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Ayala R, Gewehr DM, Godoi A, Velasquez C, Fernandez M, Carvalho PEP, Goebel N. Preoperative Levosimendan in Patients With Severe Left Ventricular Dysfunction Undergoing Isolated Coronary Artery Bypass Grafting: A Meta-Analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2024; 38:649-659. [PMID: 38228424 DOI: 10.1053/j.jvca.2023.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/21/2023] [Accepted: 11/26/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE To verify the impact of preoperative levosimendan on patients with severe left ventricular dysfunction (ejection fraction <35%) undergoing isolated coronary artery bypass grafting. DESIGN A meta-analysis. SETTING Hospitals. PARTICIPANTS The authors included 1,225 patients from 6 randomized controlled trials. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The authors performed a meta-analysis of trials that compared preoperative levosimendan with placebo or no therapy, reporting efficacy and safety endpoints. Statistical analyses used mean differences and risk ratios (RR), with a random effects model. Six studies were included, comprising 1,225 patients, of whom 615 (50.2%) received preoperative levosimendan, and 610 (49.8%) received placebo/no therapy. Preoperative levosimendan showed a lower risk of all-cause mortality (RR 0.31; 95% CI 0.16-0.60; p < 0.01; I2 = 0%), postoperative acute kidney injury (RR 0.44; 95% CI 0.25-0.77; p < 0.01; I2 = 0%), low-cardiac-output syndrome (RR 0.45; 95% CI 0.30-0.66; p < 0.001; I2 = 0%), and postoperative atrial fibrillation (RR 0.49; 95% CI 0.25-0.98; p = 0.04; I2 = 85%) compared to control. Moreover, levosimendan significantly reduced the need for postoperative inotropes and increased the cardiac index at 24 hours postoperatively. There were no differences between groups for perioperative myocardial infarction, hypotension, or any adverse events. CONCLUSION Preoperative levosimendan in patients with severe left ventricular dysfunction undergoing isolated coronary artery bypass grafting was associated with reduced all-cause mortality, low-cardiac-output syndrome, acute kidney injury, postoperative atrial fibrillation, and the need for circulatory support without compromising safety.
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Affiliation(s)
- Rafael Ayala
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany.
| | | | - Amanda Godoi
- Cardiff University School of Medicine, Wales, United Kingdom
| | | | - Miguel Fernandez
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil
| | - Pedro E P Carvalho
- Department of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Nora Goebel
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
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Wöhrle T, Kilger E. [Pro: Levosimendan in Cardiac Surgery]. DIE ANAESTHESIOLOGIE 2024; 73:60-61. [PMID: 38051380 DOI: 10.1007/s00101-023-01360-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/07/2023]
Affiliation(s)
- Tobias Wöhrle
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Marchioninistraße 15, 81377, München, Deutschland.
| | - Erich Kilger
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Marchioninistraße 15, 81377, München, Deutschland
- Herzklinik der Universität am Augustinum, München, Deutschland
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Yang Y, Liu F, Wang Y, Xia L, Wang C, Ji Q. Moderate Ischemic Mitral Regurgitation with Ejection Fraction <40% Undergoing Concomitant Mitral Valve Repair during Revascularization: A Single-Center Observational Study. Rev Cardiovasc Med 2023; 24:328. [PMID: 39076453 PMCID: PMC11272872 DOI: 10.31083/j.rcm2411328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 07/31/2024] Open
Abstract
Background Numerous studies have examined the therapeutic effects of mitral valve repair during revascularization on moderate ischemic mitral regurgitation (IMR), as well as the incremental benefit of subvalvular repair alongside an annuloplasty ring. However, the impact of depressed left ventricular (LV) function on the surgical outcome of patients with moderate IMR has been rarely investigated. The aims of this single-center, retrospective, observational study were firstly to evaluate short- and medium-term outcomes in this patient group after undergoing mitral valve repair during revascularization, and secondly to assess the impact of depressed LV function on surgical outcomes. Methods A total of 272 eligible patients who had moderate IMR and underwent concomitant mitral valve repair and revascularization from January 2010 to December 2017 were included in the study. These patients were categorized into different groups based on their ejection fraction (EF) levels: an EF < 40% group (n = 90) and an EF ≥ 40% group (n = 182). The median time course of follow-up was 42 months and the shortest follow-up time was 30 months. This study compared in-hospital outcomes (major postoperative morbidity and surgical mortality) as well as midterm outcomes (moderate or more mitral regurgitation, all-cause mortality, and reoperation) of the two groups before and after propensity score (PS) matching (1:1). Results No significant difference was observed in surgical mortality between groups (8.9% vs. 3.3%, p = 0.076). More patients in the EF < 40% group developed low cardiac output (8.9% vs. 2.7%, p = 0.034) and prolonged ventilation (13.3% vs. 5.5%, p = 0.026) compared to the EF ≥ 40% group. Propensity score (PS) matching successfully established 82 patient pairs in a 1:1 ratio. No significance was discovered between the matched cohorts in terms of major postoperative morbidity and surgical mortality, except for prolonged ventilation. Conditional mixed-effects logistic regression analysis revealed that EF < 40% had an independent impact on prolonged ventilation (odds ratio (OR) = 2.814, 95% CI 1.321-6.151, p = 0.031), but was not an independent risk factor for surgical mortality (OR = 2.967, 95% CI 0.712-7.245, p = 0.138) or other major postoperative morbidity. Furthermore, the two groups showed similar cumulative survival before (log-rank p = 0.278) and after (stratified log-rank p = 0.832) PS matching. Cox regression analysis suggested that EF < 40% was not related to mortality compared with EF ≥ 40% (PS-adjusted hazard ratio (HR) = 1.151, 95% CI 0.763-1.952, p = 0.281). Conclusions Patients with moderate IMR and EF < 40% shared similar midterm outcomes and surgical mortality to patients with moderate IMR and EF ≥ 40%, but received prolonged ventilation more often. Depressed LV function may be not associated with surgical or midterm mortality.
