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Kocabeyoglu SS, Kervan U, Sert DE, Karahan M, Aygun E, Beyazal OF, Unal EU, Akin Y, Demirkan B, Pac M. Optimization with levosimendan improves outcomes after left ventricular assist device implantation. Eur J Cardiothorac Surg 2021; 57:176-182. [PMID: 31155645 DOI: 10.1093/ejcts/ezz159] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 04/19/2019] [Accepted: 04/24/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The aim of this study was to examine the haemodynamic effects of preoperative levosimendan infusion in patients who underwent left ventricular assist device implantation and evaluate the prognoses. METHODS Between May 2013 and October 2018, 85 adult patients who underwent left ventricular assist device implantation were included; 44 and 41 patients suffered from dilated cardiomyopathy and ischaemic cardiomyopathy, respectively. Patients were divided into 2 groups: group A (58 patients) included those who received levosimendan infusion in addition to other inotropes and group B (27 patients) included those who received inotropic agents other than levosimendan. Levosimendan infusion was started at a dose of 0.1 µg⋅kg-1⋅min-1 for a maximum of 48 h without a bolus. The primary outcome was early right ventricular failure (RVF). The secondary outcomes were in-hospital mortality, need for right ventricular assist device, late RVF and recovery of end-organ functions. The safety end points of levosimendan included hypotension, atrial fibrillation, ventricular tachycardia or fibrillation and resuscitated cardiac arrest. RESULTS Patient characteristics were similar in both groups. No significant differences between groups were observed in the rates of early mortality, RVF, need for right ventricular assist device, cardiopulmonary bypass time and intensive care unit stay. Survival rates at 30 days, 1 year and 3 years and freedom from late RVF were similar between the groups. Administration of levosimendan was safe, generally well-tolerated and not interrupted because of side effects. CONCLUSIONS Levosimendan therapy was well-tolerated in patients who received permanent left ventricular assist devices. Combined preoperative therapy with inotropes and levosimendan significantly improves end-organ functions.
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Affiliation(s)
| | - Umit Kervan
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Dogan Emre Sert
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Mehmet Karahan
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Emre Aygun
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Osman Fehmi Beyazal
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Ertekin Utku Unal
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Yesim Akin
- Department of Cardiology, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Burcu Demirkan
- Department of Cardiology, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
| | - Mustafa Pac
- Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
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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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Jawitz OK, Stebbins AS, Raman V, Alhanti B, van Diepen S, Heringlake M, Fremes S, Whitlock R, Meyer SR, Mehta RH, Stafford-Smith M, Goodman SG, Alexander JH, Lopes RD. Association between levosimendan, postoperative AKI, and mortality in cardiac surgery: Insights from the LEVO-CTS trial. Am Heart J 2021; 231:18-24. [PMID: 33127531 DOI: 10.1016/j.ahj.2020.10.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/23/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVES We aimed to evaluate the association between levosimendan treatment and acute kidney injury (AKI) as well as assess the clinical sequelae of AKI in cardiac surgery patients with depressed left ventricular function (ejection fraction <35%). METHODS Patients in the LEVO-CTS trial undergoing on-pump coronary artery bypass grafting (CABG), valve, or CABG/valve surgery were stratified by occurrence and severity of postoperative AKI using the AKIN classification. The association between levosimendan infusion and AKI was modeled using multivariable regression. RESULTS Among 854 LEVO-CTS patients, 231 (27.0%) experienced postoperative AKI, including 182 (21.3%) with stage 1, 35 (4.1%) with stage 2, and 14 (1.6%) with stage 3 AKI. The rate of AKI was similar between patients receiving levosimendan or placebo. The odds of 30-day mortality significantly increased by AKI stage compared to those without AKI (stage 1: adjusted odds ratio [aOR] 2.0, 95% confidence interval [CI] 0.8-4.9; stage 2: aOR 9.1, 95% CI 3.2-25.7; stage 3: aOR 12.4, 95% CI 3.0-50.4). No association was observed between levosimendan, AKI stage, and odds of 30-day mortality (interaction P = .69). Factors independently associated with AKI included increasing age, body mass index, diabetes, and increasing baseline systolic blood pressure. Increasing baseline eGFR and aldosterone antagonist use were associated with a lower risk of AKI. CONCLUSIONS Postoperative AKI is common among high-risk patients undergoing cardiac surgery and associated with significantly increased risk of 30-day death or dialysis. Levosimendan was not associated with the risk of AKI.
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Uhlig K, Efremov L, Tongers J, Frantz S, Mikolajczyk R, Sedding D, Schumann J. Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev 2020; 11:CD009669. [PMID: 33152122 PMCID: PMC8094388 DOI: 10.1002/14651858.cd009669.pub4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cardiogenic shock (CS) and low cardiac output syndrome (LCOS) are potentially life-threatening complications of acute myocardial infarction (AMI), heart failure (HF) or cardiac surgery. While there is solid evidence for the treatment of other cardiovascular diseases of acute onset, treatment strategies in haemodynamic instability due to CS and LCOS remains less robustly supported by the given scientific literature. Therefore, we have analysed the current body of evidence for the treatment of CS or LCOS with inotropic and/or vasodilating agents. This is the second update of a Cochrane review originally published in 2014. OBJECTIVES Assessment of efficacy and safety of cardiac care with positive inotropic agents and vasodilator agents in CS or LCOS due to AMI, HF or after cardiac surgery. SEARCH METHODS We conducted a search in CENTRAL, MEDLINE, Embase and CPCI-S Web of Science in October 2019. We also searched four registers of ongoing trials and scanned reference lists and contacted experts in the field to obtain further information. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials (RCTs) enrolling patients with AMI, HF or cardiac surgery complicated by CS or LCOS. DATA COLLECTION AND ANALYSIS We used standard methodological procedures according to Cochrane standards. MAIN RESULTS We identified 19 eligible studies including 2385 individuals (mean or median age range 56 to 73 years) and three ongoing studies. We categorised studies into 11 comparisons, all against standard cardiac care and additional other drugs or placebo. These comparisons investigated the efficacy of levosimendan versus dobutamine, enoximone or placebo; enoximone versus dobutamine, piroximone or epinephrine-nitroglycerine; epinephrine versus norepinephrine or norepinephrine-dobutamine; dopexamine versus dopamine; milrinone versus dobutamine and dopamine-milrinone versus dopamine-dobutamine. All trials were published in peer-reviewed journals, and analyses were done by the intention-to-treat (ITT) principle. Eighteen of 19 trials were small with only a few included participants. An acknowledgement of funding by the pharmaceutical industry or missing conflict of interest statements occurred in nine of 19 trials. In general, confidence in the results of analysed studies was reduced due to relevant study limitations (risk of bias), imprecision or indirectness. Domains of concern, which showed a high risk in more than 50% of included studies, encompassed performance bias (blinding of participants and personnel) and bias affecting the quality of evidence on adverse events. All comparisons revealed uncertainty on the effect of inotropic/vasodilating drugs on all-cause mortality with a low to very low quality of evidence. In detail, the findings were: levosimendan versus dobutamine (short-term mortality: RR 0.60, 95% CI 0.36 to 1.03; participants = 1701; low-quality evidence; long-term mortality: RR 0.84, 95% CI 0.63 to 1.13; participants = 1591; low-quality evidence); levosimendan versus placebo (short-term mortality: no data available; long-term mortality: RR 0.55, 95% CI 0.16 to 1.90; participants = 55; very low-quality evidence); levosimendan versus enoximone (short-term mortality: RR 0.50, 0.22 to 1.14; participants = 32; very low-quality evidence; long-term mortality: no data available); epinephrine versus norepinephrine-dobutamine (short-term mortality: RR 1.25; 95% CI 0.41 to 3.77; participants = 30; very low-quality evidence; long-term mortality: no data available); dopexamine versus dopamine (short-term mortality: no deaths in either intervention arm; participants = 70; very low-quality evidence; long-term mortality: no data available); enoximone versus dobutamine (short-term mortality RR 0.21; 95% CI 0.01 to 4.11; participants = 27; very low-quality evidence; long-term mortality: no data available); epinephrine versus norepinephrine (short-term mortality: RR 1.81, 0.89 to 3.68; participants = 57; very low-quality evidence; long-term mortality: no data available); and dopamine-milrinone versus dopamine-dobutamine (short-term mortality: RR 1.0, 95% CI 0.34 to 2.93; participants = 20; very low-quality evidence; long-term mortality: no data available). No information regarding all-cause mortality were available for the comparisons milrinone versus dobutamine, enoximone versus piroximone and enoximone versus epinephrine-nitroglycerine. AUTHORS' CONCLUSIONS At present, there are no convincing data supporting any specific inotropic or vasodilating therapy to reduce mortality in haemodynamically unstable patients with CS or LCOS. Considering the limited evidence derived from the present data due to a high risk of bias and imprecision, it should be emphasised that there is an unmet need for large-scale, well-designed randomised trials on this topic to close the gap between daily practice in critical care of cardiovascular patients and the available evidence. In light of the uncertainties in the field, partially due to the underlying methodological flaws in existing studies, future RCTs should be carefully designed to potentially overcome given limitations and ultimately define the role of inotropic agents and vasodilator strategies in CS and LCOS.
