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Comparative Effectiveness and Safety of Milrinone and Levosimendan as Initial Inotrope Therapy in Patients With Acute Heart Failure With Renal Dysfunction. J Cardiovasc Pharmacol 2022; 79:781-790. [PMID: 35507915 DOI: 10.1097/fjc.0000000000001255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/22/2022] [Indexed: 11/26/2022]
Abstract
ABSTRACT Levosimendan and milrinone are 2 effective inotropic drugs used to maintain cardiac output in acute heart failure (AHF). Using data from patients with AHF with and without abnormal renal function, we performed this single-center, retrospective cohort study to compare the effectiveness and safety of milrinone and levosimendan for the initial management of AHF. Patients admitted for heart failure between December 2016 and September 2019 who received levosimendan or milrinone as initial inotrope therapy in the cardiology department were identified. A total of 436 levosimendan and 417 milrinone patients with creatinine clearance (CrCl) ≥30 mL/min and 50 levosimendan and 71 milrinone patients with CrCl <30 mL/min or on dialysis were included. The primary outcome was a composite of changes in clinical status at 15 and 30 days after initial inotrope therapy discontinuation. Between subgroups of patients with CrCl ≥30 mL/min, there were no significant differences in primary outcomes; milrinone was associated with more frequent hypotension and cardiac arrhythmias during the infusion period (P < 0.01), while levosimendan was associated with more frequent cardiac arrhythmias within 48 hours after discontinuation (P < 0.05). Of the patients with CrCl <30 mL/min or on dialysis, more initial levosimendan than milrinone patients and those who switched to alternative inotropes experienced clinical worsening at 15 days and 30 days (P < 0.05). According to our results, patients with AHF with severe renal dysfunction should avoid initial inotrope therapy with levosimendan.
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Monaco F, Di Prima AL, Kim JH, Plamondon MJ, Yavorovskiy A, Likhvantsev V, Lomivorotov V, Hajjar LA, Landoni G, Riha H, Farag A, Gazivoda G, Silva F, Lei C, Bradic N, El-Tahan M, Bukamal N, Sun L, Wang C. Management of Challenging Cardiopulmonary Bypass Separation. J Cardiothorac Vasc Anesth 2020; 34:1622-1635. [DOI: 10.1053/j.jvca.2020.02.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 11/11/2022]
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Treskatsch S, Balzer F, Geyer T, Spies CD, Kastrup M, Grubitzsch H, Wernecke KD, Erb JM, Braun JP, Sander M. Early levosimendan administration is associated with decreased mortality after cardiac surgery. J Crit Care 2015; 30:859.e1-6. [PMID: 25837801 DOI: 10.1016/j.jcrc.2015.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/04/2015] [Accepted: 03/07/2015] [Indexed: 12/29/2022]
Abstract
PURPOSE The aim of this study was to assess the effects on postoperative outcome of levosimendan with respect to timing of its administration in cardiac surgery patients. MATERIALS AND METHODS Levosimendan administration was triggered by a severely reduced left ventricular systolic function (left ventricular ejection fraction, <35%) and/or signs of a low cardiac output syndrome. A total of 159 patients were retrospectively assigned depending on an early (perioperatively up to the first hour after intensive care unit [ICU] admission) vs late (later than the first hour after ICU admission) start of treatment. RESULTS Patients receiving levosimendan after the first hour of ICU admission (n = 89) had a significantly increased inhospital (P = .004) and 1-year (P = .027) mortality. Duration of mechanical ventilation (P = .002), incidence of renal dysfunction (P = .002), and need of renal replacement therapy (P = .032) were significantly increased in the late start group. A late start of levosimendan treatment was associated with an odds ratio of 2.258 (95% confidence interval, 1.139-4.550; P = .021) for inhospital mortality and an adjusted hazard ratio of 1.827 (95% confidence interval, 1.155-2.890; P = .010) for 1-year survival. CONCLUSIONS Findings of this retrospective analysis favor an "early," that is, intraoperatively up to the first hour after ICU admission, start of perioperative levosimendan treatment to maximize its ability to reduce mortality and morbidity.