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Affiliation(s)
- Ye Yang
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University, 200032 Shanghai, China
| | - Fangyu Liu
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University, 200032 Shanghai, China
| | - Yulin Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University, 200032 Shanghai, China
| | - Limin Xia
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University, 200032 Shanghai, China
- Department of Cardiovascular Surgery, Xiamen Branch of Zhongshan Hospital Fudan University, 361015 Xiamen, Fujian, China
| | - Chunsheng Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University, 200032 Shanghai, China
- Shanghai Municipal Institute for Cardiovascular Diseases, 200032 Shanghai, China
| | - Qiang Ji
- Department of Cardiovascular Surgery, Zhongshan Hospital Fudan University, 200032 Shanghai, China
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Wannaz L, Boillat L, Perez MH, Di Bernardo S. Prophylactic use of levosimendan in preoperative setting for surgical repair of congenital heart disease in children. Front Pediatr 2023; 11:1205971. [PMID: 37539009 PMCID: PMC10394616 DOI: 10.3389/fped.2023.1205971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/04/2023] [Indexed: 08/05/2023] Open
Abstract
Introduction Low cardiac output syndrome (LCOS) is a significant cause of morbidity and the leading cause of mortality after pediatric cardiac surgery. Levosimendan has been shown safe and effective in pediatrics to treat LCOS. We aimed to review our local strategy with preoperative prophylactic Levosimendan infusion to minimize LCOS after heart surgery in identified high-risk patients. Methods Retrospective monocentric study. As there is no reliable cardiac output measurement in children, we recorded hemodynamic parameters as surrogates of cardiac output after extracorporeal circulation through an electronic patient survey system at different time points. Results Seventy-two children received Levosimendan before surgery between 2010 and 2019. As expected, most patients were newborns and infants with prolonged open-heart surgeries. Median cardiopulmonary bypass time was 182 [137-234] min, and aortic clamping time was 95 [64-126] min. The postoperative hemodynamic parameters, vasoactive-inotropic score, and urine output remained stable throughout the first 48 h. Only a tiny portion of the patients had combined surrogate markers of LCOS with a maximal median arterial lactate of 2.6 [1.9-3.5] mmol/L during the first six postoperative hours, which then progressively normalized. The median arterio-venous difference in oxygen saturation was 31 [23-38] % between 12 and 18 h post-surgery and gradually decreased. The median venous-to-arterial CO2 difference was the highest at 10 [7-12] mmHg between 12 and 18 h post-surgery. Nine patients (13%) required extracorporeal membrane oxygenation. No patient required dialysis or hemofiltration. Mortality was 0%. Conclusion Before congenital heart surgery, preoperative prophylactic administration of Levosimendan seems effective and safe for decreasing occurrence and duration of LCOS in high-risk children.
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Affiliation(s)
- L. Wannaz
- Pediatric Cardiology, Women-Mother-Child Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - L. Boillat
- Pediatric Intensive Care Unit, Women-Mother-Child Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - M. H. Perez
- Pediatric Intensive Care Unit, Women-Mother-Child Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - S. Di Bernardo
- Pediatric Cardiology, Women-Mother-Child Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Akhtar MS, Hassan MQ, Siddiqui A, Alavudeen SS, Afzal O, Altamimi ASA, Rahman SO, Khurana M, Ahsan MJ, Sharma AK, Tabassum F. Levosimendan: mechanistic insight and its diverse future aspects in cardiac care. Acta Cardiol 2022; 78:170-187. [PMID: 36222590 DOI: 10.1080/00015385.2022.2115761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
| | - Md Quamrul Hassan
- Department of Pharmacology, SNS College of Pharmacy, Motihari, India
| | - Aisha Siddiqui
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Selangor, Malaysia
| | | | - Obaid Afzal
- Department of Pharmaceutical Chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Abdulmalik S A Altamimi
- Department of Pharmaceutical Chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Syed Obaidur Rahman
- Department of Pharmacology, School of Pharmaceutical Education and Research, New Delhi, India
| | - Mallika Khurana
- Department of Pharmacology, School of Pharmaceutical Education and Research, New Delhi, India
| | - Mohamed Jawed Ahsan
- Department of Pharmaceutical Chemistry, Maharishi Arvind College of Pharmacy, Jaipur, India
| | - Arun Kumar Sharma
- Department of Pharmacology, Amity Institute of Pharmacy, Noida, India
| | - Fauzia Tabassum
- Department of Pharmacology, College of Dentistry and Pharmacy, Buraydah, Saudi Arabia
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Caruba T, Charles-Nelson A, Alexander JH, Mehta RH, Heringlake M, Toller W, Yavchitz A, Sabatier B, Chatellier G, Cholley B. Prophylactic levosimendan in patients with low ejection fraction undergoing coronary artery bypass grafting: A pooled analysis of two multicentre randomised controlled trials. Anaesth Crit Care Pain Med 2022; 41:101107. [PMID: 35643391 DOI: 10.1016/j.accpm.2022.101107] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Thibaut Caruba
- AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France
| | | | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Rajendra H Mehta
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Matthias Heringlake
- Dept. of Anaesthesiology and Intensive Care Medicine, Heart- and Diabetes Center, Karlsburg, Germany
| | | | - Amelie Yavchitz
- AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France
| | - Brigitte Sabatier
- AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France; Inserm UMR_1138, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris Cité, F-75006 Paris, France and Inria, HeKA, PariSantéCampus, Paris, France
| | - Gilles Chatellier
- AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France; Université de Paris, F-75006 Paris, France
| | - Bernard Cholley
- AP-HP, Hôpital Européen Georges Pompidou, F-75015 Paris, France; Université de Paris, INSERM UMR_S 1140 "Innovations Thérapeutiques en Hémostase", F-75006 Paris, France.