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Affiliation(s)
- Konstantin Uhlig
- Department of Anaesthesiology and Surgical Intensive Care, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
| | - Ljupcho Efremov
- Institute for Medical Epidemiology, Biometrics and Informatics (IMEBI), Interdisciplinary Center for Health Sciences, Medical School of the Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Jörn Tongers
- Cardiology, Angiology and Intensive Care Medicine, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Stefan Frantz
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Rafael Mikolajczyk
- Institute for Medical Epidemiology, Biometrics and Informatics (IMEBI), Interdisciplinary Center for Health Sciences, Medical School of the Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Daniel Sedding
- Cardiology, Angiology and Intensive Care Medicine, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Julia Schumann
- Department of Anaesthesiology and Surgical Intensive Care, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
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Zarragoikoetxea I, Vicente R, Pajares A, Carmona P, Lopez M, Moreno I, Argente P, Hornero F, Valera F, Aguero J. Quantitative Transthoracic Echocardiography of the Response to Dobutamine in Cardiac Surgery Patients With Low Cardiac Output Syndrome. J Cardiothorac Vasc Anesth 2020; 34:87-96. [DOI: 10.1053/j.jvca.2019.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 12/15/2022]
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Wang A, Cui C, Fan Y, Zi J, Zhang J, Wang G, Wang F, Wang J, Tan Q. Prophylactic use of levosimendan in pediatric patients undergoing cardiac surgery: a prospective randomized controlled trial. Crit Care 2019; 23:428. [PMID: 31888711 PMCID: PMC6937718 DOI: 10.1186/s13054-019-2704-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 12/13/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The administration of levosimendan prophylactically to patients undergoing cardiac surgery remains a controversial practice, and few studies have specifically assessed the value of this approach in pediatric patients. This study therefore sought to explore the safety and efficacy of prophylactic levosimendan administration to pediatric patients as a means of preventing low cardiac output syndrome (LCOS) based upon hemodynamic, biomarker, and pharmacokinetic readouts. METHODS This was a single-center, double-blind, randomized, placebo-controlled trial. Patients ≤ 48 months old were enrolled between July 2018 and April 2019 and were randomly assigned to groups that received either placebo or levosimendan infusions for 48 h post-surgery, along with all other standard methods of care. LCOS incidence was the primary outcome of this study. RESULTS A total of 187 patients were enrolled, of whom 94 and 93 received levosimendan and placebo, respectively. LCOS incidence did not differ significantly between the levosimendan and placebo groups (10 [10.6%] versus 18 [19.4%] patients, respectively; 95% confidence interval [CI] 0.19-1.13; p = 0.090) nor did 90-day mortality (3 [3.2%] versus 4 [4.3%] patients, CI 0.14-3.69, p = 0.693), duration of mechanical ventilation (median, 47.5 h and 39.5 h, respectively; p = 0.532), ICU stay (median, 114.5 h and 118 h, respectively; p = 0.442), and hospital stay (median, 20 days and 20 days, respectively; p = 0.806). The incidence of hypotension and cardiac arrhythmia did not differ significantly between the groups. Levels of levosimendan fell rapidly without any plateau in plasma concentrations during infusion. A multiple logistic regression indicated that randomization to the levosimendan group was a predictor of LCOS. CONCLUSIONS Prophylactic levosimendan administration was safe in pediatric patients and had some benefit to postoperative hemodynamic parameters, but failed to provide significant benefit with respect to LCOS or 90-day mortality relative to placebo. TRIAL REGISTRATION Name of the registry: Safety evaluation and therapeutic effect of levosimendan on the low cardiac output syndrome in patients after cardiopulmonary bypass. TRIAL REGISTRATION NUMBER ChiCTR1800016594. Date of registration: 11 June 2018. URL of trial registry record: http://www.chictr.org.cn/index.aspx.
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Affiliation(s)
- Anbiao Wang
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Chaomei Cui
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Yiou Fan
- Department of Toxicological and Functional Test, Centers for Disease Control and Prevention of Shandong, Jinan, 250014 China
| | - Jie Zi
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Jie Zhang
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Guanglai Wang
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Fang Wang
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Jun Wang
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, 250021 China
| | - Qi Tan
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021 China
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Habicher M, Zajonz T, Heringlake M, Böning A, Treskatsch S, Schirmer U, Markewitz A, Sander M. [S3 guidelines on intensive medical care of cardiac surgery patients : Hemodynamic monitoring and cardiovascular system-an update]. Anaesthesist 2019; 67:375-379. [PMID: 29644444 DOI: 10.1007/s00101-018-0433-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
An update of the S3- guidelines for treatment of cardiac surgery patients in the intensive care unit, hemodynamic monitoring and cardiovascular system was published by the Association of Scientific Medical Societies in Germany (AWMF) in January 2018. This publication updates the guidelines from 2006 and 2011. The guidelines include nine sections that in addition to different methods of hemodynamic monitoring also reviews the topic of volume therapy as well as vasoactive and inotropic drugs. Furthermore, the guidelines also define the goals for cardiovascular treatment. This article describes the most important innovations of these comprehensive guidelines.
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Affiliation(s)
- M Habicher
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Gießen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Deutschland
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité - Universitätsmedizin Berlin, Charité Campus Mitte und Campus Virchow Klinikum, Berlin, Deutschland
| | - T Zajonz
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Gießen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Deutschland
| | - M Heringlake
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Lübeck, Deutschland
| | - A Böning
- Klinik für Herz- und Gefäßchirurgie, Universitätsklinikum Gießen, Gießen, Deutschland
| | - S Treskatsch
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité - Universitätsmedizin Berlin, Charité Campus Mitte und Campus Virchow Klinikum, Berlin, Deutschland
| | - U Schirmer
- Herz- und Diabeteszentrum NRW Institut für Anästhesiologie, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Deutschland
| | - A Markewitz
- Klinik für Herz- und Gefäßchirurgie, Bundeszentralwehrkrankenhaus Koblenz, Koblenz, Deutschland
| | - M Sander
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Gießen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Deutschland.
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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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Perioperative Use of Levosimendan Improves Clinical Outcomes in Patients After Cardiac Surgery: A Systematic Review and Meta-Analysis. J Cardiovasc Pharmacol 2019; 72:11-18. [PMID: 29672418 DOI: 10.1097/fjc.0000000000000584] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Severe postoperative complications can affect cardiac surgery patients. Levosimendan is a novel calcium sensitizer commonly administered after cardiac surgery. However, the patient benefits are controversial. PubMed, Embase, and the Cochrane library were systematically searched for randomized controlled trials comparing levosimendan with control in adult cardiac surgery patients. Twenty-five studies (3247 patients) were included. Pooled data indicated that levosimendan reduced mortality after cardiac surgery [odds ratio (OR) 0.63, 95% confidence interval (CI): 0.47-0.84, P = 0.001]. However, this reduction was restricted to patients with low (<50%) left ventricular ejection fraction (OR 0.49, 95% CI: 0.35-0.70, P = 0.0001). It significantly reduced the incidence of postoperative acute kidney injury (OR 0.55, 95% CI: 0.41-0.74, P < 0.0001) and renal replacement therapy use (OR 0.56, 95% CI: 0.39-0.80, P = 0.002). Moreover, levosimendan significantly shortened the duration of the intensive care unit stay (weighted mean differences -0.49 day, 95% CI: -0.75 to -0.24, P = 0.0002) and mechanical ventilation use (weighted mean differences -2.30 hours, 95% CI: -3.76 to -0.84, P = 0.002). In conclusion, levosimendan reduced the mortality in patients with low left ventricular ejection fraction and decreased the incidence of acute renal injury and renal replacement therapy use. In addition, it shortened the duration of the intensive care unit stay and mechanical ventilation use.
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Sartini C, Lomivorotov V, Pieri M, Lopez-Delgado JC, Baiardo Redaelli M, Hajjar L, Pisano A, Likhvantsev V, Fominskiy E, Bradic N, Cabrini L, Novikov M, Avancini D, Riha H, Lembo R, Gazivoda G, Paternoster G, Wang C, Tamà S, Alvaro G, Wang CY, Roasio A, Ruggeri L, Yong CY, Pasero D, Severi L, Pasin L, Mancino G, Mura P, Musu M, Spadaro S, Conte M, Lobreglio R, Silvetti S, Votta CD, Belletti A, Di Fraja D, Corradi F, Brusasco C, Saporito E, D'Amico A, Sardo S, Ortalda A, Riefolo C, Fabrizio M, Zangrillo A, Bellomo R, Landoni G. A Systematic Review and International Web-Based Survey of Randomized Controlled Trials in the Perioperative and Critical Care Setting: Interventions Reducing Mortality. J Cardiothorac Vasc Anesth 2019; 33:1430-1439. [DOI: 10.1053/j.jvca.2018.11.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Indexed: 12/15/2022]
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Kislitsina ON, Rich JD, Wilcox JE, Pham DT, Churyla A, Vorovich EB, Ghafourian K, Yancy CW. Shock - Classification and Pathophysiological Principles of Therapeutics. Curr Cardiol Rev 2019; 15:102-113. [PMID: 30543176 PMCID: PMC6520577 DOI: 10.2174/1573403x15666181212125024] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 10/11/2018] [Accepted: 12/10/2018] [Indexed: 01/10/2023] Open
Abstract
The management of patients with shock is extremely challenging because of the myriad of possible clinical presentations in cardiogenic shock, septic shock and hypovolemic shock and the limitations of contemporary therapeutic options. The treatment of shock includes the administration of endogenous catecholamines (epinephrine, norepinephrine, and dopamine) as well as various vasopressor agents that have shown efficacy in the treatment of the various types of shock. In addition to the endogenous catecholamines, dobutamine, isoproterenol, phenylephrine, and milrinone have served as the mainstays of shock therapy for several decades. Recently, experimental studies have suggested that newer agents such as vasopressin, selepressin, calcium-sensitizing agents like levosimendan, cardiac-specific myosin activators like omecamtiv mecarbil (OM), istaroxime, and natriuretic peptides like nesiritide can enhance shock therapy, especially when shock presents a more complex clinical picture than normal. However, their ability to improve clinical outcomes remains to be proven. It is the purpose of this review to describe the mechanism of action, dosage requirements, advantages and disadvantages, and specific indications and contraindications for the use of each of these catecholamines and vasopressors, as well as to elucidate the most important clinical trials that serve as the basis of contemporary shock therapy.
