Influence of levosimendan on organ dysfunction in patients with severely reduced left ventricular function undergoing cardiac surgery

Understanding the Clinical Use of Levosimendan and Perspectives on its Future in Oncology

Drug repurposing, also known as repositioning or reprofiling, has emerged as a promising strategy to accelerate drug discovery and development. This approach involves identifying new medical indications for existing approved drugs, harnessing the extensive knowledge of their bioavailability, pharmacokinetics, safety and efficacy. Levosimendan, a calcium sensitizer initially approved for heart failure, has been repurposed for oncology due to its multifaceted pharmacodynamics, including phosphodiesterase 3 inhibition, nitric oxide production and reduction of reactive oxygen species. Studies have demonstrated that levosimendan inhibits cancer cell migration and sensitizes hypoxic cells to radiation. Moreover, it exerts organ-protective effects by activating mitochondrial potassium channels. Combining levosimendan with traditional anticancer agents such as 5-fluorouracil (5-FU) has shown a synergistic effect in bladder cancer cells, highlighting its potential as a novel therapeutic approach. This drug repurposing strategy offers a cost-effective and time-efficient solution for developing new treatments, ultimately contributing to the advancement of cancer therapeutics and improved outcomes for patients. Further investigations and clinical trials are warranted to validate the effectiveness of levosimendan in oncology and explore its potential benefits in a clinical setting.

Levosimendan administration is not associated with increased risk of bleeding and blood transfusion requirement in patients undergoing off-pump coronary artery bypass grafting: a retrospective study from single center

BACKGROUND

Levosimendan (LEVO) is a positive inotropic drug which could increase myocardial contractility and reduce the mortality rate in cardiac surgical patients. However, Whether LEVO is associated with postoperative bleeding and blood transfusion in cardiac surgical patients is controversial. Therefore, the current study was designed to investigate the impact of LEVO administration on bleeding and blood transfusion requirement in off-pump coronary artery bypass grafting (OPCAB) patients.

METHODS

In a retrospective analysis, a total of 292 patients, aged 40-87 years, undergoing elective OPCAB between January 2019 and July 2019, were divided into LEVO group (n = 151) and Control group (n = 141). Patients in LEVO group continuously received LEVO at a rate of 0.1-0.2 μg kg^-1 min^-1 after anesthesia induction until 24 hours after OPCAB or patients in Control group received no LEVO. The primary outcome was postoperative chest drainage volume. The secondary outcomes were reoperation for postoperative bleeding, transfusion requirement of red blood cells (RBCs), fresh frozen plasma (FFP) and platelet concentrate (PC), etc. Comparisons of two groups were performed with the Student's t-test or Wilcoxon-Mann-Whitney test.

RESULTS

There was no significant difference with respect to chest drainage volume ((956.29 ± 555.45) ml vs (1003.19 ± 572.25) ml, p = 0.478) and the incidence of reoperation for postoperative bleeding (1.32% vs 1.42%, p = 0.945) between LEVO group and Control group. The transfusion incidence and volume of allogeneic RBCs, FFP, and PC were comparable between two groups.

CONCLUSIONS

LEVO administration was neither associated with more postoperative blood loss nor increased allogeneic blood transfusion requirement in OPCAB patients.

Perioperative Management of the Patient at High-Risk for Cardiac Surgery-Associated Acute Kidney Injury

Acute kidney injury (AKI) is one of the most common major complications of cardiac surgery, and is associated with increased morbidity and mortality. Cardiac surgery-associated AKI has a complex, multifactorial etiology, including numerous factors such as primary cardiac dysfunction, hemodynamic derangements of cardiac surgery and cardiopulmonary bypass, and the possibility of a large volume of blood transfusion. There are no truly effective pharmacologic therapies for the management of AKI, and, therefore, anesthesiologists, intensivists, and cardiac surgeons must remain vigilant and attempt to minimize the risk of developing renal dysfunction. This narrative review describes the current state of the scientific literature concerning the specific aspects of cardiac surgery-associated AKI, and presents it in a chronological fashion to aid the perioperative clinician in their approach to this high-risk patient group. The evidence was considered for risk prediction models, preoperative optimization, and the intraoperative and postoperative management of cardiac surgery patients to improve renal outcomes.