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Li ZS, Wang K, Pan T, Sun YH, Liu C, Cheng YQ, Zhang H, Zhang HT, Wang DJ, Chen ZJ. The evaluation of levosimendan in patients with acute myocardial infarction related ventricular septal rupture undergoing cardiac surgery: a prospective observational cohort study with propensity score analysis. BMC Anesthesiol 2022; 22:135. [PMID: 35501683 PMCID: PMC9063086 DOI: 10.1186/s12871-022-01663-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 04/18/2022] [Indexed: 11/26/2022] Open
Abstract
STUDY OBJECTIVE The purpose of the present study was to evaluate the efficacy of levosimendan in patients with acute myocardial infarction related ventricular septal rupture (AMI-VSR) underwent cardiac surgery. DESIGN Prospective observational cohort study with propensity score analysis. PATIENTS There were 261 patients with AMI-VSR in our study. After 1:1 propensity matching, 106 patients (53 levosimendan and 53 control) were selected in the matched cohort. INTERVENTIONS None. MEASUREMENTS Patients who received levosimendan were assigned to the levosimendan group (n = 164). The patients who were not received were levosimendan assigned to the control group (n = 97). The levosimendan was initiated immediately after cardiopulmonary bypass. Then, it has been maintained during the postoperative 3 days. The poor outcomes were identified as follows: death and postoperative complications (postoperative stroke, low cardiac output syndromeneeded mechanical circulatory support after surgery, acute kidney injury (≥ stage III), postoperative infection or septic shock, new developed atrial fibrillation or ventricular arrhythmias). MAIN RESULTS Before matching, the control group had more length of ICU stay (6.69 ± 3.90 d vs. 5.20 ± 2.24 d, p < 0.001) and longer mechanical ventilation time (23 h, IQR: 16-53 h vs. 16 h, IQR: 11-23 h, p < 0.001). Other postoperative outcomes have not shown significant differences between two groups. After matching, no significant difference was found between both groups for all postoperative outcomes. The Kaplan-Meier survivul estimate and log-rank test showed that the 90-day survival had no significant differences between two groups before and after matching. CONCLUSION Our study found that a low-dose infusion of levosimendan in AMI-VSR patients underwent surgical repair did not associated with positively affect to postoperative outcomes.
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Affiliation(s)
- Ze-Shi Li
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, 210008, Jiangsu, China
| | - Kuo Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, XuZhou Medical University, Nanjing, Jiangsu, China
| | - Tuo Pan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, 210008, Jiangsu, China
| | - Yan-Hua Sun
- Department of Anesthesia, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Chang Liu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yong-Qing Cheng
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - He Zhang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, 210008, Jiangsu, China
| | - Hai-Tao Zhang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, 210008, Jiangsu, China
| | - Dong-Jin Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, 210008, Jiangsu, China.
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, XuZhou Medical University, Nanjing, Jiangsu, China.
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China.
| | - Zu-Jun Chen
- The Department of Intensive Care Unite, Chinese Academy of Medical sciences & Peking Union Medical College, Fuwai Hospital, Beijing, China.
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Conti N, Gatti M, Raschi E, Diemberger I, Potena L. Evidence and Current Use of Levosimendan in the Treatment of Heart Failure: Filling the Gap. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:3391-3409. [PMID: 34376973 PMCID: PMC8350150 DOI: 10.2147/dddt.s295214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/22/2021] [Indexed: 12/14/2022]
Abstract
Levosimendan is a distinctive inodilator combing calcium sensitization, phosphodiesterase inhibition and vasodilating properties through the opening of adenosine triphosphate-dependent potassium channels. It was first approved in Sweden in 2000 for the short-term treatment of acutely decompensated severe chronic heart failure when conventional therapy is not sufficient, and in cases where inotropic support is considered appropriate. After more than 20 years, clinical applications have considerably expanded across critical care and emergency medicine, and levosimendan is now under investigation in different cardiac settings (eg, septic shock, pulmonary hypertension) and for non-cardiac applications (eg, amyotrophic lateral sclerosis). This narrative review outlines key milestones in levosimendan history, by addressing regulatory issues, pharmacological peculiarities and clinical aspects (efficacy and safety) of a drug that did not receive great attention in the heart failure guidelines. A brief outlook to the ongoing clinical trials is also offered.
