan, an inotropic positive agent, has been proved to be effective in acute heart failure, reducing the mortality and improving cardiac and renal performance. We report the case of a 75-year-old woman with history of heart and renal failure and hip fracture. Levosimendan was used in preoperative preparation as an adjuvant therapy, to improve cardiac and renal function and to allow surgery.
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Affiliation(s)
| | - Margarita Revelo
- Hospital Universitario de La Paz, Servicio de Anestesiologia, Madrid, Spain
| | - Alexander Salazar
- Hospital Universitario de La Paz, Servicio de Anestesiologia, Madrid, Spain
| | - Genaro Maggi
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Renato Schiraldi
- Hospital Universitario de La Paz, Servicio de Anestesiologia, Madrid, Spain
| | - Nicolas Brogly
- Hospital Universitario de La Paz, Servicio de Anestesiologia, Madrid, Spain
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Gencer E, Doğan V, Öztürk MT, Nadir A, Musmul A, Cavuşoğlu Y. Comparison of the Effects of Levosimendan Dobutamine and Vasodilator Therapy on Ongoing Myocardial Injury in Acute Decompensated Heart Failure. J Cardiovasc Pharmacol Ther 2016; 22:153-158. [PMID: 27390145 DOI: 10.1177/1074248416657612] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cardiac troponins (cTn) are reliable and the most sensitive biomarker in the setting of acute decompensated heart failure (ADHF). Acute decompensated heart failure is usually associated with worsening chronic heart failure, and it may be caused by ongoing minor myocardial cell damage that may occur without any reported precipitating factors. METHODS We compared the short-term effect of levosimendan (LEV), dobutamine (DOB), and vasodilator treatment (nitroglycerin [NTG]) on myocardial injury with hemodynamic, neurohumoral, and inflammatory indicators. One hundred twenty-two patients with a mean age of 66 ± 9 years were treated with LEV (n = 40), DOB (n = 42), and NTG (n = 40) and examined retrospectively. Blood samples (cTnI, N-terminal probrain natriuretic peptide [NT-proBNP], highly sensitive C-reactive protein [HsCRP], and others), left ventricular ejection fraction (LVEF), systolic pulmonary artery pressure (sPAP), and 6-minute walk distance (6MWD) were compared before and after treatment. RESULTS At admission, detectable levels of cTnI were observed in 53% of patients (≥0.05 ng/mL). Serial changes in the mean cTnI levels were not significantly different between the groups (LEV 0.04 ± 0.01 to 0.03 ± 0.01 ng/mL; DOB 0.145 ± 0.08 to 0.08 ± 0.03 ng/mL; NTG 0.1 ± 0.03 to 0.09 ± 0.02 ng/mL; overall P = .859). Favourable effects on the NT-proBNP, sPAP values, LVEF, 6MWD, and HsCRP were observed overall, especially in the LEV groups. CONCLUSION Beneficial effects of short-term use of LEV, DOB, and NTG on ongoing myocardial injury were demonstrated. These findings can be attributed to the anti-ischemic properties as well as the hemodynamic, neurohumoral, and functional benefits from the positive inotropes, especially LEV, in patients with ADHF.
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Affiliation(s)
- Erkan Gencer
- 1 Department of Cardiology, Cardiology Clinic, Kilis State Hospital, Kilis, Turkey
| | - Volkan Doğan
- 2 Department of Cardiology, Mugla Sıtkı Kocman University, Mugla, Turkey
| | - Müjgan Tek Öztürk
- 3 Department of Cardiology, Cardiology Clinic, Kecioren Education and Research Hospital, Ankara, Turkey
| | - Aydın Nadir
- 4 Department of Cardiology, Cardiology Clinic, Bozuyuk State Hospital, Bilecik, Turkey
| | - Ahmet Musmul
- 5 Department of Biostatistics, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Yüksel Cavuşoğlu
- 6 Department of Cardiology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
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Alvarez Escudero J, Calvo Vecino JM, Veiras S, García R, González A. Clinical Practice Guideline (CPG). Recommendations on strategy for reducing risk of heart failure patients requiring noncardiac surgery: reducing risk of heart failure patients in noncardiac surgery. ACTA ACUST UNITED AC 2015; 62:359-419. [PMID: 26164471 DOI: 10.1016/j.redar.2015.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/04/2015] [Indexed: 12/29/2022]
Affiliation(s)
- J Alvarez Escudero
- Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain
| | - J M Calvo Vecino
- Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain; Associated Professor and Head of the Department of Anesthesiology, Infanta Leonor University Hospital, Complutense University of Madrid, Madrid, Spain.