The effects of levosimendan in patients undergoing transcatheter aortic valve replacement- a retrospective analysis

Background: Aortic stenosis (AS) increases left ventricular afterload, leading to cardiac damage and heart failure (HF). Transcatheter aortic valve replacement (TAVR) is an effective therapy for AS. No inotropic agents including levosimendan have been evaluated in patients undergoing TAVR.

Methods: A total of 285 patients underwent TAVR between 2014 and 2019; 210 were included in the matched analysis and 105 received 0.1 μg/kg body weight/min levosimendan immediately after the prosthesis had been successfully implanted. Medical history, laboratory tests, and echocardiography results were analyzed. Endpoints including 2-year all-cause mortality, stroke, or HF-related hospitalization, and a combination of the above were analyzed by Cox proportional hazard models.

Results: The levosimendan group had no difference in 2-year mortality compared with the control group (hazard ratio [HR]: 0.603, 95% confidence interval [CI]: 0.197–1.844; p = 0.375). However, levosimendan reduced stroke or HF-related hospitalization (HR: 0.346; 95% CI: 0.135–0.884; p = 0.027) and the combined endpoint (HR: 0.459, 95% CI: 0.215–0.980; p = 0.044). After adjusting for multiple variants, levosimendan still reduced stroke or HF-related hospitalization (HR: 0.346, 95% CI: 0.134–0.944; p = 0.038).

Conclusion: Prophylactic levosimendan administration immediately after valve implantation in patients undergoing TAVR can reduce stroke or HF-related hospitalization but does not lower all-cause mortality.

Strategies for post–cardiac surgery acute kidney injury prevention: A network meta-analysis of randomized controlled trials

Objects

Cardiac surgery is associated with acute kidney injury (AKI). However, the effects of various pharmacological and non-pharmacological strategies for AKI prevention have not been thoroughly investigated, and their effectiveness in preventing AKI-related adverse outcomes has not been systematically evaluated.

Methods

Studies from PubMed, Embase, and Medline and registered trials from published through December 2021 that evaluated strategies for preventing post–cardiac surgery AKI were identified. The effectiveness of these strategies was assessed through a network meta-analysis (NMA). The secondary outcomes were prevention of dialysis-requiring AKI, mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS. The interventions were ranked using the P-score method. Confidence in the results of the NMA was assessed using the Confidence in NMA (CINeMA) framework.

Results

A total of 161 trials (involving 46,619 participants) and 53 strategies were identified. Eight pharmacological strategies {natriuretic peptides [odds ratio (OR): 0.30, 95% confidence interval (CI): 0.19–0.47], nitroprusside [OR: 0.29, 95% CI: 0.12–0.68], fenoldopam [OR: 0.36, 95% CI: 0.17–0.76], tolvaptan [OR: 0.35, 95% CI: 0.14–0.90], N-acetyl cysteine with carvedilol [OR: 0.37, 95% CI: 0.16–0.85], dexmedetomidine [OR: 0.49, 95% CI: 0.32–0.76;], levosimendan [OR: 0.56, 95% CI: 0.37–0.84], and erythropoietin [OR: 0.62, 95% CI: 0.41–0.94]} and one non-pharmacological intervention (remote ischemic preconditioning, OR: 0.76, 95% CI: 0.63–0.92) were associated with a lower incidence of post–cardiac surgery AKI with moderate to low confidence. Among these nine strategies, five (fenoldopam, erythropoietin, natriuretic peptides, levosimendan, and remote ischemic preconditioning) were associated with a shorter ICU LOS, and two (natriuretic peptides [OR: 0.30, 95% CI: 0.15–0.60] and levosimendan [OR: 0.68, 95% CI: 0.49–0.95]) were associated with a lower incidence of dialysis-requiring AKI. Natriuretic peptides were also associated with a lower risk of mortality (OR: 0.50, 95% CI: 0.29–0.86). The results of a sensitivity analysis support the robustness and effectiveness of natriuretic peptides and dexmedetomidine.

Conclusion

Nine potentially effective strategies were identified. Natriuretic peptide therapy was the most effective pharmacological strategy, and remote ischemic preconditioning was the only effective non-pharmacological strategy. Preventive strategies might also help prevent AKI-related adverse outcomes. Additional studies are required to explore the optimal dosages and protocols for potentially effective AKI prevention strategies.