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Affiliation(s)
- Nicolina Conti
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Milo Gatti
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy.,SSD Clinical Pharmacology, IRCSS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Igor Diemberger
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum - University of Bologna, Bologna, Italy.,Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luciano Potena
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Heringlake M, Alvarez J, Bettex D, Bouchez S, Fruhwald S, Girardis M, Grossini E, Guarracino F, Herpain A, Toller W, Tritapepe L, Pollesello P. An update on levosimendan in acute cardiac care: applications and recommendations for optimal efficacy and safety. Expert Rev Cardiovasc Ther 2021; 19:325-335. [PMID: 33739204 DOI: 10.1080/14779072.2021.1905520] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction: In the 20 years since its introduction to the palette of intravenous hemodynamic therapies, the inodilator levosimendan has established itself as a valuable asset for the management of acute decompensated heart failure. Its pharmacology is notable for delivering inotropy via calcium sensitization without an increase in myocardial oxygen consumption.Areas covered: Experience with levosimendan has led to its applications expanding into perioperative hemodynamic support and various critical care settings, as well as an array of situations associated with acutely decompensated heart failure, such as right ventricular failure, cardiogenic shock with multi-organ dysfunction, and cardio-renal syndrome. Evidence suggests that levosimendan may be preferable to milrinone for patients in cardiogenic shock after cardiac surgery or for weaning from extracorporeal life support and may be superior to dobutamine in terms of short-term survival, especially in patients on beta-blockers. Positive effects on kidney function have been noted, further differentiating levosimendan from catecholamines and phosphodiesterase inhibitors.Expert opinion:Levosimendan can be a valuable resource in the treatment of acute cardiac dysfunction, especially in the presence of beta-blockers or ischemic cardiomyopathy. When attention is given to avoiding or correcting hypovolemia and hypokalemia, an early use of the drug in the treatment algorithm is preferred.
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Affiliation(s)
- Matthias Heringlake
- Klinik Für Anästhesie Und Intensivmedizin, Herz- Und Diabeteszentrum Mecklenburg Vorpommern, Karlsburg, Germany
| | - Julian Alvarez
- Department of Anesthesia and Surgical ICU, University of Santiago De Compostela, Santiago De Compostela, Spain
| | - Dominique Bettex
- Institute for Anaesthesiology, University Zürich and University Hospital Zürich, Zürich, Switzerland
| | - Stefaan Bouchez
- Department of Anesthesiology, University Hospital, Ghent, Belgium
| | - Sonja Fruhwald
- Department of Anaesthesiology and Intensive Care Medicine, Division of Anaesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Massimo Girardis
- Struttura Complessa Di Anestesia 1, Policlinico Di Modena, Modena, Italy
| | - Elena Grossini
- Laboratory of Physiology, Department of Translational Medicine, Università Piemonte Orientale, Novara, Italy
| | - Fabio Guarracino
- Dipartimento Di Anestesia E Rianimazione, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Antoine Herpain
- Department of Intensive Care, Erasme University Hospital, Université Libre De Bruxelles, Brussels, Belgium
| | - Wolfgang Toller
- Department of Anaesthesiology and Intensive Care Medicine, Division of Anaesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Luigi Tritapepe
- UOC Anestesia E Rianimazione, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy; and
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10
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Jawitz OK, Stebbins AS, Raman V, Alhanti B, van Diepen S, Heringlake M, Fremes S, Whitlock R, Meyer SR, Mehta RH, Stafford-Smith M, Goodman SG, Alexander JH, Lopes RD. Association between levosimendan, postoperative AKI, and mortality in cardiac surgery: Insights from the LEVO-CTS trial. Am Heart J 2021; 231:18-24. [PMID: 33127531 DOI: 10.1016/j.ahj.2020.10.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/23/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVES We aimed to evaluate the association between levosimendan treatment and acute kidney injury (AKI) as well as assess the clinical sequelae of AKI in cardiac surgery patients with depressed left ventricular function (ejection fraction <35%). METHODS Patients in the LEVO-CTS trial undergoing on-pump coronary artery bypass grafting (CABG), valve, or CABG/valve surgery were stratified by occurrence and severity of postoperative AKI using the AKIN classification. The association between levosimendan infusion and AKI was modeled using multivariable regression. RESULTS Among 854 LEVO-CTS patients, 231 (27.0%) experienced postoperative AKI, including 182 (21.3%) with stage 1, 35 (4.1%) with stage 2, and 14 (1.6%) with stage 3 AKI. The rate of AKI was similar between patients receiving levosimendan or placebo. The odds of 30-day mortality significantly increased by AKI stage compared to those without AKI (stage 1: adjusted odds ratio [aOR] 2.0, 95% confidence interval [CI] 0.8-4.9; stage 2: aOR 9.1, 95% CI 3.2-25.7; stage 3: aOR 12.4, 95% CI 3.0-50.4). No association was observed between levosimendan, AKI stage, and odds of 30-day mortality (interaction P = .69). Factors independently associated with AKI included increasing age, body mass index, diabetes, and increasing baseline systolic blood pressure. Increasing baseline eGFR and aldosterone antagonist use were associated with a lower risk of AKI. CONCLUSIONS Postoperative AKI is common among high-risk patients undergoing cardiac surgery and associated with significantly increased risk of 30-day death or dialysis. Levosimendan was not associated with the risk of AKI.
