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

The Perioperative Use of Levosimendan as a Means of Optimizing the Surgical Outcome in Patients with Severe Heart Insufficiency Undergoing Cardiac Surgery

BACKGROUND

Postoperative myocardial dysfunction following cardiac surgery is a relatively common occurrence. Levosimendan, a calcium sensitizer and inotropic drug, has shown potential in improving outcomes for patients with low preoperative ejection fraction (EF) and myocardial dysfunction after cardiac surgery. This study aims to evaluate the efficacy of levosimendan in optimizing the surgical outcome for such patients.

METHODS

A retrospective analysis was conducted on 314 patients with preoperative severe heart failure who underwent cardiac surgery. Among them, 184 patients received perioperative adjunctive therapy with levosimendan, while a comparable group of 130 patients received conventional treatment.

RESULTS

The use of levosimendan demonstrated several advantages in postoperative outcomes. It significantly improved short- and long-term survival rates after cardiac surgery, enhanced hemodynamic stability, reduced the requirement for inotropic support, and facilitated faster weaning from ventilator support. Patients who received levosimendan reported reduced angina and dyspnea symptoms, as well as fewer postoperative arrhythmias. Furthermore, levosimendan helped minimize myocardial injury inevitable after cardiac surgery. The levosimendan group also exhibited a notable reduction in hospital readmissions.

CONCLUSIONS

This study provides evidence of several benefits associated with the perioperative use of levosimendan. However, further prospective randomized studies are warranted to standardize and comprehensively document the other perioperative therapies, in order to validate these findings and establish stronger conclusions.

The impact of levosimendan on survival and weaning from ECMO after extracorporeal cardiopulmonary resuscitation

OBJECTIVES

Extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly used due to its beneficial outcomes and results compared to conventional CPR. After cardiac arrest, the overall ejection fraction is severely impaired; thus, weaning from ECMO is often prolonged or impossible. We hypothesized that early application of levosimendan in these patients facilitates ECMO weaning and survival.

METHODS

From 2016 until 2020, patients who underwent eCPR after cardiac arrest at our institution were analyzed retrospectively and divided into two groups: patients who received levosimendan during ICU stay (n = 24) and those who did not receive levosimendan (n = 84) and analyzed for outcome parameters. Furthermore, we used propensity-score matching and multinomial regression analysis to show the effect of levosimendan on outcome parameters.

RESULTS

Overall, in-hospital mortality was significantly lower in the group which received levosimendan (28% vs. 88%, p ≤ 0.01), and ECMO weaning was more feasible in patients who received levosimendan (88% vs. 20%, p ≤ 0.01). CPR duration until ECMO cannulation was significantly shorter in the levosimendan group (44 + 26 vs. 65 + 28, p = 0.002); interestingly, the rate of mechanical chest compressions before ECMO cannulation was lower in the levosimendan group (50% vs. 69%, p = 0.005).

CONCLUSION

In patients after cardiac arrest treated with eCPR, levosimendan seems to contribute to higher success rates of ECMO weaning, potentially due to a short to mid-term increase in inotropy. Also, the survival after levosimendan application was higher than patients who did not receive levosimendan.

Levosimendan: mechanistic insight and its diverse future aspects in cardiac care

Inotropic agents are generally recommended to use in patients with acute decompensated heart failure (HF) with reduced ejection fraction (HFrEF) concurrent to end-organ dysfunction. However, due to certain pharmacological limitations like developing life threatening arrhythmia and tolerance, cannot be employed as much as needed. Meanwhile, Calcium ion (Ca²⁺) sensitisers exhibits their inotropic action by increasing the sensitivity of the cardiomyocyte to intracellular Ca²⁺ ion and have been reported as emerging therapeutic alternative in HF cases. Levosimendan (LEVO) is an inodilator and with its unique pharmacology justifying its use in a wide range of cardiac alterations in HF particularly in undergoing cardiac surgery. It is also reported to be better than classical inotropes in maintaining cardiac mechanical efficacy and reducing congestion in acute HF with hypotension. This review paper was designed to compile various evidence about basic pharmacology and potential clinical aspects of LEVO in cardiac surgery and other HF associated alterations. This will benefit directly to the researcher in initiating research and to fill the gaps in the area of thrust.