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Affiliation(s)
- Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
| | - Felix Balzer
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
| | - Torsten Geyer
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
| | - Claudia D Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
| | - Marc Kastrup
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
| | - Herko Grubitzsch
- Department of Cardiovascular Surgery, Campus Charité Mitte, Charité-Universitätsmedizin, Berlin, Germany.
| | | | - Joachim M Erb
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital of Basel, Basel, Switzerland.
| | - Jan P Braun
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Helios Klinikum Hildesheim GmbH, Hildesheim, Germany.
| | - Michael Sander
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Berlin, Germany.
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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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Barisin S, Djuzel V, Barisin A, Rudez I. Levosimendan reverses right-heart failure in a 51-year-old patient after heart transplantation. Wien Klin Wochenschr 2014; 126:495-9. [PMID: 24652017 DOI: 10.1007/s00508-014-0528-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Accepted: 02/18/2014] [Indexed: 11/30/2022]
Abstract
Primary graft failure in the early postoperative period after heart transplantation, remains a main cause of a poor outcome. Current treatment options include pharmacological (catecholamines and phosphodiesterase inhibitors) and mechanical assist device support. Pharmacological support with catecholamines is related to elevated myocardial oxygen consumption and regional hypoperfusion leading to organ damage. On the other hand, levosimendan, as a calcium-sensitizing agent increases cardiac contractility without altering intracellular Ca(2+) levels and increase in oxygen demand. We present a case of a 51-year-old man, who was suffering from acute right-heart failure in the early postoperative period after heart transplantation. As a rescue therapy at the late stage of a low cardiac output state, levosimendan was started as continuous infusion at 0.1 μg/kg/min for 12 h and thereafter, at 0.2 μg/kg/min for the following 36 h. Levosimendan demonstrated an advanced pharmacological option as was portrayed in this case, where the right ventricle was under a prolonged severe depression and acutely overloaded after heart transplantation.
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Affiliation(s)
- Stjepan Barisin
- Clinical Department of Cardiovascular Anesthesia and Intensive Care, University Department of Anesthesiology, Resuscitation and Intensive Care, Dubrava University Hospital, Av. G. Suska 6, 10000, Zagreb, Croatia,
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Bangash MN, Kong ML, Pearse RM. Use of inotropes and vasopressor agents in critically ill patients. Br J Pharmacol 2012; 165:2015-33. [PMID: 21740415 DOI: 10.1111/j.1476-5381.2011.01588.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Inotropes and vasopressors are biologically and clinically important compounds that originate from different pharmacological groups and act at some of the most fundamental receptor and signal transduction systems in the body. More than 20 such agents are in common clinical use, yet few reviews of their pharmacology exist outside of physiology and pharmacology textbooks. Despite widespread use in critically ill patients, understanding of the clinical effects of these drugs in pathological states is poor. The purpose of this article is to describe the pharmacology and clinical applications of inotropic and vasopressor agents in critically ill patients.
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Affiliation(s)
- Mansoor N Bangash
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, London, UK
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Abstract
Levosimendan is a unique therapeutic agent that decreases mortality in acute episodes of decompensated heart failure by increasing myocardial contractility without increasing oxygen consumption or ATP demands, decreasing preload, or decreasing afterload. The mechanism for each accomplishment is novel. The drug is a calcium sensitizer, which increases myocyte contractility by stabilizing troponin C rather than by increasing intracellular calcium. The drug may have implications in numerous other common and chronic medical ailments, even in overdoses of drugs that stun and depress the myocardium.
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Affiliation(s)
- Daun Johnson Milligan
- San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, Division of Anesthesiology and Critical Care, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA.