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Affiliation(s)
- Olga N Kislitsina
- Department of Cardiac Surgery Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States.,Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Jonathan D Rich
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Jane E Wilcox
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Duc T Pham
- Department of Cardiac Surgery Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Andrei Churyla
- Department of Cardiac Surgery Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Esther B Vorovich
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Kambiz Ghafourian
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
| | - Clyde W Yancy
- Department of Cardiology Bluhm Cardiovascular Institute Feinberg School of Medicine Northwestern University Medical Center, Chicago, Illinois, IL, United States
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Beiras-Fernandez A, Kornberger A, Oberhoffer M, Kur F, Weis M, Vahl CF, Weis F. Levosimendan as rescue therapy in low output syndrome after cardiac surgery: effects and predictors of outcome. J Int Med Res 2019; 47:3502-3512. [PMID: 30909776 PMCID: PMC6726822 DOI: 10.1177/0300060519835087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives Calcium sensitizers have been shown to improve outcomes in patients with low cardiac output syndrome (LCOS) after cardiac surgery. We assessed the effects of levosimendan on LCOS in cardiac surgical patients to identify outcome predictors. Methods A total of 106 patients in whom LCOS persisted despite conventional therapy additionally received 0.1 µg/kg/min of levosimendan for 24 hours according to a defined treatment algorithm. Baseline and treatment data as well as hemodynamic and outcome parameters were compared between survivors and nonsurvivors, and a multivariate correlation and regression tree analysis was implemented. Results The ejection fraction significantly increased from 27% ± 4% to 38% ± 8% within 24 hours and to 45% ± 10% within 48 hours of starting levosimendan. These changes were accompanied by a significant increase in cardiac output from 5.2 ± 0.6 to 6.2 ± 0.7 L/min within 24 hours and significant dose reductions in vasopressors and inotropes. In contrast to nonsurvivors, survivors’ need for inotropic support decreased after the addition of levosimendan to the therapy. Conclusion In our patients, all of whom were treated according to the same algorithm, the response to levosimendan in terms of the post-levosimendan need for inotropes and vasopressors predicted survival.
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Affiliation(s)
- Andres Beiras-Fernandez
- 1 Department of Cardiothoracic and Vascular Surgery, University Hospital Mainz, Mainz, Germany
| | - Angela Kornberger
- 1 Department of Cardiothoracic and Vascular Surgery, University Hospital Mainz, Mainz, Germany
| | - Martin Oberhoffer
- 1 Department of Cardiothoracic and Vascular Surgery, University Hospital Mainz, Mainz, Germany
| | - Felix Kur
- 2 Department of Cardiac Surgery, University Hospital Grosshadern, Munich, Germany
| | - Marion Weis
- 3 Department of Anaesthesiology, University Hospital Grosshadern, Munich, Germany
| | | | - Florian Weis
- 3 Department of Anaesthesiology, University Hospital Grosshadern, Munich, Germany
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Levosimendan in patients with low cardiac output syndrome undergoing cardiac surgery: A systematic review and meta-analysis. Anaesth Crit Care Pain Med 2018; 38:243-249. [PMID: 30342103 DOI: 10.1016/j.accpm.2018.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/28/2018] [Accepted: 08/10/2018] [Indexed: 12/30/2022]
Abstract
Levosimendan is an inotropic agent that has been shown in small studies to treat low cardiac output syndrome in cardiac surgery. However, large randomised controlled trials (RCTs) have been recently published and presented neutral results. We sought to determine the effect of levosimendan on mortality in adults with low ejection fraction undergoing cardiac surgery. We searched different databases: Medline, Embase, Cochrane Central Register of Controlled Trials, and clinical trial registries. We included RCTs comparing events in the levosimendan versus placebo in adult patients with ejection fraction ≤ 35% undergoing cardiac surgery. Outcomes were mortality at 30-day, mortality beyond 30-day, acute kidney injury and myocardial infarction. Five trials with a total of 1519 patients were selected. Four trials were rated as low risk of bias. Our meta-analysis showed no significant difference between levosimendan versus placebo mortality at 30-day [odds radio (OR): 0.62; 95% confidence intervals (CI): 0.32 to 1.20; I2 = 33%; high quality evidence] and mortality beyond 30-day (OR: 0.71; 95% CI: 0.46 to 1.11; I2 = 0%). Similarly, there were no significant differences between the levosimendan versus placebo in the incidence of acute kidney injury (OR: 0.61, 95% CI: 0.33-1.13) and myocardial infarction (OR: 0.41, 95% CI: 0.08 to 1.22). The current evidence suggests that levosimendan is not associated with significantly reduced mortality in patients with reduced ejection fraction undergoing cardiac surgery.
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Chen P, Wu X, Wang Z, Li Z, Tian X, Wang J, Yan T. Effects of levosimendan on mortality in patients undergoing cardiac surgery: A systematic review and meta-analysis. J Card Surg 2018; 33:322-329. [PMID: 29785788 DOI: 10.1111/jocs.13716] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We sought to determine the impact of levosimendan on mortality following cardiac surgery based on large-scale randomized controlled trials (RCTs). METHODS We searched PubMed, Web of Science, Cochrane databases, and ClinicalTrials.gov for RCTs published up to December 2017, on levosimendan for patients undergoing cardiac surgery. RESULTS A total of 25 RCTs enrolling 2960 patients met the inclusion criteria; data from 15 placebo-controlled randomized trials were included for meta-analysis. Pooled analysis showed that the all-cause mortality rate was 6.4% (71 of 1106) in the levosimendan group and 8.4% (93 of 1108) in the placebo group (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.55-1.04; P = 0.09). There were no significant differences between the two groups in the rates of myocardial infarction (OR: 0.91; 95% CI, 0.68-1.21; P = 0.52), serious adverse events (OR: 0.84; 95% CI, 0.66-1.07; P = 0.17), hypotension (OR: 1.69; 95% CI, 0.94-3.03; P = 0.08), and low cardiac output syndrome (OR: 0.47; 95% CI, 0.22-1.02; P = 0.05). CONCLUSION Levosimendan did not result in a reduction in mortality in adult cardiac surgery patients. Well designed, adequately powered, multicenter trials are necessary to determine the role of levosimendan in adult cardiac surgery.
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Affiliation(s)
- Peili Chen
- Department of Intensive Care, First People's Hospital of Shangqiu, Shangqiu, China
| | - Xiaoqiang Wu
- Department of Urology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Zhiwei Wang
- Department of Urology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Zhenya Li
- Department of Ultrasound, Zhengzhou Central Hospital, Zhengzhou, China
| | - Xiangyong Tian
- Department of Urology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Junpeng Wang
- Department of Urology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Tianzhong Yan
- Department of Urology, Henan Provincial People's Hospital, Zhengzhou, China
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Xing Z, Tang L, Chen P, Huang J, Peng X, Hu X. Levosimendan in patients with left ventricular dysfunction undergoing cardiac surgery: a meta-analysis and trial sequential analysis of randomized trials. Sci Rep 2018; 8:7775. [PMID: 29773835 PMCID: PMC5958056 DOI: 10.1038/s41598-018-26206-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/08/2018] [Indexed: 01/18/2023] Open
Abstract
Patients with left ventricular dysfunction (LVD) undergoing cardiac surgery have a high mortality rate. Levosimendan, a calcium sensitizer, improves myocardial contractility without increasing myocardial oxygen demand. It is not clear whether levosimendan can reduce mortality in cardiac surgery patients with LVD. The PubMed, Embase, and Cochrane Central databases were searched to identify randomized trials comparing levosimendan with conventional treatment in cardiac surgery patients with LVD. We derived pooled risk ratios (RRs) with random effects models. The primary endpoint was perioperative mortality. Secondary endpoints were renal replacement treatment, atrial fibrillation, myocardial infarction, ventricular arrhythmia, and hypotension. Fifteen studies enrolling 2606 patients were included. Levosimendan reduced the incidence of perioperative mortality (RR: 0.64, 95%CI: 0.45–0.91) and renal replacement treatment (RR:0.71, 95%CI:0.52–0.95). However, sensitivity analysis, subgroup analysis and Trial Sequential Analysis (TSA) indicated that more evidence was needed. Furthermore, levosimendan did not reduce the incidence of atrial fibrillation (RR:0.82, 95%CI:0.64–1.07), myocardial infarction (RR:0.56, 95%CI:0.26–1.23), or ventricular arrhythmia (RR:0.74, 95%CI:0.49–1.11), but it increased the incidence of hypotension (RR:1.11,95%CI:1.00–1.23). There was not enough high-quality evidence to either support or contraindicate the use of levosimendan in cardiac surgery patients with LVD.
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Affiliation(s)
- Zhenhua Xing
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Liang Tang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Pengfei Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Jiabing Huang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Xiaofan Peng
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Xinqun Hu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China.
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Wang B, He X, Gong Y, Cheng B. Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery: An Update Meta-Analysis and Trial Sequential Analysis. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7563083. [PMID: 29854789 PMCID: PMC5964575 DOI: 10.1155/2018/7563083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/19/2018] [Accepted: 03/28/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Recent studies suggest that levosimendan does not provide mortality benefit in patients with low cardiac output syndrome undergoing cardiac surgery. These results conflict with previous findings. The aim of the current study is to assess whether levosimendan reduces postoperative mortality in patients with impaired left ventricular function (mean EF ≤ 40%) undergoing cardiac surgery. METHODS We conducted a comprehensive search of PubMed, EMBASE, and Cochrane Library Database through November 20, 2017. Inclusion criteria were random allocation to treatment with at least one group receiving levosimendan and another group receiving placebo or other treatments and cardiac surgery patients with a left ventricular ejection fraction of 40% or less. The primary endpoint was postoperative mortality. Secondary outcomes were cardiac index, pulmonary capillary wedge pressure (PCWP), length of intensive care unit (ICU) stay, postoperative atrial fibrillation, and postoperative renal replacement therapy. We performed trial sequential analysis (TSA) to evaluate the reliability of the primary endpoint. RESULTS Data from 2,152 patients in 15 randomized clinical trials were analyzed. Pooled results demonstrated a reduction in postoperative mortality in the levosimendan group [RR = 0.53, 95% CI (0.38-0.73), I2 = 0]. However, the result of TSA showed that the conclusion may be a false positive. Secondary outcomes demonstrated that PCWP, postoperative renal replacement therapy, and length of ICU stay were significantly reduced. Cardiac index was greater in the levosimendan group. No difference was found in the rate of postoperative atrial fibrillation. CONCLUSIONS Levosimendan reduces the rate of death and other adverse outcomes in patients with low ejection fraction who were undergoing cardiac surgery, but results remain inconclusive. More large-volume randomized clinical trials (RCTs) are warranted.