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Gayatri D, Tongers J, Efremov L, Mikolajczyk R, Sedding D, Schumann J. Prophylactic use of inotropic agents for the prevention of low cardiac output syndrome and mortality in adults undergoing cardiac surgery. Hippokratia 2020. [DOI: 10.1002/14651858.cd013781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Dwi Gayatri
- Department of Anaesthesiology and Surgical Intensive Care; Martin-Luther-University Halle-Wittenberg; Halle (Saale) Germany
| | - Jörn Tongers
- Cardiology, Angiology and Intensive Care Medicine; University Hospital Halle (Saale); Halle (Saale) Germany
| | - Ljupcho Efremov
- Institute for Medical Epidemiology, Biometrics and Informatics (IMEBI), Interdisciplinary Center for Health Sciences; Medical School of the Martin-Luther-University Halle-Wittenberg; Halle (Saale) Germany
| | - Rafael Mikolajczyk
- Institute for Medical Epidemiology, Biometrics and Informatics (IMEBI), Interdisciplinary Center for Health Sciences; Medical School of the Martin-Luther-University Halle-Wittenberg; Halle (Saale) Germany
| | - Daniel Sedding
- Cardiology, Angiology and Intensive Care Medicine; University Hospital Halle (Saale); Halle (Saale) Germany
| | - Julia Schumann
- Department of Anaesthesiology and Surgical Intensive Care; Martin-Luther-University Halle-Wittenberg; Halle (Saale) Germany
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12
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Uhlig K, Efremov L, Tongers J, Frantz S, Mikolajczyk R, Sedding D, Schumann J. Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev 2020; 11:CD009669. [PMID: 33152122 PMCID: PMC8094388 DOI: 10.1002/14651858.cd009669.pub4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cardiogenic shock (CS) and low cardiac output syndrome (LCOS) are potentially life-threatening complications of acute myocardial infarction (AMI), heart failure (HF) or cardiac surgery. While there is solid evidence for the treatment of other cardiovascular diseases of acute onset, treatment strategies in haemodynamic instability due to CS and LCOS remains less robustly supported by the given scientific literature. Therefore, we have analysed the current body of evidence for the treatment of CS or LCOS with inotropic and/or vasodilating agents. This is the second update of a Cochrane review originally published in 2014. OBJECTIVES Assessment of efficacy and safety of cardiac care with positive inotropic agents and vasodilator agents in CS or LCOS due to AMI, HF or after cardiac surgery. SEARCH METHODS We conducted a search in CENTRAL, MEDLINE, Embase and CPCI-S Web of Science in October 2019. We also searched four registers of ongoing trials and scanned reference lists and contacted experts in the field to obtain further information. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials (RCTs) enrolling patients with AMI, HF or cardiac surgery complicated by CS or LCOS. DATA COLLECTION AND ANALYSIS We used standard methodological procedures according to Cochrane standards. MAIN RESULTS We identified 19 eligible studies including 2385 individuals (mean or median age range 56 to 73 years) and three ongoing studies. We categorised studies into 11 comparisons, all against standard cardiac care and additional other drugs or placebo. These comparisons investigated the efficacy of levosimendan versus dobutamine, enoximone or placebo; enoximone versus dobutamine, piroximone or epinephrine-nitroglycerine; epinephrine versus norepinephrine or norepinephrine-dobutamine; dopexamine versus dopamine; milrinone versus dobutamine and dopamine-milrinone versus dopamine-dobutamine. All trials were published in peer-reviewed journals, and analyses were done by the intention-to-treat (ITT) principle. Eighteen of 19 trials were small with only a few included participants. An acknowledgement of funding by the pharmaceutical industry or missing conflict of interest statements occurred in nine of 19 trials. In general, confidence in the results of analysed studies was reduced due to relevant study limitations (risk of bias), imprecision or indirectness. Domains of concern, which showed a high risk in more than 50% of included studies, encompassed performance bias (blinding of participants and personnel) and bias affecting the quality of evidence on adverse events. All comparisons revealed uncertainty on the effect of inotropic/vasodilating drugs on all-cause mortality with a low to very low quality of evidence. In detail, the findings were: levosimendan versus dobutamine (short-term mortality: RR 0.60, 95% CI 0.36 to 1.03; participants = 1701; low-quality evidence; long-term mortality: RR 0.84, 95% CI 0.63 to 1.13; participants = 1591; low-quality evidence); levosimendan versus placebo (short-term mortality: no data available; long-term mortality: RR 0.55, 95% CI 0.16 to 1.90; participants = 55; very low-quality evidence); levosimendan versus enoximone (short-term mortality: RR 0.50, 0.22 to 1.14; participants = 32; very low-quality evidence; long-term mortality: no data available); epinephrine versus norepinephrine-dobutamine (short-term mortality: RR 1.25; 95% CI 0.41 to 3.77; participants = 30; very low-quality evidence; long-term mortality: no data available); dopexamine versus dopamine (short-term mortality: no deaths in either intervention arm; participants = 70; very low-quality evidence; long-term mortality: no data available); enoximone versus dobutamine (short-term mortality RR 0.21; 95% CI 0.01 to 4.11; participants = 27; very low-quality evidence; long-term mortality: no data available); epinephrine versus norepinephrine (short-term mortality: RR 1.81, 0.89 to 3.68; participants = 57; very low-quality evidence; long-term mortality: no data available); and dopamine-milrinone versus dopamine-dobutamine (short-term mortality: RR 1.0, 95% CI 0.34 to 2.93; participants = 20; very