| | - S Veiras
- Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain
| | - R García
- Department of Anesthesiology, Puerta del Mar University Hospital. Cadiz, Spain
| | - A González
- Department of Anesthesiology, Puerta de Hierro University Hospital. Madrid, Spain
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Hinojosa FQ, Revelo M, Salazar A, Maggi G, Schiraldi R, Brogly N, Gilsanz F. [Levosimendan as a treatment for acute renal failure associated with cardiogenic shock after hip fracture]. Rev Bras Anestesiol 2015; 67:89-91. [PMID: 25896643 DOI: 10.1016/j.bjan.2014.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 07/07/2014] [Indexed: 10/23/2022] Open
Abstract
Inotropic drugs are part of the treatment of heart failure; however, inotropic treatment has been largely debated due to the increased incidence of adverse effects and increased mortality. Recently levosimendan, an inotropic positive agent, has been proved to be effective in acute heart failure, reducing the mortality and improving cardiac and renal performance. We report the case of a 75-year-old woman with history of heart and renal failure and hip fracture. Levosimendan was used in preoperative preparation as an adjuvant therapy, to improve cardiac and renal function and to allow surgery.
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Affiliation(s)
| | - Margarita Revelo
- Hospital Universitario de La Paz, Servicio de Anestesiologia, Madri, Espanha
| | - Alexander Salazar
- Hospital Universitario de La Paz, Servicio de Anestesiologia, Madri, Espanha
| | - Genaro Maggi
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Renato Schiraldi
- Hospital Universitario de La Paz, Servicio de Anestesiologia, Madri, Espanha
| | - Nicolas Brogly
- Hospital Universitario de La Paz, Servicio de Anestesiologia, Madri, Espanha
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Koster G, Wetterslev J, Gluud C, Zijlstra JG, Scheeren TWL, van der Horst ICC, Keus F. Effects of levosimendan for low cardiac output syndrome in critically ill patients: systematic review with meta-analysis and trial sequential analysis. Intensive Care Med 2014; 41:203-21. [DOI: 10.1007/s00134-014-3604-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 12/04/2014] [Indexed: 11/24/2022]
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Perioperative Levosimendan Therapy Is Associated With a Lower Incidence of Acute Kidney Injury After Cardiac Surgery. J Cardiovasc Pharmacol 2014; 63:107-12. [DOI: 10.1097/fjc.0000000000000028] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Huang X, Lei S, Zhu MF, Jiang RL, Huang LQ, Xia GL, Zhi YH. Levosimendan versus dobutamine in critically ill patients: a meta-analysis of randomized controlled trials. J Zhejiang Univ Sci B 2014; 14:400-15. [PMID: 23645177 DOI: 10.1631/jzus.b1200290] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To evaluate the clinical efficacy of levosimendan versus dobutamine in critically ill patients requiring inotropic support. METHODS Clinical trials were searched in PubMed, EMBASE, and the Cochrane Central Registry of Clinical Trials, as well as Web of Science. Studies were included if they compared levosimendan with dobutamine in critically ill patients requiring inotropic support, and provided at least one outcome of interest. Outcomes of interest included mortality, incidence of hypotension, supraventricular arrhythmias, and ventricular arrhythmias. RESULTS Data from a total of 3052 patients from 22 randomized controlled trials (RCTs) were included in the analysis. Overall analysis showed that the use of levosimendan was associated with a significant reduction in mortality (269 of 1373 [19.6%] in the levosimendan group, versus 328 of 1278 [25.7%] in the dobutamine group, risk ratio (RR)=0.81, 95% confidence interval (CI) 0.70-0.92, P for effect=0.002). Subgroup analysis indicated that the benefit from levosimendan could be found in the subpopulations of cardiac surgery, ischemic heart failure, and concomitant β-blocker therapy in comparison with dobutamine. There was no significant difference in the incidence of hypotension, supraventricular arrhythmias, or ventricular arrhythmias between the two drugs. CONCLUSIONS In contrast with dobutamine, levosimendan is associated with a significant improvement in mortality in critically ill patients requiring inotropic support. Patients having cardiac surgery, with ischemic heart failure, and receiving concomitant β-blocker therapy may benefit from levosimendan. More RCTs are required to address the questions about no positive outcomes in the subpopulation in a cardiology setting, and to confirm the advantages in long-term prognosis.