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Affiliation(s)
- Benji Wang
- Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Xiaojie He
- School of Ophthalmology and Optometry and Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Yuqiang Gong
- Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Bihuan Cheng
- Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
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Møller MH, Granholm A, Junttila E, Haney M, Oscarsson-Tibblin A, Haavind A, Laake JH, Wilkman E, Sverrisson KÖ, Perner A. Scandinavian SSAI clinical practice guideline on choice of inotropic agent for patients with acute circulatory failure. Acta Anaesthesiol Scand 2018; 62:420-450. [PMID: 29479665 PMCID: PMC5888146 DOI: 10.1111/aas.13089] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 12/28/2017] [Accepted: 01/03/2018] [Indexed: 12/22/2022]
Abstract
Background Adult critically ill patients often suffer from acute circulatory failure and those with low cardiac output may be treated with inotropic agents. The aim of this Scandinavian Society of Anaesthesiology and Intensive Care Medicine guideline was to present patient‐important treatment recommendations on this topic. Methods This guideline was developed according to GRADE. We assessed the following subpopulations of patients with shock: (1) shock in general, (2) septic shock, (3) cardiogenic shock, (4) hypovolemic shock, (5) shock after cardiac surgery, and (6) other types of shock, including vasodilatory shock. We assessed patient‐important outcome measures, including mortality and serious adverse reactions. Results For all patients, we suggest against the routine use of any inotropic agent, including dobutamine, as compared to placebo/no treatment (very low quality of evidence). For patients with shock in general, and in those with septic and other types of shock, we suggest using dobutamine rather than levosimendan or epinephrine (very low quality of evidence). For patients with cardiogenic shock and in those with shock after cardiac surgery, we suggest using dobutamine rather than milrinone (very low quality of evidence). For the other clinical questions, we refrained from giving any recommendations or suggestions. Conclusions We suggest against the routine use of any inotropic agent in adult patients with shock. If used, we suggest using dobutamine rather than other inotropic agents for the majority of patients, however, the quality of evidence was very low, implying high uncertainty on the balance between the benefits and harms of inotropic agents.
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Affiliation(s)
- M. H. Møller
- Department of Intensive Care 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - A. Granholm
- Department of Intensive Care 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - E. Junttila
- Department of Anaesthesiology; Tampere University Hospital; Tampere Finland
| | - M. Haney
- Anaesthesiology and Intensive Care Medicine; Umeå University; Umeå Sweden
| | - A. Oscarsson-Tibblin
- Department of Anaesthesiology and Intensive Care; Department of Medicine and Health; Linköping University; Linköping Sweden
| | - A. Haavind
- Department of Anaesthesiology and Intensive Care; University Hospital Northern Norway; Tromsø Norway
| | - J. H. Laake
- Division of Critical Care; Oslo University Hospital; Oslo Norway
| | - E. Wilkman
- Division of Intensive Care Medicine; Department of Perioperative, Intensive Care and Pain Medicine; Helsinki University Hospital; University of Helsinki; Helsinki Finland
| | - K. Ö. Sverrisson
- Department of Anesthesia & Critical Care; Landspitali University Hospital of Iceland; Reykjavik Iceland
| | - A. Perner
- Department of Intensive Care 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
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Levosimendan: new indications and evidence for reduction in perioperative mortality? Curr Opin Anaesthesiol 2018; 29:454-61. [PMID: 27168089 DOI: 10.1097/aco.0000000000000357] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW In the last years, the perioperative use of levosimendan in cardiac surgery patients is spreading. Moreover, newer indications have been suggested such as the treatment of sepsis-associated myocardial dysfunction. In the present review, we discuss the most recent evidences in these settings. RECENT FINDINGS Levosimendan has been seemingly confirmed to reduce mortality in patients undergoing cardiac surgery. In particular, it appears to be the only inotropic drug to have a favorable effect on survival in any clinical setting. Moreover, levosimendan has been shown to exert a cardioprotective action and to reduce acute kidney injury, renal replacement therapy, and ICU stay in cardiac surgery patients. Finally, levosimendan has been suggested to reduce mortality in patients with severe sepsis and to improve renal outcomes in critically ill patients. SUMMARY Although a strong rationale likely exists to use levosimendan in the setting of perioperative and critical care medicine, evidence mainly comes from small and often poor-quality randomized clinical trials, whose results acquire significance only when pooled in meta-analyses. Moreover, some aspects related to which subgroups of patients may derive the most benefits from receiving levosimendan, to the optimal timing of administration, and to the potential adverse effects need to be further clarified. Important insights will be hopefully provided soon by the several large multicenter investigations which are currently ongoing.
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Zhou X, Hu C, Xu Z, Liu P, Zhang Y, Sun L, Wang Y, Gao X. Effect of levosimendan on clinical outcomes in adult patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials. Interact Cardiovasc Thorac Surg 2018; 26:1016-1026. [PMID: 29415177 DOI: 10.1093/icvts/ivy017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 01/09/2018] [Indexed: 12/11/2022] Open
Affiliation(s)
- Xiaoyang Zhou
- Department of Intensive Care Unit, Ningbo No. 2 Hospital, Ningbo, China
| | - Caibao Hu
- Department of Intensive Care Unit, Zhejiang Hospital, Hangzhou, China
| | - Zhaojun Xu
- Department of Intensive Care Unit, Ningbo No. 2 Hospital, Ningbo, China
| | - Peng Liu
- Department of Intensive Care Unit, Ningbo No. 2 Hospital, Ningbo, China
| | - Yuchu Zhang
- Department of Intensive Care Unit, Ningbo No. 2 Hospital, Ningbo, China
| | - Lingling Sun
- Department of Geriatrics, Ningbo No. 2 Hospital, Ningbo, China
| | - Yang Wang
- Department of Intensive Care Unit, Ningbo No. 2 Hospital, Ningbo, China
| | - Xiaofei Gao
- Department of Cardiology, Hangzhou First People’s Hospital, Hangzhou, China
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Landoni G, Lomivorotov V, Silvetti S, Nigro Neto C, Pisano A, Alvaro G, Hajjar LA, Paternoster G, Riha H, Monaco F, Szekely A, Lembo R, Aslan NA, Affronti G, Likhvantsev V, Amarelli C, Fominskiy E, Baiardo Redaelli M, Putzu A, Baiocchi M, Ma J, Bono G, Camarda V, Covello RD, Di Tomasso N, Labonia M, Leggieri C, Lobreglio R, Monti G, Mura P, Scandroglio AM, Pasero D, Turi S, Roasio A, Votta CD, Saporito E, Riefolo C, Sartini C, Brazzi L, Bellomo R, Zangrillo A. Nonsurgical Strategies to Reduce Mortality in Patients Undergoing Cardiac Surgery: An Updated Consensus Process. J Cardiothorac Vasc Anesth 2018; 32:225-235. [DOI: 10.1053/j.jvca.2017.06.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Indexed: 11/11/2022]
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Schumann J, Henrich EC, Strobl H, Prondzinsky R, Weiche S, Thiele H, Werdan K, Frantz S, Unverzagt S. Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev 2018; 1:CD009669. [PMID: 29376560 PMCID: PMC6491099 DOI: 10.1002/14651858.cd009669.pub3] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cardiogenic shock (CS) and low cardiac output syndrome (LCOS) as complications of acute myocardial infarction (AMI), heart failure (HF) or cardiac surgery are life-threatening conditions. While there is a broad body of evidence for the treatment of people with acute coronary syndrome under stable haemodynamic conditions, the treatment strategies for people who become haemodynamically unstable or develop CS remain less clear. We have therefore summarised here the evidence on the treatment of people with CS or LCOS with different inotropic agents and vasodilative drugs. This is the first update of a Cochrane review originally published in 2014. OBJECTIVES To assess efficacy and safety of cardiac care with positive inotropic agents and vasodilator strategies in people with CS or LCOS due to AMI, HF or cardiac surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CPCI-S Web of Science in June 2017. We also searched four registers of ongoing trials and scanned reference lists and contacted experts in the field to obtain further information. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials in people with myocardial infarction, heart failure or cardiac surgery complicated by cardiogenic shock or LCOS. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We identified 13 eligible studies with 2001 participants (mean or median age range 58 to 73 years) and two ongoing studies. We categorised studies into eight comparisons, all against cardiac care and additional other active drugs or placebo. These comparisons investigated the efficacy of levosimendan versus dobutamine, enoximone or placebo, epinephrine versus norepinephrine-dobutamine, amrinone versus dobutamine, dopexamine versus dopamine, enoximone versus dopamine and nitric oxide versus placebo.All trials were published in peer-reviewed journals, and analysis was done by the intention-to-treat (ITT) principle. Twelve of 13 trials were small with few included participants. Acknowledgement of funding by the pharmaceutical industry or missing conflict of interest statements emerged in five of 13 trials. In general, confidence in the results of analysed studies was reduced due to serious study limitations, very serious imprecision or indirectness. Domains of concern, which show a high risk of more than 50%, include performance bias (blinding of participants and personnel) and bias affecting the quality of evidence on adverse events.Levosimendan may reduce short-term mortality compared to a therapy with dobutamine (RR 0.60, 95% CI 0.37 to 0.95; 6 studies; 1776 participants; low-quality evidence; NNT: 16 (patients with moderate risk), NNT: 5 (patients with CS)). This initial short-term survival benefit with levosimendan vs. dobutamine is not confirmed on long-term follow up. There is uncertainty (due to lack of statistical power) as to the effect of levosimendan compared to therapy with placebo (RR 0.48, 95% CI 0.12 to 1.94; 2 studies; 55 participants, very low-quality evidence) or enoximone (RR 0.50, 95% CI 0.22 to 1.14; 1 study; 32 participants, very low-quality evidence).All comparisons comparing other positive inotropic, inodilative or vasodilative drugs presented uncertainty on their effect on short-term mortality with very low-quality evidence and based on only one RCT. These single studies compared epinephrine with norepinephrine-dobutamine (RR 1.25, 95% CI 0.41 to 3.77; 30 participants), amrinone with dobutamine (RR 0.33, 95% CI 0.04 to 2.85; 30 participants), dopexamine with dopamine (no in-hospital deaths from 70 participants), enoximone with dobutamine (two deaths from 40 participants) and nitric oxide with placebo (one death from three participants). AUTHORS' CONCLUSIONS Apart from low quality of evidence data suggesting a short-term mortality benefit of levosimendan compared with dobutamine, at present there are no robust and convincing data to support a distinct inotropic or vasodilator drug-based therapy as a superior solution to reduce mortality in haemodynamically unstable people with cardiogenic shock or LCOS.Considering the limited evidence derived from the present data due to a generally high risk of bias and imprecision, it should be emphasised that there remains a great need for large, well-designed randomised trials on this topic to close the gap between daily practice in critical care medicine and the available evidence. It seems to be useful to apply the concept of 'early goal-directed therapy' in cardiogenic shock and LCOS with early haemodynamic stabilisation within predefined timelines. Future clinical trials should therefore investigate whether such a therapeutic concept would influence survival rates much more than looking for the 'best' drug for haemodynamic support.