Prospective Study on the Postoperative Use of Levosimendan After Conventional Heart Valve Replacement

Background

The aim of this study was to explore the effect of levosimendan in patients after heart valve replacement and its influence on postoperative recovery.

Material/Methods

This prospective study included 185 patients with valvular diseases undergoing conventional valve replacement. Patients were divided into 2 groups using a random number table before surgery. Patients in the levosimendan group were administrated levosimendan intravenous infusion immediately after entering the Intensive Care Unit (ICU). The left ventricular ejection fraction (LVEF), cardiac output, and heart failure-related index, such as B-type natriuretic peptide (BNP) level, were recorded at 1, 3, and 7 days after surgery. The dosage and administration time of dopamine and epinephrine, mechanical ventilation time, ICU length of stay, and postoperative adverse events were recorded.

Results

Cardiac output and LVEF of patients in the levosimendan group were significantly higher than those in the control group at different time points (P<0.05), and BNP level was lower than that of the control group (P<0.0001). Dosage and administration time of dopamine and epinephrine in the levosimendan group were lower than those of the control group (P<0.0001, P<0.0001, respectively). ICU length of stay and total incidence of postoperative adverse events were lower than those of the control group (P<0.0001, P=0.002, respectively).

Conclusions

Levosimendan administration immediately after heart valve replacement effectively improved the heart function of patients, reduced administration of vasoactive drugs, shortened length of ICU stay, reduced incidence of postoperative adverse events, and promoted recovery of patients after surgery.

Levosimendan in venoarterial ECMO weaning. Rational and design of a randomized double blind multicentre trial

AIMS

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used in circulatory failure. The main indications are cardiogenic shock, post-cardiotomy cardiac failure, and refractory cardiac arrest. However, VA-ECMO weaning is particularly challenging, and weaning failure is reported to be as high as 50%, with increased related mortality. Levosimendan is a novel long acting effect inodilator used in cardiogenic shock and terminal heart failure decompensation. Levosimendan use in VA-ECMO patients seems to reduce weaning failure regardless of the initial aetiology and to reduce mortality when administrated early after VA-ECMO initiation. However, studies are limited to retrospective analyses and reported case series. The aim of the WEANILEVO trial is to evaluate whether administration of levosimendan before VA-ECMO weaning is associated with a reduced rates of weaning failure and recourse to other temporary circulatory support.

METHODS AND RESULTS

WEANILEVO is a randomized, prospective, multicentre, double-blind, parallel-group, controlled trial. One hundred eighty patients will be enrolled if they had acute circulatory heart failure treated with VA-ECMO and for whom weaning is expected within 48 h. The study drugs are either levosimendan (0.2 μg/kg/min for 24 h) or a placebo. The primary endpoint of the trial is the absence of VA-ECMO weaning, recourse to another VA-ECMO, or other temporary circulatory assistance or death within 7 days of VA-ECMO weaning.

CONCLUSIONS

Levosimendan use in VA-ECMO appears to be beneficial for reducing weaning failure and mortality. The results of WEANILEVO should significantly influence decisions regarding the use of levosimendan for VA-ECMO weaning.

Multivariate meta-analysis of critical care meta-analyses: a meta-epidemiological study

Background

Meta-analyses typically consider multiple outcomes and report univariate effect sizes considered as independent. Multivariate meta-analysis (MVMA) incorporates outcome correlation and synthesises direct evidence and related outcome estimates within a single analysis. In a series of meta-analyses from the critically ill literature, the current study contrasts multiple univariate effect estimates and their precision with those derived from MVMA.

Methods

A previous meta-epidemiological study was used to identify meta-analyses with either one or two secondary outcomes providing sufficient detail to structure bivariate or tri-variate MVMA, with mortality as primary outcome. Analysis was performed using a random effects model for both odds ratio (OR) and risk ratio (RR); borrowing of strength (BoS) between multivariate outcome estimates was reported. Estimate comparisons, β coefficients, standard errors (SE) and confidence interval (CI) width, univariate versus multivariate, were performed using Lin’s concordance correlation coefficient (CCC).