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Affiliation(s)
- Xuan Huang
- Department of Gastroenterology, the First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou 310006, China
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Abstract
Background Levosimendan is a new calcium sensitizing drug with vasodilatory and inotropic properties, which is used for the treatment of postoperative low cardiac output syndrome and difficult weaning from cardiopulmonary bypass. Objective To evaluate the hemodynamic effects of levosimendan during and after coronary artery bypass grafting on cardiopulmonary bypass and mitral valve repair in patients with low left ventricular ejection fractions (<30%). Methods 40 patients were enrolled in this double-blind prospective randomized controlled trial. They received either levosimendan or a placebo preoperatively ( n = 20) for 24 h. Clinical parameters were measured before and after administration. Any adverse events during and after drug administration and postoperative complications were evaluated. Results Patients treated with levosimendan exhibited a higher cardiac index and mean arterial pressure intraoperative and in the early postoperative period, compared to the control group. Patients treated with levosimendan required less ventilatory support ( p < 0.0001) and had shorter intensive care unit ( p < 0.0001) and hospital stay ( p < 0.0001). Conclusions Preoperative treatment with levosimendan in patients undergoing coronary artery bypass grafting and mitral valve repair resulted in improved hemodynamics and a stable postoperative course.
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Resumen del documento de consenso «Guías de práctica clínica para el manejo del síndrome de bajo gasto cardiaco en el postoperatorio de cirugía cardiaca». Med Intensiva 2012; 36:277-87. [DOI: 10.1016/j.medin.2012.01.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 12/17/2011] [Accepted: 01/07/2012] [Indexed: 11/18/2022]
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Pérez Vela J, Martín Benítez J, Carrasco González M, De la Cal López M, Hinojosa Pérez R, Sagredo Meneses V, del Nogal Saez F. Guías de práctica clínica para el manejo del síndrome de bajo gasto cardíaco en el postoperatorio de cirugía cardíaca. Med Intensiva 2012; 36:e1-44. [DOI: 10.1016/j.medin.2012.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 01/07/2012] [Indexed: 01/04/2023]
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Hernández A, Miranda A, Parada A. [Levosimendan reduces mortality in cardiac surgery: a systematic review and meta-analysis]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 59:6-11. [PMID: 22429630 DOI: 10.1016/j.redar.2012.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 12/05/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVES To evaluate whether Levosimendan has any impact on peri-operative mortality in cardiac surgery. MATERIAL AND METHODS A literature search was performed with the main purpose of looking for mortality in cardiac surgery. Data tabulated by both the fixed effects model and the random effects model were analysed based on the method by Peto. The statistical heterogeneity and inconsistency was estimated and quantified, as well as performing a sensitivity analysis to test the influence of individual studies on the overall result. All the calculations and statistical analyses were performed using the software; "Comprehensive Meta-Analysis" V2.0 and "StatsDirect statistical software" V 2.7.8. At the same time, possible publication bias was also determined. RESULTS A total of 169 articles were found, from which 13 studies were finally included in the meta-analysis; 12 randomised and one of them retrospective with paired data. The global analysis showed that the use of levosimendan was associated with a significant reduction in postoperative mortality. CONCLUSIONS The meta-analysis showed that the use of Levosimendan was associated with a reduction in mortality in patients subjected to cardiac surgery, although there is still no definitively clear evidence. Additional randomised and multicentre clinical studies, with a much larger number of patients are required, in which hospital mortality and mortality at 6 months are analysed as the primary outcomes.