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Affiliation(s)
- Julia Schumann
- Martin‐Luther‐University Halle‐WittenbergDepartment of Anaesthesiology and Surgical Intensive CareHalle/SaaleGermany
| | - Eva C Henrich
- Martin‐Luther‐University Halle‐WittenbergInstitute of Medical Epidemiology, Biostatistics and InformaticsHalle/SaaleGermany06112
| | - Hellen Strobl
- Martin‐Luther‐University Halle‐WittenbergInstitute of Medical Epidemiology, Biostatistics and InformaticsHalle/SaaleGermany06112
| | - Roland Prondzinsky
- Carl von Basedow Klinikum MerseburgCardiology/Intensive Care MedicineWeisse Mauer 42MerseburgGermany06217
| | - Sophie Weiche
- Martin‐Luther‐University Halle‐WittenbergDepartment of Internal Medicine IIIHalle/SaaleGermany
| | - Holger Thiele
- University Clinic Schleswig‐Holstein, Campus LübeckMedical Clinic II (Kardiology, Angiology, Intensive Care Medicine)Ratzeburger Allee 160LubeckD‐23538Germany
| | - Karl Werdan
- Martin‐Luther‐University Halle‐WittenbergDepartment of Internal Medicine IIIHalle/SaaleGermany
| | - Stefan Frantz
- Martin‐Luther‐University Halle‐WittenbergDepartment of Internal Medicine IIIHalle/SaaleGermany
| | - Susanne Unverzagt
- Martin‐Luther‐University Halle‐WittenbergInstitute of Medical Epidemiology, Biostatistics and InformaticsHalle/SaaleGermany06112
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Putzu A, Clivio S, Belletti A, Cassina T. Perioperative levosimendan in cardiac surgery: A systematic review with meta-analysis and trial sequential analysis. Int J Cardiol 2017; 251:22-31. [PMID: 29126653 DOI: 10.1016/j.ijcard.2017.10.077] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/24/2017] [Accepted: 10/17/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Several studies suggested beneficial effects of perioperative levosimendan on postoperative outcome after cardiac surgery. However, three large randomized controlled trials (RCTs) have been recently published and presented neutral results. We performed a systematic review with meta-analysis and trial sequential analysis (TSA) to assess benefits and harms of perioperative levosimendan therapy in cardiac surgery. METHODS Electronic databases were searched up to September 2017 for RCTs on preoperative levosimendan versus any type of control. The Cochrane methodology was employed. We calculated odds ratio (OR) or Risk Ratio (OR) and 95% confidence interval (CI) using fixed-effects meta-analyses and we further performed TSA. RESULTS We included data from 40 RCTs and 4246 patients. Pooled analysis of 5 low risk of bias trials (1910 patients) showed no association between levosimendan and mortality (OR 0.86 [95% CI, 0.62, 1.18], p=0.34, TSA inconclusive), acute kidney injury, need of renal replacement therapy, myocardial infarction, ventricular arrhythmias, and serious adverse events, but an association with higher incidence of supraventricular arrhythmias (RR 1.11 [95% CI, 1.00, 1.24], p=0.05, TSA inconclusive) and hypotension (RR 1.15 [95% CI, 1.01, 1.30], p=0.04, TSA inconclusive). Analysis including all 40 trials found that levosimendan was associated with lower postoperative mortality (OR 0.56 [95% CI, 0.44, 0.71], p<0.00001, TSA conclusive), acute kidney injury, and renal replacement therapy, and higher incidence of hypotension. CONCLUSIONS There is not enough high-quality evidence to neither support nor discourage the systematic use of levosimendan in cardiac surgery.
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Affiliation(s)
- Alessandro Putzu
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland.
| | - Sara Clivio
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland.
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Tiziano Cassina
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland.
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Mehta RH, Leimberger JD, van Diepen S, Meza J, Wang A, Jankowich R, Harrison RW, Hay D, Fremes S, Duncan A, Soltesz EG, Luber J, Park S, Argenziano M, Murphy E, Marcel R, Kalavrouziotis D, Nagpal D, Bozinovski J, Toller W, Heringlake M, Goodman SG, Levy JH, Harrington RA, Anstrom KJ, Alexander JH. Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery. N Engl J Med 2017; 376:2032-2042. [PMID: 28316276 DOI: 10.1056/nejmoa1616218] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Levosimendan is an inotropic agent that has been shown in small studies to prevent or treat the low cardiac output syndrome after cardiac surgery. METHODS In a multicenter, randomized, placebo-controlled, phase 3 trial, we evaluated the efficacy and safety of levosimendan in patients with a left ventricular ejection fraction of 35% or less who were undergoing cardiac surgery with the use of cardiopulmonary bypass. Patients were randomly assigned to receive either intravenous levosimendan (at a dose of 0.2 μg per kilogram of body weight per minute for 1 hour, followed by a dose of 0.1 μg per kilogram per minute for 23 hours) or placebo, with the infusion started before surgery. The two primary end points were a four-component composite of death through day 30, renal-replacement therapy through day 30, perioperative myocardial infarction through day 5, or use of a mechanical cardiac assist device through day 5; and a two-component composite of death through day 30 or use of a mechanical cardiac assist device through day 5. RESULTS A total of 882 patients underwent randomization, 849 of whom received levosimendan or placebo and were included in the modified intention-to-treat population. The four-component primary end point occurred in 105 of 428 patients (24.5%) assigned to receive levosimendan and in 103 of 421 (24.5%) assigned to receive placebo (adjusted odds ratio, 1.00; 99% confidence interval [CI], 0.66 to 1.54; P=0.98). The two-component primary end point occurred in 56 patients (13.1%) assigned to receive levosimendan and in 48 (11.4%) assigned to receive placebo (adjusted odds ratio, 1.18; 96% CI, 0.76 to 1.82; P=0.45). The rate of adverse events did not differ significantly between the two groups. CONCLUSIONS Prophylactic levosimendan did not result in a rate of the short-term composite end point of death, renal-replacement therapy, perioperative myocardial infarction, or use of a mechanical cardiac assist device that was lower than the rate with placebo among patients with a reduced left ventricular ejection fraction who were undergoing cardiac surgery with the use of cardiopulmonary bypass. (Funded by Tenax Therapeutics; LEVO-CTS ClinicalTrials.gov number, NCT02025621 .).