Results

In bivariate meta-analyses, for OR (n = 49) and RR (n = 48), there was substantial concordance (≥ 0.69) between estimates; but this was less so for tri-variate meta-analyses for both OR (n = 25; ≥ 0.38) and RR (≥ -0.10; n = 22). A variable change in the multivariate precision of primary mortality outcome estimates compared with univariate was present for both bivariate and tri-variate meta-analyses and for metrics. For second outcomes, precision tended to decrease and CI width increase for bivariate meta-analyses, but was variable in the tri-variate. For third outcomes, precision increased and CI width decreased. In bivariate meta-analyses, OR coefficient significance reversal, univariate versus MVMA, occurred once for mortality and 6 cases for second outcomes. RR coefficient significance reversal occurred in 4 cases; 2 were discordant with OR. For tri-variate OR meta-analyses reversal of coefficient estimate significance occurred in two cases for mortality, nine cases for second and 7 cases for third outcomes. In RR meta-analyses significance reversals occurred for mortality in 2 cases, 6 cases for second and 3 cases for third; there were 7 discordances with OR. BoS was greater in trivariate MVMAs compared with bivariate and for OR versus RR.

Conclusions

MVMA would appear to be the preferred solution to multiple univariate analyses; parameter significance changes may occur. Analytic metric appears to be a determinant.

Effect of levosimendan on renal function in background of left ventricular dysfunction: a meta-analysis of randomized trials

OBJECTIVE

Levosimendan, an inotrope, is widely used in the management of heart failure (HF) and cardiac surgery, but it remains uncertain whether levosimendan can improve renal function in patients with left ventricular dysfunction (LVD).

METHODS

PubMed, Embase, and Cochrane CENTRAL from the inception to June 2020 were systematically screened for randomized controlled trials (RCTs) to investigate whether levosimendan offers kidney-related advantages in cardiovascular patients with LVD. We pooled the effects using a random-effect model.

RESULTS

Twenty-eight studies enrolling 5069 patients were included. Levosimendan reduced the sCr (SMD -0.28, 95% CI (-0.48, -0.09), P = 0.005, I² = 52.5%, high quality) and the risk of ARF (relative risk 0.75, 95%CI (0.60, 0.95), P = 0.017, I² = 11.3%, moderate-quality) in patients with LVD compared with control group. The reduction of sCr was more pronounced in patients with a relatively higher baseline sCr level. For secondary outcomes, levosimendan therapy was associated with the improvement of GFR (SMD 0.32, 95%CI (-0.05, 0.68), P = 0.092, I² = 55.1%, low-quality) and urine output (SMD 0.42, 95%CI (0.06, 0.79), P = 0.024, I² = 50.0%, very low-quality), but there was no significant reduction in BUN (SMD -0.14, 95%CI (-0.97, 0.70), P = 0.774, I² = 77.9%, very low-quality).

CONCLUSIONS

Levosimendan might improve renal function of patients with LVD.

[S3-Guideline Intensive Care Therapy of Cardiac Surgery Patients - a Practical Approach]

The current S3-Guideline for intensive care therapy in patients after cardiac surgery provides a wealth of information and recommendations ranging from monitoring to treatment options for various perioperative clinical situations. This article focuses on the most relevant information applicable to every-day critical care practice, covering important aspects of general and advanced monitoring, goal directed hemodynamic therapy and treatment principles for perioperative left and right heart failure.

Prophylactic use of levosimendan in pediatric patients undergoing cardiac surgery: a prospective randomized controlled trial

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

[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.

Risk related therapy in meta-analyses of critical care interventions: Bayesian meta-regression analysis

PURPOSE

The relationship between treatment efficacy and patient risk is explored in a series of meta-analyses from the critical care domain, focusing on mortality outcome.

METHODS

Systematic reviews of randomized controlled trials were identified by electronic search over the period 2002 to July 2018. A Bayesian meta-regression model was employed, using the risk difference metric to estimate the relationship between mortality difference and control arm risk, and estimate the mortality difference with and without adjusting for control arm risk.

RESULTS

Of 780 initially identified published systematic reviews, 113 had appropriate mortality data comprising 123 analysable groups. The 123 meta-analyses were pharmaceutical therapeutic (59.3%), non-pharmaceutical therapeutic (24.4%) and nutritional (16.3%), with a 25% overall average control arm mortality. In 25/123 (20%) analyses, meta-regression indicated significant baseline risk (Bayesian 95% credible intervals excluding zero). In all analyses, the relationship between risk-difference and control arm risk was negative indicating a positive treatment effect with increasing control arm risk. Adjusted estimates identified six studies with significant positive treatment effects, not evident until after adjustment for control arm risk.