Prophylactic levosimendan in patients with low ejection fraction undergoing coronary artery bypass grafting: A pooled analysis of two multicentre randomised controlled trials

OBJECTIVES

To assess the effect of preoperative levosimendan on mortality at Day-90 in patients with left ventricular ejection fraction (LVEF) ≤ 40%, and to investigate a possible differential effect between patients undergoing isolated coronary artery bypass grafting (CABG) versus CABG combined with valve replacement surgery.

DESIGN

Pooled analysis of two multicentre randomised controlled trials (RCT) investigating prophylactic levosimendan versus placebo prior to CABG surgery on mortality at Day-90 in patients with LVEF ≤ 40%. A meta-analysis of all RCT investigating the same issue was also conducted.

RESULTS

A cohort of 1084 patients (809 isolated CABG, and 275 combined surgery) resulted from the merging of LEVO-CTS and LICORN databases. Seventy-two patients were dead at day 90. The mortality at day 90 was not different between levosimendan and placebo (Hazard Ratio (HR): 0.73, 95% CI: 0.41-1.28, p = 0.27). However, there was a significant interaction between the type of surgery and the study drug (p =  0.004). We observed a decrease in mortality at day 90 in the isolated CABG subgroup (HR: 0.39, 95% CI: 0.19-0.82, p = 0.013), but not in the combined surgery subgroup (HR: 1.73, 95% CI: 0.77-3.92, p = 0.19). The meta-analysis of 6 RCT involving 1441 patients confirmed the differential effect on mortality at day 30 between the 2 subgroups.

CONCLUSIONS

Preoperative levosimendan did not reduce mortality in a mixed surgical population with LV dysfunction. However, the subgroup of patients undergoing isolated CABG had a reduction in mortality at day 90, whereas there was no significant effect in combined surgery patients. This finding requires confirmation with a specific prospective trial.

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

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.

Pharmacological interventions for heart failure in people with chronic kidney disease

BACKGROUND

Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD.

OBJECTIVES

This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence.

MAIN RESULTS

One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I² = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I² = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I² = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I² = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I² = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I² = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies.

AUTHORS' CONCLUSIONS

The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.

Levosimendan and systemic vascular resistance in cardiac surgery patients: a systematic review and meta-analysis

Levosimendan is a potent non-adrenergic inodilator agent. The net effect of hemodynamic changes may result in a hyperdynamic state with low systemic vascular resistance. We conducted a systematic review and meta-analysis assessing hemodynamics in cardiac surgery patients treated with levosimendan. English-language literature was searched systematically from 2006 until October 2018, including randomized controlled trials and case-matched or retrospective studies providing at least two sequentially measured hemodynamic variables in adult patients who underwent cardiac surgery with cardiopulmonary bypass and were treated with levosimendan in comparison to alternative drugs or devices. Cardiac index significantly increased in the levosimendan group by 0.74 (0.24 to 1.23) [standardized mean difference (95% CI); p = 0.003] from baseline to postoperative day (POD) 1, and by 0.75 (0.25 to 1.25; p = 0.003) from baseline to POD 7, when corrected for the standardized mean difference at baseline by a multivariate mixed effects meta-analysis model. With this correction for baseline differences, other hemodynamic variables including systemic vascular resistance did not significantly differ until POD 1 [−0.17 (−0.64 to 0.30), p = 0.48] and POD 7 [−0.13 (−0.61 to 0.34), p = 0.58] between the levosimendan and the comparator group. Levosimendan increases cardiac index in patients undergoing cardiac surgery. Although levosimendan has inodilator properties, this meta-analysis finds no clinical evidence that levosimendan produces vasopressor-resistant vasoplegic syndrome.

[S3 guidelines on intensive medical care of cardiac surgery patients : Hemodynamic monitoring and cardiovascular system-an update]

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.