low-quality evidence; long-term mortality: no data available). No information regarding all-cause mortality were available for the comparisons milrinone versus dobutamine, enoximone versus piroximone and enoximone versus epinephrine-nitroglycerine. AUTHORS' CONCLUSIONS At present, there are no convincing data supporting any specific inotropic or vasodilating therapy to reduce mortality in haemodynamically unstable patients with CS or LCOS. Considering the limited evidence derived from the present data due to a high risk of bias and imprecision, it should be emphasised that there is an unmet need for large-scale, well-designed randomised trials on this topic to close the gap between daily practice in critical care of cardiovascular patients and the available evidence. In light of the uncertainties in the field, partially due to the underlying methodological flaws in existing studies, future RCTs should be carefully designed to potentially overcome given limitations and ultimately define the role of inotropic agents and vasodilator strategies in CS and LCOS.
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Affiliation(s)
- Konstantin Uhlig
- Department of Anaesthesiology and Surgical Intensive Care, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
| | - Ljupcho Efremov
- Institute for Medical Epidemiology, Biometrics and Informatics (IMEBI), Interdisciplinary Center for Health Sciences, Medical School of the Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Jörn Tongers
- Cardiology, Angiology and Intensive Care Medicine, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Stefan Frantz
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Rafael Mikolajczyk
- Institute for Medical Epidemiology, Biometrics and Informatics (IMEBI), Interdisciplinary Center for Health Sciences, Medical School of the Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Daniel Sedding
- Cardiology, Angiology and Intensive Care Medicine, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Julia Schumann
- Department of Anaesthesiology and Surgical Intensive Care, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
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Sander D, Dusse F. [S3-Guideline Intensive Care Therapy of Cardiac Surgery Patients - a Practical Approach]. Anasthesiol Intensivmed Notfallmed Schmerzther 2020; 55:635-642. [PMID: 33053589 DOI: 10.1055/a-1011-2078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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14
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Poveda-Jaramillo R. Heart Dysfunction in Sepsis. J Cardiothorac Vasc Anesth 2020; 35:298-309. [PMID: 32807603 DOI: 10.1053/j.jvca.2020.07.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 06/11/2020] [Accepted: 07/05/2020] [Indexed: 12/24/2022]
Abstract
Cardiac involvement during sepsis frequently occurs. A series of molecules induces a set of changes at the cellular level that result in the malfunction of the myocardium. The understanding of these molecular alterations has simultaneously promoted the implementation of diagnostic strategies that are much more precise and allowed the advance of the therapeutics. The heart is a vital organ for survival. Its well-being ensures the adequate supply of essential elements for organs and tissues.
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15
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Mauriat P, Bojan M, Soulie S, Foulgoc H, Tafer N, Ouattara A. Impact of the perioperative inotropic support in grown-up congenital heart patients undergoing cardiac surgery: a propensity score adjusted analysis. Ann Intensive Care 2020; 10:91. [PMID: 32648069 PMCID: PMC7344035 DOI: 10.1186/s13613-020-00709-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 06/30/2020] [Indexed: 12/30/2022] Open
Abstract
Background Grown-up congenital heart (GUCH) patients represent a growing population with a high morbidity risk when undergoing reparative surgery. A main preoperative feature is right ventricular failure, which represents a risk factor for postoperative low cardiac output syndrome. Levosimendan has a potentially beneficial effect. This retrospective study included consecutive GUCH patients with surgeries in a tertiary cardiothoracic centre between 01-01-2013 and 01-10-2017, to test the hypothesis that the postoperative use of levosimendan might be associated with shorter time of mechanical ventilation, when compared with the use of milrinone. To adjust for bias related to the probability of treatment assignment, it uses the inverse propensity score weighting methodology. Results Overall 363 patients had GUCH surgeries during the study period, their mean age was 31.39 ± 15.31 years, 87 patients were eligible for analysis in the Levosimendan group and 117 in the Milrinone group. The propensity score used pre- and intraoperative variables and resulted in a good balance between covariates. The Levosimendan group included patients with higher preoperative risk scores, a higher prevalence of left and right ventricular failure, who required more often the addition of epinephrine, renal replacement therapy, prolonged mechanical ventilation and intensive care stay. However, after propensity score weighting, patients in the Levosimendan group had shorter durations of mechanical ventilation (average treatment effect − 37.59 h IQR [− 138.85 to − 19.13], p = 0.01) and intensive care stay (average treatment effect − 3.11 days IQR [− 10.03 to − 1.48], p = 0.009). The number of days of additional epinephrine support was shorter and the vasoactive inotropic scores lower. Conclusion We report a beneficial effect in terms of duration of mechanical ventilation and intensive care stay, and on inotropic requirements of the use of levosimendan following GUCH surgeries. The use of levosimendan in this setting requires validation at a larger scale.