CONCLUSION

Underlying risk-related therapy is apparent in meta-analyses of the critically-ill and identification is of importance to both the conduct and interpretation of these meta-analyses.

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.

Effects of restrictive red blood cell transfusion on the prognoses of adult patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials

PURPOSE

Restrictive red blood cell transfusion strategies remain controversial in patients undergoing cardiac surgery. We performed a meta-analysis to assess the prognostic benefits of restrictive red blood cell transfusion strategies in patients undergoing cardiac surgery.

METHODS

We identified randomized clinical trials through the 9th of December 2017 that investigated a restrictive red blood cell transfusion strategy versus a liberal transfusion strategy in patients undergoing cardiac surgery. Individual patient data from each study were collected. Meta-analyses were performed for the primary and secondary outcomes. The risk of bias was assessed using the Cochrane Risk of Bias Tool. A trial sequential analysis (TSA)-adjusted random-effects model was used to pool the results from the included studies for the primary outcomes.

RESULTS

Seven trials involving a total of 8886 patients were included. The TSA evaluations suggested that this meta-analysis could draw firm negative results, and the data were sufficient. There was no evidence that the risk of 30-day mortality differed between the patients assigned to a restrictive blood cell transfusion strategy and a liberal transfusion strategy (odds ratio (OR) 0.98; 95% confidence interval (CI) 0.77 to 1.24; p = 0.87). Furthermore, the study suggested that the restrictive transfusion strategy was not associated with significant increases in pulmonary morbidity (OR 1.09; 95% CI 0.88 to 1.34; p = 0.44), postoperative infection (OR 1.11; 95% CI 0.95 to 1.3; p = 0.58), acute kidney injury (OR 1.03; 95% CI 0.92 to 1.14; p = 0.71), acute myocardial infarction (OR 1.01; 95% CI 0.80 to 1.27; p = 0.78), or cerebrovascular accidents (OR 0.97; 95% CI 0.72 to 1.30; p = 0.66).

CONCLUSIONS

Our meta-analysis demonstrates that the restrictive red blood cell transfusion strategy was not inferior to the liberal strategy with respect to 30-day mortality, pulmonary morbidity, postoperative infection, cerebrovascular accidents, acute kidney injury, or acute myocardial infarction, and fewer red blood cells were transfused.

Effects of restrictive red blood cell transfusion on the prognoses of adult patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials

PURPOSE

Restrictive red blood cell transfusion strategies remain controversial in patients undergoing cardiac surgery. We performed a meta-analysis to assess the prognostic benefits of restrictive red blood cell transfusion strategies in patients undergoing cardiac surgery.

METHODS

We identified randomized clinical trials through the 9th of December 2017 that investigated a restrictive red blood cell transfusion strategy versus a liberal transfusion strategy in patients undergoing cardiac surgery. Individual patient data from each study were collected. Meta-analyses were performed for the primary and secondary outcomes. The risk of bias was assessed using the Cochrane Risk of Bias Tool. A trial sequential analysis (TSA)-adjusted random-effects model was used to pool the results from the included studies for the primary outcomes.

RESULTS

Seven trials involving a total of 8886 patients were included. The TSA evaluations suggested that this meta-analysis could draw firm negative results, and the data were sufficient. There was no evidence that the risk of 30-day mortality differed between the patients assigned to a restrictive blood cell transfusion strategy and a liberal transfusion strategy (odds ratio (OR) 0.98; 95% confidence interval (CI) 0.77 to 1.24; p = 0.87). Furthermore, the study suggested that the restrictive transfusion strategy was not associated with significant increases in pulmonary morbidity (OR 1.09; 95% CI 0.88 to 1.34; p = 0.44), postoperative infection (OR 1.11; 95% CI 0.95 to 1.3; p = 0.58), acute kidney injury (OR 1.03; 95% CI 0.92 to 1.14; p = 0.71), acute myocardial infarction (OR 1.01; 95% CI 0.80 to 1.27; p = 0.78), or cerebrovascular accidents (OR 0.97; 95% CI 0.72 to 1.30; p = 0.66).