Hurdles to Cardioprotection in the Critically Ill

Cardiovascular disease is the largest contributor to worldwide mortality, and the deleterious impact of heart failure (HF) is projected to grow exponentially in the future. As heart transplantation (HTx) is the only effective treatment for end-stage HF, development of mechanical circulatory support (MCS) technology has unveiled additional therapeutic options for refractory cardiac disease. Unfortunately, despite both MCS and HTx being quintessential treatments for significant cardiac impairment, associated morbidity and mortality remain high. MCS technology continues to evolve, but is associated with numerous disturbances to cardiac function (e.g., oxidative damage, arrhythmias). Following MCS intervention, HTx is frequently the destination option for survival of critically ill cardiac patients. While effective, donor hearts are scarce, thus limiting HTx to few qualifying patients, and HTx remains correlated with substantial post-HTx complications. While MCS and HTx are vital to survival of critically ill cardiac patients, cardioprotective strategies to improve outcomes from these treatments are highly desirable. Accordingly, this review summarizes the current status of MCS and HTx in the clinic, and the associated cardiac complications inherent to these treatments. Furthermore, we detail current research being undertaken to improve cardiac outcomes following MCS/HTx, and important considerations for reducing the significant morbidity and mortality associated with these necessary treatment strategies.

Perioperative Use of Levosimendan Improves Clinical Outcomes in Patients After Cardiac Surgery: A Systematic Review and Meta-Analysis

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.

Use of Levosimendan in Cardiac Surgery: An Update After the LEVO-CTS, CHEETAH, and LICORN Trials in the Light of Clinical Practice

Levosimendan is a calcium sensitizer and adenosine triphosphate-dependent potassium channel opener, which exerts sustained hemodynamic, symptomatic, and organ-protective effects. It is registered for the treatment of acute heart failure, and when inotropic support is considered appropriate. In the past 15 years, levosimendan has been widely used in clinical practice and has also been tested in clinical trials to stabilize at-risk patients undergoing cardiac surgery. Recently, 3 randomized, placebo-controlled, multicenter studies (LICORN, CHEETAH, and LEVO-CTS) have been published reporting on the perioperative use of levosimendan in patients with compromised cardiac ventricular function. Taken together, many smaller trials conducted in the past suggested beneficial outcomes with levosimendan in perioperative settings. By contrast, the latest 3 studies were neutral or inconclusive. To understand the reasons for such dissimilarity, a group of experts from Austria, Belgium, Finland, France, Germany, Italy, Switzerland, and Russia, including investigators from the 3 most recent studies, met to discuss the study results in the light of both the previous literature and current clinical practice. Despite the fact that the null hypothesis could not be ruled out in the recent multicenter trials, we conclude that levosimendan can still be viewed as a safe and effective inodilator in cardiac surgery.

Levosimendan in patients with low cardiac output syndrome undergoing cardiac surgery: A systematic review and meta-analysis

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.

Levosimendan for Perioperative Cardioprotection: Myth or Reality?

BACKGROUND

Levosimendan is a calcium sensitizer drug causing increased contractility in the myocardium and vasodilation in the vascular system. It is mainly used for the therapy of acute decompensated heart failure. Several studies on animals and humans provided evidence of the cardioprotective properties of levosimendan including preconditioning and anti-apoptotic. In view of these favorable effects, levosimendan has been tested in patients undergoing cardiac surgery for the prevention or treatment of low cardiac output syndrome. However, initial positive results from small studies have not been confirmed in three recent large trials.

AIM

To summarize levosimendan mechanisms of action and clinical use and to review available evidence on its perioperative use in a cardiac surgery setting.

METHODS

We searched two electronic medical databases for randomized controlled trials studying levosimendan in cardiac surgery patients, ranging from January 2000 to August 2017. Metaanalyses, consensus documents and retrospective studies were also reviewed.

RESULTS

In the selected interval of time, 54 studies on the use of levosimendan in heart surgery have been performed. Early small size studies and meta-analyses have suggested that perioperative levosimendan infusion could diminish mortality and other adverse outcomes (i.e. intensive care unit stay and need for inotropic support). Instead, three recent large randomized controlled trials (LEVO-CTS, CHEETAH and LICORN) showed no significant survival benefits from levosimendan. However, in LEVO-CTS trial, prophylactic levosimendan administration significantly reduced the incidence of low cardiac output syndrome.

CONCLUSIONS

Based on most recent randomized controlled trials, levosimendan, although effective for the treatment of acute heart failure, can't be recommended as standard therapy for the management of heart surgery patients. Further studies are needed to clarify whether selected subgroups of heart surgery patients may benefit from perioperative levosimendan infusion.