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Affiliation(s)
- Philippe Mauriat
- Department of Anaesthesia and Critical Care, University of Bordeaux, Haut-Levêque Hospital, Avenue Magellan, 33000, Pessac, France.
| | - Mirela Bojan
- Department of Anaesthesia, Congenital Cardiac Unit, Marie-Lannelongue Hospital, Paris-Sud University, 133 Avenue de la Résistance, 92350, Le Plessis-Robinson, France
| | - Sylvie Soulie
- Department of Anesthesia and Critical Care, Louis Pradel Hospital, University of Lyon, 59 Boulevard Pinel, 69500, Bron, France
| | - Hélène Foulgoc
- Department of Anaesthesia and Critical Care, University of Bordeaux, Haut-Levêque Hospital, Avenue Magellan, 33000, Pessac, France
| | - Nadir Tafer
- Department of Anaesthesia and Critical Care, University of Bordeaux, Haut-Levêque Hospital, Avenue Magellan, 33000, Pessac, France
| | - Alexandre Ouattara
- Department of Anaesthesia and Critical Care, University of Bordeaux, Haut-Levêque Hospital, Avenue Magellan, 33000, Pessac, France.,Biology of Cardiovascular Diseases, University of Bordeaux, INSERM, UMR 1034, 33600, Pessac, France
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16
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Papp Z, Agostoni P, Alvarez J, Bettex D, Bouchez S, Brito D, Černý V, Comin-Colet J, Crespo-Leiro MG, Delgado JF, Édes I, Eremenko AA, Farmakis D, Fedele F, Fonseca C, Fruhwald S, Girardis M, Guarracino F, Harjola VP, Heringlake M, Herpain A, Heunks LM, Husebye T, Ivancan V, Karason K, Kaul S, Kivikko M, Kubica J, Masip J, Matskeplishvili S, Mebazaa A, Nieminen MS, Oliva F, Papp JG, Parissis J, Parkhomenko A, Põder P, Pölzl G, Reinecke A, Ricksten SE, Riha H, Rudiger A, Sarapohja T, Schwinger RH, Toller W, Tritapepe L, Tschöpe C, Wikström G, von Lewinski D, Vrtovec B, Pollesello P. Levosimendan Efficacy and Safety: 20 years of SIMDAX in Clinical Use. Card Fail Rev 2020; 6:e19. [PMID: 32714567 PMCID: PMC7374352 DOI: 10.15420/cfr.2020.03] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/16/2020] [Indexed: 12/12/2022] Open
Abstract
Levosimendan was first approved for clinic use in 2000, when authorisation was granted by Swedish regulatory authorities for the haemodynamic stabilisation of patients with acutely decompensated chronic heart failure. In the ensuing 20 years, this distinctive inodilator, which enhances cardiac contractility through calcium sensitisation and promotes vasodilatation through the opening of adenosine triphosphate-dependent potassium channels on vascular smooth muscle cells, has been approved in more than 60 jurisdictions, including most of the countries of the European Union and Latin America. Areas of clinical application have expanded considerably and now include cardiogenic shock, takotsubo cardiomyopathy, advanced heart failure, right ventricular failure and pulmonary hypertension, cardiac surgery, critical care and emergency medicine. Levosimendan is currently in active clinical evaluation in the US. Levosimendan in IV formulation is being used as a research tool in the exploration of a wide range of cardiac and non-cardiac disease states. A levosimendan oral form is at present under evaluation in the management of amyotrophic lateral sclerosis. To mark the 20 years since the advent of levosimendan in clinical use, 51 experts from 23 European countries (Austria, Belgium, Croatia, Cyprus, Czech Republic, Estonia, Finland, France, Germany, Greece, Hungary, Italy, the Netherlands, Norway, Poland, Portugal, Russia, Slovenia, Spain, Sweden, Switzerland, UK and Ukraine) contributed to this essay, which evaluates one of the relatively few drugs to have been successfully introduced into the acute heart failure arena in recent times and charts a possible development trajectory for the next 20 years.