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Affiliation(s)
- Rajendra H Mehta
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Jeffrey D Leimberger
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Sean van Diepen
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - James Meza
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Alice Wang
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Rachael Jankowich
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Robert W Harrison
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Douglas Hay
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Stephen Fremes
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Andra Duncan
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Edward G Soltesz
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - John Luber
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Soon Park
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Michael Argenziano
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Edward Murphy
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Randy Marcel
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Dimitri Kalavrouziotis
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Dave Nagpal
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - John Bozinovski
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Wolfgang Toller
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Matthias Heringlake
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Shaun G Goodman
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Jerrold H Levy
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Robert A Harrington
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Kevin J Anstrom
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - John H Alexander
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
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Landoni G, Pisano A, Lomivorotov V, Alvaro G, Hajjar L, Paternoster G, Nigro Neto C, Latronico N, Fominskiy E, Pasin L, Finco G, Lobreglio R, Azzolini ML, Buscaglia G, Castella A, Comis M, Conte A, Conte M, Corradi F, Dal Checco E, De Vuono G, Ganzaroli M, Garofalo E, Gazivoda G, Lembo R, Marianello D, Baiardo Redaelli M, Monaco F, Tarzia V, Mucchetti M, Belletti A, Mura P, Musu M, Pala G, Paltenghi M, Pasyuga V, Piras D, Riefolo C, Roasio A, Ruggeri L, Santini F, Székely A, Verniero L, Vezzani A, Zangrillo A, Bellomo R. Randomized Evidence for Reduction of Perioperative Mortality: An Updated Consensus Process. J Cardiothorac Vasc Anesth 2017; 31:719-730. [DOI: 10.1053/j.jvca.2016.07.017] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Indexed: 11/11/2022]
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Mehta RH, Van Diepen S, Meza J, Bokesch P, Leimberger JD, Tourt-Uhlig S, Swartz M, Parrotta J, Jankowich R, Hay D, Harrison RW, Fremes S, Goodman SG, Luber J, Toller W, Heringlake M, Anstrom KJ, Levy JH, Harrington RA, Alexander JH. Levosimendan in patients with left ventricular systolic dysfunction undergoing cardiac surgery on cardiopulmonary bypass: Rationale and study design of the Levosimendan in Patients with Left Ventricular Systolic Dysfunction Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass (LEVO-CTS) trial. Am Heart J 2016; 182:62-71. [PMID: 27914501 DOI: 10.1016/j.ahj.2016.09.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 09/06/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Low cardiac output syndrome is associated with increased mortality and occurs in 3% to 14% of patients undergoing cardiac surgery on cardiopulmonary bypass (CPB). Levosimendan, a novel calcium sensitizer and KATP channel activator with inotropic, vasodilatory, and cardioprotective properties, has shown significant promise in reducing the incidence of low cardiac output syndrome and related adverse outcomes in patients undergoing cardiac surgery on CPB. METHODS LEVO-CTS is a phase 3 randomized, controlled, multicenter study evaluating the efficacy, safety, and cost-effectiveness of levosimendan in reducing morbidity and mortality in high-risk patients with reduced left ventricular ejection fraction (≤35%) undergoing cardiac surgery on CPB. Patients will be randomly assigned to receive either intravenous levosimendan (0.2 μg kg-1 min-1 for the first hour followed by 0.1 μg/kg for 23hours) or matching placebo initiated within 8hours of surgery. The co-primary end points are (1) the composite of death or renal replacement therapy through day 30 or perioperative myocardial infarction, or mechanical assist device use through day 5 (quad end point tested at α<.01), and (2) the composite of death through postoperative day 30 or mechanical assist device use through day 5 (dual end point tested at α<.04). Safety end points include new atrial fibrillation and death through 90days. In addition, an economic analysis will address the cost-effectiveness of levosimendan compared with placebo in high-risk patients undergoing cardiac surgery on CPB. Approximately 880 patients will be enrolled at approximately 60 sites in the United States and Canada between July 2014 and September 2016, with results anticipated in January 2017. CONCLUSION LEVO-CTS, a large randomized multicenter clinical trial, will evaluate the efficacy, safety, and cost-effectiveness of levosimendan in reducing adverse outcomes in high-risk patients undergoing cardiac surgery on CPB. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (NCT02025621).
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Caruba T, Hourton D, Sabatier B, Rousseau D, Tibi A, Hoffart-Jourdain C, Souag A, Freitas N, Yjjou M, Almeida C, Gomes N, Aucouturier P, Djadi-Prat J, Menasché P, Chatellier G, Cholley B. Rationale and design of the multicenter randomized trial investigating the effects of levosimendan pretreatment in patients with low ejection fraction (≤40 %) undergoing CABG with cardiopulmonary bypass (LICORN study). J Cardiothorac Surg 2016; 11:127. [PMID: 27496105 PMCID: PMC4974786 DOI: 10.1186/s13019-016-0530-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 07/28/2016] [Indexed: 12/04/2022] Open
Abstract
Background Patients with a left ventricular ejection fraction (LVEF) of less than 40 % are at high risk of developing postoperative low cardiac output syndrome (LCOS). Despite actual treatments (inotropic agents and/or mechanical assist devices), the mortality rate of such patients remains very high (13 to 24 %). The LICORN trial aims at assessing the efficacy of a preoperative infusion of levosimendan in reducing postoperative LCOS in patients with poor LVEF undergoing coronary artery bypass grafting (CABG). Methods/Design LICORN study is a multicenter, randomized double-blind, placebo-controlled trial in parallel groups. 340 patients with LVEF ≤40 %, undergoing CABG will be recruited from 13 French hospitals. The study drug will be started after anaesthesia induction and infused over 24 h (0.1 μg/kg/min). The primary outcome (postoperative LCOS) is evaluated using a composite criterion composed of: 1) need for inotropic agents beyond 24 h following discontinuation of the study drug; 2) need for post-operative mechanical assist devices or failure to wean from these techniques when inserted pre-operatively; 3) need for renal replacement therapy. Secondary outcomes include: 1) mortality at Day 28 and Day 180; 2) each item of the composite criterion of the primary outcome; 3) the number of “ventilator-free” days and “out of intensive care unit” days at Day 28. Discussion The usefulness of levosimendan in the perioperative period has not yet been documented with a high level of evidence. The LICORN study is the first randomized controlled trial evaluating the clinical value of preoperative levosimendan in high risk cardiac surgical patients undergoing CABG. Trial registration number NCT02184819 (ClinicalTrials.gov).
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Affiliation(s)
- Thibaut Caruba
- Department of Pharmacy, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Delphine Hourton
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Brigitte Sabatier
- Department of Pharmacy, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.,INSERM Centre de Recherche des Cordeliers UMR S 872 eq 22 Université Paris Descartes, Paris, France
| | - Dominique Rousseau
- Department of Pharmacy, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Annick Tibi
- Agence Générale des Equipements et des Produits de Santé (AGEPS), AP-HP, Paris, France
| | - Cécile Hoffart-Jourdain
- Département de la Recherche Clinique et du Développement (DRCD), Hôpital Saint-Louis, (AP-HP), Paris, France
| | - Akim Souag
- Département de la Recherche Clinique et du Développement (DRCD), Hôpital Saint-Louis, (AP-HP), Paris, France
| | - Nelly Freitas
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Mounia Yjjou
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Carla Almeida
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Nathalie Gomes
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Pascaline Aucouturier
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Juliette Djadi-Prat
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Philippe Menasché
- Department of Cardiovascular Surgery, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Gilles Chatellier
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Bernard Cholley
- Department of Anaesthesiology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, 20 rue Leblanc, 75015, Paris, France. .,Université Paris Descartes, Sorbonne Paris Cité, Paris, France.
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Lomivorotov VV, Efremov SM, Kirov MY, Fominskiy EV, Karaskov AM. Low-Cardiac-Output Syndrome After Cardiac Surgery. J Cardiothorac Vasc Anesth 2016; 31:291-308. [PMID: 27671216 DOI: 10.1053/j.jvca.2016.05.029] [Citation(s) in RCA: 168] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia.
| | - Sergey M Efremov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Mikhail Y Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia
| | - Evgeny V Fominskiy
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Alexander M Karaskov
- Department of Cardiac Surgery, Research Institute of Circulation Pathology, Novosibirsk, Russia
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Guerrero Orriach JL, Galán Ortega M, Ramírez Fernandez A, Ariza Villanueva D, Florez Vela A, Moreno Cortés I, Rubio Navarro M, Cruz Mañas J. Assessing the effect of preoperative levosimendan on renal function in patients with right ventricular dysfunction. J Clin Monit Comput 2016; 31:227-230. [PMID: 26762127 DOI: 10.1007/s10877-016-9827-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/06/2016] [Indexed: 10/22/2022]
Abstract
The Acute Kidney Injury Network (AKIN) classification considers SCr values, urea and urine output in order to improve timely diagnose ARF and improve patient prognosis by early treatment. Preoperative levosimendan is a new way for cardiac and kidney protection, we try to evaluate this drug in fifteen patients comparing values of AKIN scale parameters pre and post cardiac surgery in patients with right ventricle dysfunction.
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Affiliation(s)
- Jose L Guerrero Orriach
- Department of Anaesthesia, Hospital Virgen de la Victoria, Campus Universitario Teatinos, 29010, Málaga, Spain.
| | - M Galán Ortega
- Department of Anaesthesia, Hospital Virgen de la Victoria, Campus Universitario Teatinos, 29010, Málaga, Spain
| | - A Ramírez Fernandez
- Department of Anaesthesia, Hospital Virgen de la Victoria, Campus Universitario Teatinos, 29010, Málaga, Spain
| | - D Ariza Villanueva
- Department of Anaesthesia, Hospital Virgen de la Victoria, Campus Universitario Teatinos, 29010, Málaga, Spain
| | - A Florez Vela
- Department of Anaesthesia, Hospital Virgen de la Victoria, Campus Universitario Teatinos, 29010, Málaga, Spain
| | - I Moreno Cortés
- Department of Anaesthesia, Hospital Virgen de la Victoria, Campus Universitario Teatinos, 29010, Málaga, Spain
| | - M Rubio Navarro
- Department of Anaesthesia, Hospital Virgen de la Victoria, Campus Universitario Teatinos, 29010, Málaga, Spain
| | - J Cruz Mañas
- Department of Anaesthesia, Hospital Virgen de la Victoria, Campus Universitario Teatinos, 29010, Málaga, Spain
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Mardiguian S, Kivikko M, Heringlake M, Smare C, Bertranou E, Apajasalo M, Pollesello P. Cost-benefits of incorporating levosimendan into cardiac surgery practice: German base case. J Med Econ 2016; 19:506-14. [PMID: 26707159 DOI: 10.3111/13696998.2015.1136312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the cost-benefit of using levosimendan compared with dobutamine, in the perioperative treatment of patients undergoing cardiac surgery who require inotropic support. METHODS A two-part Markov model was designed to simulate health-state transitions of patients undergoing cardiac surgery, and estimate the short- and long-term health benefits of treatment. Hospital length of stay (LOS), mortality, medication, and adverse events were key clinical- and cost-inputs. Cost-benefits were evaluated in terms of costs and bed stays within the German healthcare system. Drug prices were calculated from the German Drug Directory (€/2014) and published literature, with a 3% annual discount rate applied. The base case analysis was for a 1-year time horizon. RESULTS The use of levosimendan vs dobutamine was associated with cost savings of €4787 per patient from the German hospital perspective due to reduced adverse events and shorter hospital LOS, leading to increased bed capacity and hospital revenue. LIMITATIONS A pharmacoeconomic calculation for the specific situation of the German healthcare system that is based on international clinical trial carries a substantial risk of disregarding potentially relevant but unknown confounding factors (i.e., ICU-staffing, co-medications, standard-ICU care vs fast-tracking, etc.) that may either attenuate or increase the outcome pharmacoeconomic effects of a drug; however, since these conditions would also apply for patients treated with comparators, their net effects may not necessarily influence the conclusions. CONCLUSIONS The use of levosimendan in patients undergoing cardiac surgery who require inotropic support appears to be cost-saving. The results of the analysis provide a strong rationale to run local clinical studies with pharmacoeconomic end-points which would allow a much more precise computation of the benefits of levosimendan.