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Affiliation(s)
- A Hernández
- Departamento de Anestesiología y Reanimación, Hammersmith Hospital, Imperial College Healthcare NHS, Londres, Reino Unido
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Maharaj R, Metaxa V. Levosimendan and mortality after coronary revascularisation: a meta-analysis of randomised controlled trials. Crit Care 2011; 15:R140. [PMID: 21651806 PMCID: PMC3219012 DOI: 10.1186/cc10263] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 04/29/2011] [Accepted: 06/08/2011] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Patients undergoing coronary revascularization often require inotropic support that has been associated with an increased risk for death and morbidity. The purpose of this study was to evaluate the effect of levosimendan versus control on survival after coronary revascularization. METHODS A systemic review and meta-analysis of the literature was carried out on published randomized controlled clinical trials that investigated the efficacy of levosimendan compared to other therapy in patients having coronary revascularisaion. The databases searched were Pubmed, EMBASE, the Cochrane Registry of Clinical Trials and the metaRegister of Controlled Trials. Studies that compared levosimendan to any other therapy for coronary revascularisation in adult humans and reported at least one outcome of interest were considered for inclusion. Both percutaneous coronary intervention and cardiac surgery were included. Data extraction was performed independently by two reviewers using predefined criteria. Relevant outcomes included mortality, cardiac index, cardiac enzymes, length of stay and post-procedural atrial fibrillation. RESULTS The meta-analysis included 729 patients from 17 studies. Levosimendan was associated with a mortality reduction after coronary revascularization, (19/386 in the levosimendan group vs 39/343 in the control arm) odds ratio (OR) 0.40 (95% confidence interval (CI) 0.21 to 0.76, P for overall effect 0.005, P for heterogeneity = 0.33, I2 = 12% with a total of 729 patients. Levosimendan also had a favourable effect on cardiac index (standardised mean difference 1.63, 95% CI 1.43 to 1.83, P for overall effect < 0.00001), length of intensive care stay (random effects model, mean difference - 26.18 hours 95% CI 46.20 to 6.16, P for heterogeneity < 0.00001, I2 = 95%, P for overall effect P = 0.01), reductions in the rate of atrial fibrillation (OR 0.54, 95% CI 0.36 to 0.82, P for effect = 0.004, P for heterogeneity 0.84, I2 = 0% for 465 patients) and troponin I levels group (mean difference -1.59, 95% CI 1.78 to 1.40, P for overall effect < 0.00001, P for heterogeneity < 0.00001, I2 = 95%). Limitations of this analysis are discussed. CONCLUSIONS Levosimendan is associated with a significant improvement in mortality after coronary revascularization. There are also improvements in several secondary endpoints. A suitably powered randomised controlled trial is required to confirm these findings and to address the unresolved questions about the timing and dosing of levosimendan.
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Affiliation(s)
- Ritesh Maharaj
- Kings College Hospital, Denmark Hill, London, SE5 9RS, UK.
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Biarent D, Bingham R, Eich C, López-Herce J, Maconochie I, Rodrίguez-Núñez A, Rajka T, Zideman D. Lebensrettende Maßnahmen bei Kindern („paediatric life support“). Notf Rett Med 2010. [DOI: 10.1007/s10049-010-1372-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Vicente R, Pajares A, Vicente JL, Aparicio R, Loro JM, Moreno I, Soria A, López A, Porta J, de la Fuente C, Herrera P, Tur A, Osseyran F, Guillén A, Martí F, Llagunes J, Mateo E, Aguar F, Peña JJ, Marqués JI, Ripoll A, Reina C, Ferrandis P, Muedra V, Llopis E, Cantó M, García C. [Mortality following cardiac surgery in the National Health Service Hospitals of the Community of Valencia in 2007: a descriptive analysis]. ACTA ACUST UNITED AC 2010; 57:79-85. [PMID: 20336998 DOI: 10.1016/s0034-9356(10)70168-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To analyze clinical records of cardiac surgery patients in an attempt to identify factors associated with mortality in the postoperative critical care units of the public health service hospitals in the Community of Valencia, Spain, in 2007. METHODS Retrospective study of cases from January 1, 2007 to December 31, 2007. The charts of all patients who underwent cardiac surgery with or without extracorporeal circulation were reviewed. A data collection protocol was followed to obtain information on age, sex, body mass index (BMI), presurgical risk factors, type of surgery, duration of extracorporeal circulation, duration of ischemia, cause of death, and length of stay in the postoperative critical care unit. RESULTS The study population consisted of 2113 patients at 5 public hospitals; 124 patients (70 men, 54 women) died. The mean (SD) age was 70 (9.43) years (range, 36-91 years). The mean BMI was 28.19 kg/m2 (maximum, 42 kg/m2). The mean Euroscore was 21.92 (maximum, 94.29). Hypertension was present as a preoperative risk factor in most patients (74.2%); dyslipidemia was present in 51.6%, diabetes mellitus in 38.7%, stroke in 73%, and renal failure in 2.4%. It was noteworthy was that the group who underwent coronary revascularization had the highest mortality rate (nearly 35% of the 124 patients). The next highest mortality rate (19.4%) was in patients who had combined procedures (valve repair or substitution plus coronary revascularization). Mortality was 18.5% in the group undergoing aortic valve surgery and 11.3% in those undergoing mitral valve surgery. The mean duration of extracorporeal circulation was 148.63 minutes. The mean duration of myocardial ischemia was 94.91 minutes. The most frequent cause of death was cardiogenic shock (54.8%). This was followed by distributive shock (29.8%) and hemorrhagic shock (8.9%). The mean length of stay in the postoperative critical care unit was 13.6 days. Overall mortality was 5.87%. CONCLUSIONS The highest mortality rate among cardiac surgery patients in postoperative critical care units in hospitals in the Community of Valencia in 2007 was in patients who underwent coronary revascularization. The most prevalent preoperative risk factor was hypertension. Cardiogenic shock and distributive shock were the most frequent causes of death in these patients. A system for classifying risk is needed in order to predict mortality in critical care units and improve perioperative care.