Effects of levosimendan on mortality in patients undergoing cardiac surgery: A systematic review and meta-analysis

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.

Levosimendan in patients with left ventricular dysfunction undergoing cardiac surgery: a meta-analysis and trial sequential analysis of randomized trials

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.

Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery: An Update Meta-Analysis and Trial Sequential Analysis

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.

[Heart in sepsis : Molecular mechanisms, diagnosis and therapy of septic cardiomyopathy]

An impairment of cardiac function is a key feature of cardiovascular failure associated with sepsis; however, its clinical relevance is still underestimated. Recent advancements in echocardiography in patients with septic shock enable a better characterization of septic cardiomyopathy by unmasking a severe, cardiac dysfunction even in the presence of preserved left ventricular ejection fraction. The pathophysiology of septic cardiomyopathy involves a complex mixture of systemic factors and molecular, metabolic, and structural changes of the cardiomyocytes. A better understanding of these factors will enable the discovery of new therapeutic targets for urgently needed disease-modifying therapeutic interventions. To date, the cornerstone of therapeutic management lies in control of the underlying infectious process and hemodynamic stabilization. This review summarizes the pathogenesis, diagnosis, and treatment of septic cardiomyopathy, and highlights the importance of further urgently needed studies aimed at improving diagnosis and treatment for septic cardiomyopathy.

Comparative Efficacy of Drugs for Preventing Acute Kidney Injury after Cardiac Surgery: A Network Meta-Analysis

BACKGROUND

Acute kidney injury (AKI) occurs frequently after cardiac surgery and has been associated with increased hospital length of stay, mortality, and costs.

OBJECTIVE

We aimed to evaluate the efficacy of pharmacologic strategies for preventing AKI after cardiac surgery.

METHODS

We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) up to 6 May 2017 and the reference lists of relevant articles about trials. The outcome was the occurrence of AKI. This is the first network meta-analysis of the different prevention strategies using Bayesian methodology.

RESULTS

The study included 63 articles with 19,520 participants and evaluated the effect of ten pharmacologic strategies to prevent AKI in patients undergoing cardiac surgery. Compared with placebo, the odds ratio (OR) for the occurrence of AKI was 0.24 [95% confidence interval (CI) 0.16-0.34] with natriuretic peptide, 0.33 (95% CI 0.14-0.70) with fenoldopam, 0.54 (95% CI 0.31-0.84) with dexmedetomidine, 0.56 (95% CI 0.29-0.95) with low-dose erythropoietin, 0.63 (95% CI 0.43-0.88) with levosimendan, 0.76 (95% CI 0.52-1.10) with steroids, 0.83 (95% CI 0.48-1.40) with high-dose erythropoietin, 0.85 (95% CI 0.64-1.14) with N-acetylcysteine, 0.96 (95% CI 0.69-1.29) with sodium bicarbonate, and 1.05 (95% CI 0.70-1.41) with statins. The surface under the cumulative ranking curve probabilities indicated that natriuretic peptide was the best treatment therapy and that fenoldopam ranked second.

CONCLUSIONS

Natriuretic peptide is probably the preferred pharmacologic strategy to prevent AKI in adult patients undergoing cardiac surgery, especially in those at high risk of AKI.

Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome

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.

Perioperative levosimendan in cardiac surgery: A systematic review with meta-analysis and trial sequential analysis

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.

Levosimendan for patients with severely reduced left ventricular systolic function and/or low cardiac output syndrome undergoing cardiac surgery: a systematic review and meta-analysis

BACKGROUND

Previous studies have shown beneficial effects of levosimendan in high-risk patients undergoing cardiac surgery. Two large randomized controlled trials (RCTs), however, showed no advantages of levosimendan.

METHODS

We performed a systematic review and meta-analysis (MEDLINE and Embase from inception until March 30, 2017), investigating whether levosimendan offers advantages compared with placebo in high-risk cardiac surgery patients, as defined by preoperative left ventricular ejection fraction (LVEF) ≤ 35% and/or low cardiac output syndrome (LCOS). The primary outcomes were mortality at longest follow-up and need for postoperative renal replacement therapy (RRT). Secondary postoperative outcomes investigated included myocardial injury, supraventricular arrhythmias, development of LCOS, acute kidney injury (AKI), duration of mechanical ventilation, intensive care unit and hospital lengths of stay, and incidence of hypotension during drug infusion.