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Link MG, Yan GX, Kowey PR. Evaluation of toxicity for heart failure therapeutics: studying effects on the QT interval. Circ Heart Fail 2010; 3:547-55. [PMID: 20647490 DOI: 10.1161/circheartfailure.109.917781] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Michael G Link
- Main Line Heart Center and Lankenau Institute for Medical Research, Jefferson Medical College, Wynnewood, Pa 19096, USA
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Ozturk T, Gok S, Nese N. Levosimendan Attenuates Reperfusion Injury in an Isolated Perfused Rat Heart Model. J Cardiothorac Vasc Anesth 2010; 24:624-8. [DOI: 10.1053/j.jvca.2009.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2009] [Indexed: 11/11/2022]
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De Hert SG, Lorsomradee S, vanden Eede H, Cromheecke S, Van der Linden PJ. RETRACTED: A Randomized Trial Evaluating Different Modalities of Levosimendan Administration in Cardiac Surgery Patients With Myocardial Dysfunction. J Cardiothorac Vasc Anesth 2008; 22:699-705. [DOI: 10.1053/j.jvca.2008.02.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2007] [Indexed: 11/11/2022]
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Soeding PE, Royse CF, Wright CE, Royse AG, Angus JA. Inoprotection: the perioperative role of levosimendan. Anaesth Intensive Care 2008; 35:845-62. [PMID: 18084975 DOI: 10.1177/0310057x0703500602] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Levosimendan is emerging as a novel cardioprotective inotrope. Levosimendan augments myocardial contractility by sensitising contractile myofilaments to calcium without increasing myosin adenosine triphosphatase activity or oxygen consumption. Levosimendan activates cellular adenosine triphosphate-dependent potassium channels, a mechanism which is postulated to protect cells from ischaemia in a manner similar to ischaemic preconditioning. Levosimendan may therefore protect the ischaemic myocardium during ischaemia-reperfusion as well as improve the contractile function of the heart. Adenosine triphosphate-dependent potassium channel activation by levosimendan may also be protective in other tissues, such as coronary vascular endothelium, kidney and brain. Clinical trials in patients with decompensated heart failure and myocardial ischaemia show levosimendan to improve haemodynamic performance and potentially improve survival. This paper reviews the known pharmacology of levosimendan, the clinical experience with the drug to date and the potential use of levosimendan as a cardioprotective agent during surgery.
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Affiliation(s)
- P E Soeding
- Cardiovascular Therapeutics Unit, Department of Pharmacology, University of Melbourne, Melbourne, Victoria, Australia
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Abstract
Levosimendan, a drug used in the treatment of acute and decompensated heart failure, has positive inotropic and antistunning effects mediated by calcium sensitization of contractile proteins, and vasodilatory and antiischemic effects mediated via the opening of ATP-sensitive potassium channels in vascular smooth-muscle cells. Recently, it also has been shown to act on mitochondrial ATP-sensitive potassium (mitoKATP) channels, an action thought to protect the heart against ischemia-reperfusion damage. This finding has suggested a possible application for levosimendan in clinical situations in which preconditioning would be beneficial (eg, in pre- and perioperative settings in cardiac surgery). The demonstration that levosimendan can prevent or limit myocyte apoptosis via the activation of mitoKATP channels provides a potential mechanism whereby this agent might protect cardiac myocytes during episodes of acute heart failure. This finding may explain why short-term treatment with levosimendan may improve longer-term survival. The present article reviews the literature on the cardioprotective actions of levosimendan, with particular emphasis on its recently recognized effects on mitoKATP channels and the putative preconditioning effects of that action. A therapeutic approach to acute heart failure that includes a cardioprotective strategy could have a clinically meaningful benefit on disease progression beyond alleviation of symptoms.