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Affiliation(s)
- R Vicente
- Sección de Anestesiología y Cuidados Críticos de Cirugía Cardiaca en la Comunidad Valenciana.
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Pérez Vela JL, Corres Peiretti MA, Rubio Regidor M, Hernández Tejedor A, Renes Carreño E, Arribas López P, Gutiérrez Rodríguez J, Rodríguez de Viguri NP. Utilidad de levosimendán en la disfunción ventricular postoperatoria del injerto en el trasplante cardiaco. Rev Esp Cardiol (Engl Ed) 2008. [DOI: 10.1157/13119998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Álvarez J. Levosimendán en el síndrome de bajo gasto cardiaco. ¿Disminuye realmente la mortalidad? Rev Esp Cardiol 2008; 61:454-7. [DOI: 10.1157/13119992] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Levin RL, Degrange MA, Porcile R, Salvagio F, Blanco N, Botbol AL, Tanus E, del Mazo CD. Superioridad del sensibilizante al calcio levosimendán comparado con dobutamina en el síndrome de bajo gasto cardiaco postoperatorio. Rev Esp Cardiol 2008. [DOI: 10.1157/13119990] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Manzano-Fernández S, Marín F, Garrido Bravo IP, Pascual Figal DA. ¿Existe un lugar para levosimendán en los servicios de urgencias hospitalarios? Rev Esp Cardiol (Engl Ed) 2008. [DOI: 10.1157/13120000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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The Calcium Sensitizer Levosimendan Gives Superior Results to Dobutamine in Postoperative Low Cardiac Output Syndrome. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s1885-5857(08)60160-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Llorens-Soriano P, Carbajosa-Dalmau J, Fernández-Cañadas J, Murcia-Zaragoza J, Climent-Payá V, Laghzaoui F, Diéguez-Zaragoza S, Carrasco-Moreno R. Experiencia clínica con levosimendán en un servicio de urgencias de un hospital de tercer nivel. Rev Esp Cardiol 2007. [DOI: 10.1157/13109003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Klotz S, Rukosujew A, Welp H, Schmid C, Tjan TDT, Scheld HH. Primary Extracorporeal Membrane Oxygenation Versus Primary Ventricular Assist Device Implantation in Low Cardiac Output Syndrome Following Cardiac Operation. Artif Organs 2007; 31:390-4. [PMID: 17470209 DOI: 10.1111/j.1525-1594.2007.00397.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Mechanical support is often the only therapeutic option in low cardiac output (LCO) following cardiac operation using extracorporeal circulation (ECC). However, the question whether primary ventricular assist device (VAD) or primary extracorporeal membrane oxygenation (ECMO) followed by secondary VAD implantation is superior remains unclear. We analyzed the outcome of 183 patients with LCO following ECC. Primary VAD implantation (VAD) was performed on 20 patients and 163 patients underwent ECMO implantation (ECMO). Out of this group, 13 patients received a secondary VAD (ECMO-VAD). Age was significantly lower in the VAD group, while gender and type of operation were similarly distributed. Thirty-day mortalities were 50, 75, and 46% (VAD, ECMO, and ECMO-VAD, respectively; P < 0.05 ECMO vs. VAD and ECMO-VAD). Survival was best with VAD implantation 1.2 +/- 1.2 days following LCO. In conclusion, the outcome of LCO following ECC remains poor. Early VAD support provides best survival. Primary or secondary VAD implantation has no impact on survival.
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Affiliation(s)
- Stefan Klotz
- Department of Thoracic and Cardiovascular Surgery, University Hospital Muenster, Muenster, Germany.
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García-González MJ, Domínguez-Rodríguez A. Efectos del levosimendán en el tratamiento del aturdimiento miocárdico y del síndrome de bajo gasto después de cirugía cardiaca. Rev Esp Cardiol 2006. [DOI: 10.1157/13091893] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Delgado JF. Levosimendán en la insuficiencia cardiaca aguda: pasado, presente y futuro. Rev Esp Cardiol 2006. [DOI: 10.1157/13087053] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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