RESULTS

Six RCTs were included in the meta-analysis, five of which investigated only patients with LVEF ≤ 35% and one of which included predominantly patients with LCOS. Mortality was similar overall (OR 0.64 [0.37, 1.11], p = 0.11) but lower in the subgroup with LVEF < 35% (OR 0.51 [0.32, 0.82], p = 0.005). Need for RRT was reduced by levosimendan both overall (OR 0.63 [0.42, 0.94], p = 0.02) and in patients with LVEF < 35% (OR 0.55 [0.31, 0.97], p = 0.04). Among secondary outcomes, we found lower postoperative LCOS in patients with LVEF < 35% receiving levosimendan (OR 0.49 [0.27, 0.89], p = 0.02), lower overall AKI (OR 0.62 [0.42, 0.92], p = 0.02), and a trend toward lower mechanical support, both overall (p = 0.07) and in patients with LVEF < 35% (p = 0.05).

CONCLUSIONS

Levosimendan reduces mortality in patients with preoperative severely reduced LVEF but does not affect overall mortality. Levosimendan reduces the need for RRT after high-risk cardiac surgery.

Effect of levosimendan on prognosis in adult patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials

Background

Small trials suggest that levosimendan is associated with a favorable outcome in patients undergoing cardiac surgery. However, recently published larger-scale trials did not provide evidence for a similar benefit from levosimendan. We performed a meta-analysis to assess the survival benefits of levosimendan in patients undergoing cardiac surgery and to investigate its effects in subgroups of patients with preoperative low-ejection fraction (EF).

Methods

We identified randomized clinical trials through 20 April 2017 that investigated levosimendan therapy versus control in patients undergoing cardiac surgery. Individual patient data from each study were compiled. Meta-analyses were performed for primary outcomes, secondary outcomes and serious adverse events, and subgroup analyses according to the preoperative EF of enrolled patients were also conducted. The risk of bias was assessed using the Cochrane risk-of-bias tool.

Results

Seventeen studies involving a total of 2756 patients were included. Levosimendan therapy was associated with a significant reduction in 30-day mortality (RR 0.67; 95% CI, 0.49 to 0.93; p = 0.02) and reduced the risk of death in single-center trials (RR 0.49; 95% CI, 0.30 to 0.79; p = 0.004) and in subgroup trials of inferior quality (RR 0.39; 95% CI, 0.17 to 0.92; p = 0.02); however, in multicenter and in high-quality subgroup-analysis trials, no significant difference in mortality was observed between patients who received levosimendan therapy and controls (p > 0.05). However, in high-quality subgroup trials, levosimendan therapy was associated with reduced mortality in patients in a preoperative low-EF subgroup (RR 0.58; 95% CI, 0.38 to 0.88; p = 0.01). Similarly, only patients in the preoperative low-EF subgroup benefited in terms of reduced risk of renal replacement therapy (RR 0.54; 95% CI, 0.34 to 0.85; p = 0.007). Furthermore, levosimendan therapy was associated with a significant reduction in intensive care unit (ICU) length of stay (MDR −17.19; 95% CI, −34.43 to −2.94; p = 0.02).

Conclusions

In patients undergoing cardiac surgery, the benefit of levosimendan in terms of survival was not shown in multicenter or in high-quality trials; however, levosimendan therapy was associated with reduced mortality in patients with preoperative ventricular systolic dysfunction.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1848-1) contains supplementary material, which is available to authorized users.

Effect of Levosimendan on Low Cardiac Output Syndrome in Patients With Low Ejection Fraction Undergoing Coronary Artery Bypass Grafting With Cardiopulmonary Bypass: The LICORN Randomized Clinical Trial

IMPORTANCE

Low cardiac output syndrome after cardiac surgery is associated with high morbidity and mortality in patients with impaired left ventricular function.

OBJECTIVE

To assess the ability of preoperative levosimendan to prevent postoperative low cardiac output syndrome.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, double-blind, placebo-controlled trial conducted in 13 French cardiac surgical centers. Patients with a left ventricular ejection fraction less than or equal to 40% and scheduled for isolated or combined coronary artery bypass grafting with cardiopulmonary bypass were enrolled from June 2013 until May 2015 and followed during 6 months (last follow-up, November 30, 2015).