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De Hert SG, Lorsomradee S, Cromheecke S, Van der Linden PJ. The Effects of Levosimendan in Cardiac Surgery Patients with Poor Left Ventricular Function. Anesth Analg 2007; 104:766-73. [PMID: 17377079 DOI: 10.1213/01.ane.0000256863.92050.d3] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patients with poor left ventricular function often require inotropic drug support immediately after cardiopulmonary bypass. Levosimendan improves cardiac function by a novel mechanism of action compared to currently available drugs. We hypothesized that, in patients with severely compromised ventricular function, the use of levosimendan would be associated with better postoperative cardiac function than with inotropic drugs that increase myocardial oxygen consumption. METHODS Thirty patients with a preoperative ejection fraction < or =30% scheduled for elective cardiac surgery with cardiopulmonary bypass were randomized to two different inotropic protocols: milrinone 0.5 microg [corrected] x kg(-1) x min(-1) or levosimendan 0.1 microg [corrected] x kg(-1) x min(-1), started immediately after the release of the aortic crossclamp. The treatment was masked to the observers. All patients received dobutamine 5 microg [corrected] x kg(-1) x min(-1). RESULTS Stroke volume was similar between groups initially after surgery, but it declined 12 h after surgery in the milrinone group but not in the levosimendan group (P < 0.05 between groups) despite similar filling pressures. Total dose, duration of inotropic drug administration and norepinephrine dose were lower in the levosimendan group than in the milrinone group (P < 0.05). The duration of tracheal intubation was shorter in the former group compared with the milrinone group (P = 0008). Three patients in the milrinone group but none in the levosimendan group died within 30 days of surgery. CONCLUSION In cardiac surgery patients with a low preoperative ejection fraction, stroke volume was better maintained with the combination of dobutamine with levosimendan than with the combination of dobutamine with milrinone.
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Affiliation(s)
- Stefan G De Hert
- Department of Anesthesiology, University of Antwerp, University Hospital Antwerp, Belgium.
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Abstract
Calcium sensitizers are a new group of inotropic drugs. Levosimendan is the only calcium sensitizer in clinical use in Europe. Its mechanism of action includes both calcium sensitization of contractile proteins and the opening of adenosine triphosphate (ATP)-dependent potassium channels as mechanism of vasodilation. The combination of K-channel opening with positive inotropy offers potential benefits in comparison to currently available intravenous inotropes, since K-channel opening protects myocardium during ischemia. Due to the calcium-dependent binding of levosimendan to troponin C, the drug increases contractility without negative lusitropic effects. In patients with heart failure levosimendan dose-dependently increases cardiac output and reduces pulmonary capillary wedge pressure. Since levosimendan has an active metabolite OR-1896 with a half-life of some 80 hours, the duration of the hemodynamic effects significantly exceeds the 1-hour half-life of the parent compound. The hemodynamic effects of the levosimendan support its use in acute and postoperative heart failure. Several moderate-size trials (LIDO, RUSSLAN, CASINO) have previously suggested that the drug might even improve the prognosis of patients with decompensated heart failure. These trials were carried out in patients with high filling pressures. Recently two larger trials (SURVIVE and REVIVE) in patients who were hospitalized because of worsening heart failure have been finalized. These trials did not require filling pressures to be measured. The two trials showed that levosimendan improves the symptoms of heart failure, but does not improve survival. The results raise the question whether a 24-hour levosimendan infusion can be used without invasive hemodynamic monitoring.
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Affiliation(s)
- Lasse Lehtonen
- Department of Clinical Pharmacology, Helsinki University Central Hospital, Helsinki, Finland.
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Akgul A, Mavioglu L, Katircioglu SF, Pac M, Cobanoglu A. Levosimendan for Weaning from Cardiopulmonary Bypass after Coronary Artery Bypass Grafting. Heart Lung Circ 2006; 15:320-4. [DOI: 10.1016/j.hlc.2006.05.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2006] [Revised: 05/30/2006] [Accepted: 05/31/2006] [Indexed: 10/24/2022]
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