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Affiliation(s)
| | | | - Matthias Heringlake
- c c Clinic for Anesthesiology and Intensive Care Medicine, Universitätsklinikum Schleswig-Holstein , Lübeck , Germany
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Gong B, Li Z, Yat Wong PC. Levosimendan Treatment for Heart Failure: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2015; 29:1415-25. [DOI: 10.1053/j.jvca.2015.03.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Indexed: 11/11/2022]
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Zhou C, Gong J, Chen D, Wang W, Liu M, Liu B. Levosimendan for Prevention of Acute Kidney Injury After Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials. Am J Kidney Dis 2015; 67:408-16. [PMID: 26518388 DOI: 10.1053/j.ajkd.2015.09.015] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 09/03/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Levosimendan has been shown to confer direct renoprotection in renal endotoxemic and ischemia-reperfusion injury and could increase renal blood flow in patients with low-cardiac-output heart failure. Results from clinical trials of levosimendan on acute kidney injury (AKI) following cardiac surgery are controversial. STUDY DESIGN A random-effect meta-analysis was conducted based on evidence from PubMed, EMBASE, and Cochrane Library. SETTINGS & POPULATION Adult patients undergoing cardiac surgery. SELECTION CRITERIA FOR STUDIES Randomized controlled trials comparing the renal effect of levosimendan versus placebo or other inotropic drugs during cardiac surgery. INTERVENTION Perioperative levosimendan continuous infusion at a rate of 0.1 to 0.2μg/kg/min following a loading dose (6-24μg/kg) for 24 hours or only 1 loading dose (24μg/kg) within 1 hour. OUTCOMES AKI, need for renal replacement therapy, mechanical ventilation duration, intensive care unit stay during hospitalization, and postoperative mortality (in-hospital or within 30 days). RESULTS 13 trials with a total of 1,345 study patients were selected. Compared with controls, levosimendan reduced the incidence of postoperative AKI (40/460 vs 78/499; OR, 0.51; 95% CI, 0.34-0.76; P=0.001; I(2)=0.0%), renal replacement therapy (22/492 vs 49/491; OR, 0.43; 95% CI, 0.25-0.76; P=0.002; I(2)=0.0%), postoperative mortality (35/658 vs 94/657; OR, 0.41; 95% CI, 0.27-0.62; P<0.001; I(2)=0.0%), mechanical ventilation duration (in days; n=235; weighted mean difference, -0.34; 95% CI, -0.58 to -0.09; P=0.007], and intensive care unit stay (in days; n=500; weighted mean difference, -2.2; 95% CI, -4.21 to -0.13; P=0.04). LIMITATIONS Different definitions for AKI among studies. Small sample size for some trials. CONCLUSIONS Perioperative administration of levosimendan in patients undergoing cardiac surgery may reduce complications. Future trials are needed to determine the dose effect of levosimendan in improving outcomes, especially in patients with decreased baseline kidney function.
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Affiliation(s)
- Chenghui Zhou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junsong Gong
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Chen
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weipeng Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingzheng Liu
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Liu
- Department of Anesthesiology, Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China.
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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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Greco T, Calabrò M, Covello R, Greco M, Pasin L, Morelli A, Landoni G, Zangrillo A. A Bayesian network meta-analysis on the effect of inodilatory agents on mortality. Br J Anaesth 2015; 114:746-756. [DOI: 10.1093/bja/aeu446] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Preoperative and perioperative use of levosimendan in cardiac surgery: European expert opinion. Int J Cardiol 2015; 184:323-336. [DOI: 10.1016/j.ijcard.2015.02.022] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 02/09/2015] [Accepted: 02/21/2015] [Indexed: 01/07/2023]
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JUHL-OLSEN P, JAKOBSEN CJ, RASMUSSEN LA, BHAVSAR R, KLAABORG KE, FREDERIKSEN CA, SLOTH E. Effects of levosimendan in patients with left ventricular hypertrophy undergoing aortic valve replacement. Acta Anaesthesiol Scand 2015; 59:65-77. [PMID: 25348510 DOI: 10.1111/aas.12425] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 09/16/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND Left ventricular hypertrophy is associated with adverse outcomes, including death, during cardiac surgery. This may be facilitated by an increased oxygen demand and diastolic dysfunction. Levosimendan augments haemodynamics without further oxygen consumption and improves echocardiographic indices of diastolic dysfunction. This study aimed to describe the haemodynamic effects of short-term pre- and intra-operative levosimendan infusion including advanced echocardiographic measures of diastolic and systolic heart function. METHODS The study was randomised, double-blinded and placebo-controlled performed at a single-centre university hospital. Patients with left ventricular hypertrophy and ejection fraction > 45% scheduled for single procedure aortic valve replacement were included and randomised to infusion of either levosimendan 0.1 μg/kg/min or placebo from 4 h before anaesthesia to the end of surgery. Outcome measures were echocardiographic indices of left ventricular diastolic function: E/e' (primary endpoint), e', e'/a' and indices of systolic function: longitudinal strain, ejection fraction and s'. Patients were followed until 6 months after surgery. In addition, invasive haemodynamic measures were obtained perioperatively. RESULTS The trial was prematurely terminated due to an overall high incidence of post-operative atrial fibrillation (15/20, P = 0.002) after inclusion of 20 patients. The relative decrease in perioperative cardiac index was lower (P = 0.016) in the levosimendan group. There was no difference in E/e', and similar results were found for all measures of systolic function. CONCLUSION Short-term levosimendan caused a transient relative increase in cardiac index, but no effect was seen on the first post-operative day and up to 6 months post-operatively with indices of systolic and diastolic heart function.
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Affiliation(s)
- P. JUHL-OLSEN
- Department of Anaesthesiology and Intensive Care; Aarhus University Hospital; Aarhus Denmark
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
| | - C.-J. JAKOBSEN
- Department of Anaesthesiology and Intensive Care; Aarhus University Hospital; Aarhus Denmark
| | - L. A. RASMUSSEN
- Department of Anaesthesiology and Intensive Care; Aarhus University Hospital; Aarhus Denmark
| | - R. BHAVSAR
- Department of Anaesthesiology and Intensive Care; Aarhus University Hospital; Aarhus Denmark
| | - K.-E. KLAABORG
- Department of Thoracic and Vascular Surgery; Aarhus University Hospital; Aarhus Denmark
| | - C. A. FREDERIKSEN
- Department of Anaesthesiology and Intensive Care; Aarhus University Hospital; Aarhus Denmark
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
| | - E. SLOTH
- Department of Anaesthesiology and Intensive Care; Aarhus University Hospital; Aarhus Denmark
- Department of Clinical Medicine; Aarhus University; Aarhus Denmark
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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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Balzer F, Treskatsch S, Spies C, Sander M, Kastrup M, Grubitzsch H, Wernecke KD, Braun JP. Early administration of levosimendan is associated with improved kidney function after cardiac surgery - a retrospective analysis. J Cardiothorac Surg 2014; 9:167. [PMID: 25399779 PMCID: PMC4240807 DOI: 10.1186/s13019-014-0167-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 09/26/2014] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Several animal studies suggest beneficial effects on kidney function upon administration of levosimendan. As recent data from clinical studies are heterogeneous, we sought to investigate whether levosimendan is associated with improved postoperative kidney function in cardiac surgery patients with respect to timing of its administration. METHODS Retrospective, single centre, observational analysis at a university hospital in Berlin, Germany. All adult patients without preoperative renal dysfunction that underwent coronary artery bypass grafting and/or valve reconstruction/replacement between 01/01/2007 and 31/12/2011 were considered for analyses. RESULTS Out of 1.095 included patients, 46 patients were treated with levosimendan due to a severely reduced left ventricular systolic function preoperatively (LVEF < 35%) and/or clinical signs of a low cardiac output syndrome. Sixty-one percent received the drug whilst in the OR, 39% after postoperative intensive care unit admission. When levosimendan was given immediately after anaesthesia induction, creatinine plasma levels (p = 0.009 for nonparametric analysis of longitudinal data in a two-factorial design) and incidence of postoperative renal dysfunction (67.9% vs. 94.4%; p = 0.033) were significantly reduced in contrast to a later start of treatment. In addition, duration of renal replacement therapy was significantly shorter (79 [35;332] vs. 272 [132;703] minutes; p = 0.046) in that group. CONCLUSIONS Postoperative kidney dysfunction is a common condition in patients under going cardiac surgery. Patients with severely reduced left ventricular function and/or clinical signs of a low cardiac output syndrome who preoperatively presented with a normal kidney function may benefit from an early start of levosimendan administration, i.e. immediately after anaesthesia. TRIAL REGISTRATION Clinicaltrials.gov-ID: NCT01918618 .