INTERVENTIONS

Patients were assigned to a 24-hour infusion of levosimendan 0.1 µg/kg/min (n = 167) or placebo (n = 168) initiated after anesthetic induction.

MAIN OUTCOMES AND MEASURES

Composite end point reflecting low cardiac output syndrome with need for a catecholamine infusion 48 hours after study drug initiation, need for a left ventricular mechanical assist device or failure to wean from it at 96 hours after study drug initiation when the device was inserted preoperatively, or need for renal replacement therapy at any time postoperatively. It was hypothesized that levosimendan would reduce the incidence of this composite end point by 15% in comparison with placebo.

RESULTS

Among 336 randomized patients (mean age, 68 years; 16% women), 333 completed the trial. The primary end point occurred in 87 patients (52%) in the levosimendan group and 101 patients (61%) in the placebo group (absolute risk difference taking into account center effect, -7% [95% CI, -17% to 3%]; P = .15). Predefined subgroup analyses found no interaction with ejection fraction less than 30%, type of surgery, and preoperative use of β-blockers, intra-aortic balloon pump, or catecholamines. The prevalence of hypotension (57% vs 48%), atrial fibrillation (50% vs 40%), and other adverse events did not significantly differ between levosimendan and placebo.

CONCLUSIONS AND RELEVANCE

Among patients with low ejection fraction who were undergoing coronary artery bypass grafting with cardiopulmonary bypass, levosimendan compared with placebo did not result in a significant difference in the composite end point of prolonged catecholamine infusion, use of left ventricular mechanical assist device, or renal replacement therapy. These findings do not support the use of levosimendan for this indication.

TRIAL REGISTRATION

EudraCT Number: 2012-000232-25; clinicaltrials.gov Identifier: NCT02184819.

Postoperative Right Ventricular Failure in Cardiac Surgery

Two cases of patients that developed right ventricular failure (RVF) after cardiac valve surgery are presented with a narrative revision of the literature. RVF involves a great challenge due to the severity of this condition; it has a low incidence among non-congenital cardiac surgery patients, is more likely associated with cardiovascular and pulmonary complications related to cardiopulmonary bypass (CPB), and is a cause of acute graft failure and of a higher early mortality in cardiac transplant. The morphologic and hemodynamic characteristics of the right ventricle and some specific factors that breed pulmonary hypertension after cardiac surgery are in favor of the onset of RVF. Due to the possibility of complications after cardiac valve repair or replacement, measures as appropriate hemodynamic monitoring, to manage oxygenation, ventilation, sedation, acid base equilibrium and perfusion goals are a requirement, as well as a normal circulating volume, and the prevention of a disproportionate rise in the afterload, to preserve the free wall of the right ventricle (RV) and the septum's contribution to the right ventricular global function and geometry. If there is no response to these basic measures, the use of advanced therapy with inotropics, intravenous or inhaled pulmonary vasodilation agents is recommended; the use of mechanical ventricular assistance stands as a last resource.

Vasoactive agents for the treatment of sepsis

The article describes some commonly used vasoactive agents in patients with septic shock. Depending on their distinct pharmacological properties, their effects on vascular bed and cardiac function are different. For example, dopamine has equivalent effect on heart and vasculature, which can result in increases in cardiac output, mean arterial pressure and heart rate. Dobutamine is considered as inodilator because it has potent effect on cardiac systole and vasculature. Patients with sepsis and septic shock sometimes have coexisting cardiac dysfunction that justifies the use of dobutamine. Levosimendan is a relatively new agent exerting its inodilator effect by increasing sensitivity of myocardium to calcium. Some preliminary studies showed a promising result of levosimendan on reducing mortality.

Levosimendan Reduces Mortality in Adults with Left Ventricular Dysfunction Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis

INTRODUCTION

Levosimendan is implemented in patients with low cardiac output after cardiac surgery. However, the strength of evidence is limited by randomized controlled trials enrolling a small number of patients. Hence we have conducted a systematic review to determine the role of levosimendan in adult cardiac surgery.