CONCLUSIONS

Our meta-analysis demonstrates that the restrictive red blood cell transfusion strategy was not inferior to the liberal strategy with respect to 30-day mortality, pulmonary morbidity, postoperative infection, cerebrovascular accidents, acute kidney injury, or acute myocardial infarction, and fewer red blood cells were transfused.

Levosimendan in patients with low ejection fraction undergoing cardiac surgery

Introduction

Significant impairment of left ventricular function causes low cardiac output syndrome in the immediate postoperative period in 3-14% of patients undergoing surgery, increasing the mortality 15-fold.

Aim

To assess the use of levosimendan in patients undergoing cardiac surgery in 2016.

Material and methods

The analysis included 14 patients: 3 (21.4%) women and 11 (78.6%) men aged 65.4 ±11.8 years. The mean value of left ventricular ejection fraction amounted to 20 ±6.25%. In 11 patients, levosimendan infusion was started immediately after the induction of anesthesia. Three patients received the agent during the early postoperative period due to low cardiac output syndrome refractory to conventional therapy. The dosage was modified within the range of 0.05-0.2 μg/kg/min. On the day of the surgery, all patients received continuous infusion of adrenaline and levonor.

Results

The cardiac index amounted to 2.8 ±0.71 l/m² after several hours of infusion and 2.9 ±0.1 l/m² the next morning. The first examination showed that the mean systemic vascular resistance was 1010 dyn/s^-5 and the second: 940 ±100 dyn/s^-5; mixed venous blood saturation amounted to 66 ±7.5% and 65.5 ±8%, respectively. Respectively, the mean concentration of lactates was 2.0 ±0.96 mmol/l and 1.8 ±0.24 mmol/l. Mechanical lung ventilation lasting more than 48 hours was required in 50% of the patients. Two patients with chronic kidney disease required bedside renal replacement therapy before the procedure. Two (14.3%) patients died. Nine (64.3%) patients were discharged home, and three were transferred to cardiac wards.

Conclusions

Levosimendan therapy proved safe in the study group. The nature of the study and the small sample size preclude the formulation of detailed conclusions.

Effect of Levosimendan on Renal Outcome in Cardiac Surgery Patients With Chronic Kidney Disease and Perioperative Cardiovascular Dysfunction: A Substudy of a Multicenter Randomized Trial

OBJECTIVE

Acute kidney injury (AKI) occurs frequently after cardiac surgery. Levosimendan might reduce the incidence of AKI in patients undergoing cardiac surgery. The authors investigated whether levosimendan administration could reduce AKI incidence in a high-risk cardiac surgical population.

DESIGN

Post hoc analysis of a multicenter randomized trial.

SETTING

Cardiac surgery operating rooms and intensive care units of 14 centers in 3 countries.

PARTICIPANTS

The study comprised 90 patients who underwent mitral valve surgery with an estimated glomerular filtration rate <60 mL/min/1.73 m² and perioperative myocardial dysfunction.

INTERVENTIONS

Patients were assigned randomly to receive levosimendan (0.025-0.2 μg/kg/min) or placebo in addition to standard inotropic treatment.

MEASUREMENTS AND MAIN RESULTS

Forty-six patients were assigned to receive levosimendan and 44 to receive placebo. Postoperative AKI occurred in 14 (30%) patients in the levosimendan group versus 23 (52%) in the placebo group (absolute difference -21.8; 95% confidence interval -41.7 to -1.97; p = 0.035). The incidence of major complications also was lower (18 [39%]) in the levosimendan group versus that in the placebo group (29 [66%]) (absolute difference -26.8 [-46.7 to -6.90]; p = 0.011). A trend toward lower serum creatinine at intensive care unit discharge was observed in the levosimendan group (1.18 [0.99-1.49] mg/dL) versus that in the placebo group (1.39 [1.05-1.76] mg/dL) (95% confidence interval -0.23 [-0.49 to 0.01]; p = 0.07).

CONCLUSIONS

Levosimendan may improve renal outcome in cardiac surgery patients with chronic kidney disease undergoing mitral valve surgery who develop perioperative myocardial dysfunction. Results of this exploratory analysis should be investigated in future properly designed randomized controlled trials.