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Affiliation(s)
- Felix Balzer
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Michael Sander
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Mark Kastrup
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Herko Grubitzsch
- Department of Cardiovascular Surgery, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | | | - Jan P Braun
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Klinikum Hildesheim GmbH, Hildesheim, Germany.
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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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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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Unverzagt S, Wachsmuth L, Hirsch K, Thiele H, Buerke M, Haerting J, Werdan K, Prondzinsky R. Inotropic agents and vasodilator strategies for acute myocardial infarction complicated by cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev 2014:CD009669. [PMID: 24385385 DOI: 10.1002/14651858.cd009669.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The recently published German-Austrian S3 Guideline for the treatment of infarct related cardiogenic shock (CS) revealed a lack of evidence for all recommended therapeutic measures. OBJECTIVES To determine the effects in terms of efficacy, efficiency and safety of cardiac care with inotropic agents and vasodilator strategies versus placebo or against each other for haemodynamic stabilisation following surgical treatment, interventional therapy (angioplasty, stent implantation) and conservative treatment (that is no revascularization) on mortality and morbidity in patients with acute myocardial infarction (AMI) complicated by CS or low cardiac output syndrome (LCOS). SEARCH METHODS We searched CENTRAL, MEDLINE (Ovid), EMBASE (Ovid) and ISI Web of Science, registers of ongoing trials and proceedings of conferences in January 2013. Reference lists were scanned and experts in the field were contacted to obtain further information. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials in patients with AMI complicated by CS or LCOS. DATA COLLECTION AND ANALYSIS Data collection and analysis were performed according to the published protocol. All trials were analysed individually. Hazard ratios (HRs) and odds ratios with 95% confidence intervals (CI) were extracted but not pooled because of high heterogeneity between the control group interventions. MAIN RESULTS Four eligible, very small studies were identified from a total of 4065 references. Three trials with high overall risk of bias compared levosimendan to standard treatment (enoximone or dobutamine) or placebo. Data from a total of 63 participants were included in our comparisons, 31 were treated with levosimendan and 32 served as controls. Levosimendan showed an imprecise survival benefit in comparison with enoximone based on a very small trial with 32 participants (HR 0.33; 95% CI 0.11 to 0.97). Results from the other similarly small trials were too imprecise to provide any meaningful information about the effect of levosimendan in comparison with dobutamine or placebo. Only small differences in haemodynamics, length of hospital stay and the frequency of major adverse cardiac events or adverse events overall were found between study groups.Only one small randomised controlled trial with three participants was found for vasodilator strategies (nitric oxide gas versus placebo) in AMI complicated by CS or LCOS. This study was too small to draw any conclusions on the effects on our key outcomes. AUTHORS' CONCLUSIONS At present there are no robust and convincing data to support a distinct inotropic or vasodilator drug based therapy as a superior solution to reduce mortality in haemodynamically unstable patients with CS or low cardiac output complicating AMI.
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Affiliation(s)
- Susanne Unverzagt
- Institute of Medical Epidemiology, Biostatistics and Informatics, Martin Luther University Halle-Wittenberg, Magdeburge Straße 8, Halle/Saale, Germany, 06097
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Yilmaz MB, Grossini E, Silva Cardoso JC, Édes I, Fedele F, Pollesello P, Kivikko M, Harjola VP, Hasslacher J, Mebazaa A, Morelli A, le Noble J, Oldner A, Oulego Erroz I, Parissis JT, Parkhomenko A, Poelzl G, Rehberg S, Ricksten SE, Rodríguez Fernández LM, Salmenperä M, Singer M, Treskatsch S, Vrtovec B, Wikström G. Renal effects of levosimendan: a consensus report. Cardiovasc Drugs Ther 2013; 27:581-90. [PMID: 23929366 PMCID: PMC3830192 DOI: 10.1007/s10557-013-6485-6] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Renal dysfunction is common in clinical settings in which cardiac function is compromised such as heart failure, cardiac surgery or sepsis, and is associated with high morbidity and mortality. Levosimendan is a calcium sensitizer and potassium channel opener used in the treatment of acute heart failure. This review describes the effects of the inodilator levosimendan on renal function. A panel of 25 scientists and clinicians from 15 European countries (Austria, Finland, France, Hungary, Germany, Greece, Italy, Portugal, the Netherlands, Slovenia, Spain, Sweden, Turkey, the United Kingdom, and Ukraine) convened and reached a consensus on the current interpretation of the renal effects of levosimendan described both in non-clinical research and in clinical study reports. Most reports on the effect of levosimendan indicate an improvement of renal function in heart failure, sepsis and cardiac surgery settings. However, caution should be applied as study designs differed from randomized, controlled studies to uncontrolled ones. Importantly, in the largest HF study (REVIVE I and II) no significant changes in the renal function were detected. As it regards the mechanism of action, the opening of mitochondrial KATP channels by levosimendan is involved through a preconditioning effect. There is a strong rationale for randomized controlled trials seeking beneficial renal effects of levosimendan. As an example, a study is shortly to commence to assess the role of levosimendan for the prevention of acute organ dysfunction in sepsis (LeoPARDS).
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Affiliation(s)
- Mehmet B. Yilmaz
- Department of Cardiology, Cumhuriyet University School of Medicine, Sivas, Turkey
| | - Elena Grossini
- Laboratorio di Fisiologia, Dipartimento di Medicina Traslazionale, Università degli Studi del Piemonte Orientale A. Avogadro, Piemonte, Italy
| | - José C. Silva Cardoso
- Faculdade de Medicina, Alameda Prof. Hernâni Monteiro, Universidade do Porto, Porto, Portugal
| | - István Édes
- Institute of Cardiology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrological, and Geriatric Sciences, La Sapienza University of Rome, Rome, Italy
| | | | - Matti Kivikko
- Cardiology and Critical Care, Orion Pharma, Espoo, Finland
| | - Veli-Pekka Harjola
- Departments of Cardiology, Helsinki University Hospital, Helsinki, Finland
| | - Julia Hasslacher
- Internistische Intensiv- und Notfallmedizin, Universitätsklinik für Innere Medizin, Innsbruck, Austria
| | - Alexandre Mebazaa
- Department of Anaesthesia and Intensive Care, INSERM UMR 942, Lariboisière Hospital, University of Paris, Paris, France
| | - Andrea Morelli
- Department of Cardiovascular, Respiratory, Nephrological, and Geriatric Sciences, La Sapienza University of Rome, Rome, Italy
| | - Jos le Noble
- Department of Intensive Care, VieCuri Medical Center, Venlo, The Netherlands
| | - Anders Oldner
- Department of Physiology & Pharmacology, Section of Anaesthesiology & Intensive CareMedicine, Karolinska Institute, Stockholm, Sweden
| | - Ignacio Oulego Erroz
- Department of Pediatrics, Complejo Asistencial Universitario de León, León, Spain
| | | | | | - Gerhard Poelzl
- Department of Cardiology, Medical University Innsbruck, Innsbruck, Austria
| | - Sebastian Rehberg
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Muenster, Muenster, Germany
| | - Sven-Erik Ricksten
- Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Markku Salmenperä
- Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland
| | - Mervyn Singer
- Intensive Care Medicine, University College London, London, UK
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - University Medicine Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Bojan Vrtovec
- Advanced Heart Failure and Transplantation Center, Department of Cardiology, Ljubljana University Medical Center, Ljubljana, Slovenia
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Guerrero Orriach JL, Navarro Arce I, Iglesias P, Galán Ortega M, Rubio Navarro M, Cruz Mañas J. Tratamiento preoperatorio con levosimendán para paciente con disfunción ventricular derecha previa a cirugía de sustitución valvular. Rev Esp Cardiol 2013. [DOI: 10.1016/j.recesp.2013.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Guerrero Orriach JL, Navarro Arce I, Iglesias P, Galán Ortega M, Rubio Navarro M, Cruz Mañas J. Preoperative levosimendan for right ventricular dysfunction before heart valve replacement surgery. ACTA ACUST UNITED AC 2013; 66:999-1000. [PMID: 24774116 DOI: 10.1016/j.rec.2013.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 05/17/2013] [Indexed: 11/25/2022]
Affiliation(s)
| | - Isabel Navarro Arce
- Servicio de Anestesiología, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Pablo Iglesias
- Servicio de Anestesiología, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Manuel Galán Ortega
- Servicio de Anestesiología, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Manuel Rubio Navarro
- Servicio de Anestesiología, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - José Cruz Mañas
- Servicio de Anestesiología, Hospital Universitario Virgen de la Victoria, Málaga, Spain
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Toller W, Algotsson L, Guarracino F, Hörmann C, Knotzer J, Lehmann A, Rajek A, Salmenperä M, Schirmer U, Tritapepe L, Weis F, Landoni G. Perioperative use of levosimendan: best practice in operative settings. J Cardiothorac Vasc Anesth 2012; 27:361-6. [PMID: 22658687 DOI: 10.1053/j.jvca.2012.04.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Wolfgang Toller
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
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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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Severi L, Lappa A, Landoni G, Di Pirro L, Luzzi SJ, Caravetta P, Cipullo P, Menichetti A. Levosimendan Versus Intra-aortic Balloon Pump in High-Risk Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 2011; 25:632-6. [DOI: 10.1053/j.jvca.2011.03.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Indexed: 11/11/2022]
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50
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Carl M, Alms A, Braun J, Dongas A, Erb J, Goetz A, Goepfert M, Gogarten W, Grosse J, Heller A, Heringlake M, Kastrup M, Kroener A, Loer S, Marggraf G, Markewitz A, Reuter D, Schmitt D, Schirmer U, Wiesenack C, Zwissler B, Spies C. S3-Leitlinie zur intensivmedizinischen Versorgung herzchirurgischer Patienten. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2010. [DOI: 10.1007/s00398-010-0790-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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