METHODS

PUBMED, WoS, Cochrane database, and SCOPUS were systematically queried to identify original English language peer-reviewed literature (inception-October 2014) comparing clinical results of adult cardiac surgery between levosimendan and control. Pooled odds ratio (OR) was calculated using the Peto method; p < 0.05 is significant; results are presented within 95% confidence intervals. Continuous data was compared using standardized mean difference/mean difference.

RESULTS

Fourteen studies were included in the analysis. Levosimendan reduced early mortality in patients with reduced ejection fraction (5.5% vs. 9.1%) (OR 0.48 [0.23-0.76]; p = 0.004). This result was confirmed using sensitivity analysis. Postoperative acute renal failure was lower with levosimendan therapy (7.4% vs. 11.5%). Intensive care unit stay was shorter in the levosimendan cohort comparable in both groups (standardized mean difference -0.31 [-0.53, -0.09]; p = 0.006; I(2)  = 33.6%). Levosimendan-treated patients stayed 1.01 (1.61-0.42) days shorter when compared to control (p = 0.001).

CONCLUSION

Our meta-analysis demonstrates that Levosimendan improves clinical outcomes in patients with left ventricular dysfunction undergoing cardiac surgery. Results of the ongoing multicenter randomized controlled trial are awaited to provide more conclusive evidence regarding the benefit of this drug.

Feasibility and influence of hTEE monitoring on postoperative management in cardiac surgery patients

Monoplane hemodynamic TEE (hTEE) monitoring (ImaCor(®) ClariTEE(®)) might be a useful alternative to continuously evaluate cardiovascular function and we aimed to investigate the feasibility and influence of hTEE monitoring on postoperative management in cardiac surgery patients. After IRB approval we reviewed the electronic data of cardiac surgery patients admitted to our intensive care between 01/01/2012 and 30/06/2013 in a case-controlled matched-pairs design. Patients were eligible for the study when they presented a sustained hemodynamic instability postoperatively with the clinical need of an extended hemodynamic monitoring: (a) hTEE (hTEE group, n = 18), or (b) transpulmonary thermodilution (control group, n = 18). hTEE was performed by ICU residents after receiving an approximately 6-h hTEE training session. For hTEE guided hemodynamic optimization an institutional algorithm was used. The hTEE probe was blindly inserted at the first attempt in all patients and image quality was at least judged to be adequate. The frequency of hemodynamic examinations was higher (ten complete hTEE examinations every 2.6 h) in contrast to the control group (one examination every 8 h). hTEE findings, including five unexpected right heart failure and one pericardial tamponade, led to a change of current therapy in 89% of patients. The cumulative dose of epinephrine was significantly reduced (p = 0.034) and levosimendan administration was significantly increased (p = 0.047) in the hTEE group. hTEE was non-inferior to the control group in guiding norepinephrine treatment (p = 0.038). hTEE monitoring performed by ICU residents was feasible and beneficially influenced the postoperative management of cardiac surgery patients.

Early levosimendan administration is associated with decreased mortality after cardiac surgery

PURPOSE

The aim of this study was to assess the effects on postoperative outcome of levosimendan with respect to timing of its administration in cardiac surgery patients.

MATERIALS AND METHODS

Levosimendan administration was triggered by a severely reduced left ventricular systolic function (left ventricular ejection fraction, <35%) and/or signs of a low cardiac output syndrome. A total of 159 patients were retrospectively assigned depending on an early (perioperatively up to the first hour after intensive care unit [ICU] admission) vs late (later than the first hour after ICU admission) start of treatment.

RESULTS

Patients receiving levosimendan after the first hour of ICU admission (n = 89) had a significantly increased inhospital (P = .004) and 1-year (P = .027) mortality. Duration of mechanical ventilation (P = .002), incidence of renal dysfunction (P = .002), and need of renal replacement therapy (P = .032) were significantly increased in the late start group. A late start of levosimendan treatment was associated with an odds ratio of 2.258 (95% confidence interval, 1.139-4.550; P = .021) for inhospital mortality and an adjusted hazard ratio of 1.827 (95% confidence interval, 1.155-2.890; P = .010) for 1-year survival.

CONCLUSIONS

Findings of this retrospective analysis favor an "early," that is, intraoperatively up to the first hour after ICU admission, start of perioperative levosimendan treatment to maximize its ability to reduce mortality and morbidity.

Early administration of levosimendan is associated with improved kidney function after cardiac surgery - a retrospective analysis

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 .