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Affiliation(s)
- Zoltán Papp
- Department of Cardiology, Faculty of Medicine, University of Debrecen Debrecen, Hungary
| | - Piergiuseppe Agostoni
- Department of Clinical Sciences and Community Health, Centro Cardiologico Monzino, IRCCS Milan, Italy
| | - Julian Alvarez
- Department of Surgery, School of Medicine, University of Santiago de Compostela Santiago de Compostela, Spain
| | - Dominique Bettex
- Institute of Anaesthesiology, University Hospital of Zurich Zurich, Switzerland
| | - Stefan Bouchez
- Department of Anaesthesiology, University Hospital Ghent, Belgium
| | - Dulce Brito
- Cardiology Department, Centro Hospitalar Universitario Lisboa Norte, CCUI, Faculdade de Medicina, Universidade de Lisboa Lisbon, Portugal
| | - Vladimir Černý
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University Usti nad Labem, Czech Republic
| | - Josep Comin-Colet
- Heart Diseases Institute, Hospital Universitari de Bellvitge Barcelona, Spain
| | - Marisa G Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), CIBERCV, Instituto de Investigacion Biomedica A Coruña (INIBIC), Universidad de a Coruña (UDC) La Coruña, Spain
| | - Juan F Delgado
- Heart Failure and Transplant Program, Cardiology Department, University Hospital 12 Octubre Madrid, Spain
| | - Istvan Édes
- Department of Cardiology, Faculty of Medicine, University of Debrecen Debrecen, Hungary
| | - Alexander A Eremenko
- Department of Cardiac Intensive Care, Petrovskii National Research Centre of Surgery, Sechenov University Moscow, Russia
| | - Dimitrios Farmakis
- Department of Cardiology, Medical School, University of Cyprus Nicosia, Cyprus
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, La Sapienza University of Rome Rome, Italy
| | - Cândida Fonseca
- Heart Failure Clinic, São Francisco Xavier Hospital, CHLO Lisbon, Portugal
| | - Sonja Fruhwald
- Department of Anaesthesiology and Intensive Care Medicine, Division of Anaesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz Graz, Austria
| | - Massimo Girardis
- Struttura Complessa di Anestesia 1, Policlinico di Modena Modena, Italy
| | - Fabio Guarracino
- Dipartimento di Anestesia e Terapie Intensive, Azienda Ospedaliero-Universitaria Pisana Pisa, Italy
| | - Veli-Pekka Harjola
- Emergency Medicine, Meilahti Central University Hospital, University of Helsinki Helsinki, Finland
| | - Matthias Heringlake
- Department of Anaesthesiology and Intensive Care Medicine, University of Lübeck Lübeck, Germany
| | - Antoine Herpain
- Department of Intensive Care, Hôpital Erasme Brussels, Belgium
| | - Leo Ma Heunks
- Department of Intensive Care Medicine, Amsterdam UMC Amsterdam, the Netherlands
| | - Tryggve Husebye
- Department of Cardiology, Oslo University Hospital Ullevaal Oslo, Norway
| | - Višnja Ivancan
- Department of Anaesthesiology, Reanimatology and Intensive Care, University Hospital Centre Zagreb, Croatia
| | - Kristjan Karason
- Departments of Cardiology and Transplantation, Sahlgrenska University Hospital Gothenburg, Sweden
| | - Sundeep Kaul
- Intensive Care Unit, National Health Service Leeds, UK
| | - Matti Kivikko
- Global Medical Affairs, R&D, Orion Pharma Espoo, Finland
| | - Janek Kubica
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University Torun, Poland
| | - Josep Masip
- Intensive Care Department, Consorci Sanitari Integral, University of Barcelona Barcelona, Spain
| | | | - Alexandre Mebazaa
- Department of Anaesthesiology and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals Paris, France
| | | | - Fabrizio Oliva
- Department of Cardiology, Niguarda Ca'Granda Hospital Milan, Italy
| | - Julius-Gyula Papp
- MTA-SZTE Research Group of Cardiovascular Pharmacology, Hungarian Academy of Sciences, University of Szeged Szeged, Hungary
| | - John Parissis
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Athens, Greece
| | - Alexander Parkhomenko
- Emergency Cardiology Department, National Scientific Centre MD Strazhesko Institute of Cardiology Kiev, Ukraine
| | - Pentti Põder
- Department of Cardiology, North Estonia Medical Centre Tallinn, Estonia
| | - Gerhard Pölzl
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck Innsbruck, Austria
| | - Alexander Reinecke
- Klinik für Innere Medizin III, Kardiologie, Universitätsklinikum Schleswig-Holstein Kiel, Germany
| | - Sven-Erik Ricksten
- Department of Anaesthesiology and Intensive Care, Sahlgrenska University Hospital Gothenburg, Sweden
| | - Hynek Riha
- Cardiothoracic Anaesthesiology and Intensive Care, Department of Anaesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine Prague, Czech Republic
| | - Alain Rudiger
- Department of Medicine, Spittal Limmattal Schlieren, Switzerland
| | | | - Robert Hg Schwinger
- Medizinische Klinik II, Klinikum Weiden, Teaching Hospital of University of Regensburg Weiden, Germany
| | - Wolfgang Toller
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz Graz, Austria
| | - Luigi Tritapepe
- Anaesthesia and Intensive Care Division, San Camillo-Forlanini Hospital Rome, Italy
| | - Carsten Tschöpe
- Department of Cardiology, Campus Virchow Klinikum, Charité - University Medicine Berlin Berlin, Germany
| | - Gerhard Wikström
- Institute of Medical Sciences, Uppsala University Uppsala, Sweden
| | - Dirk von Lewinski
- Department of Cardiology, Myokardiale Energetik und Metabolismus Research Unit, Medical University of Graz Graz, Austria
| | - Bojan Vrtovec
- Advanced Heart Failure and Transplantation Centre, Department of Cardiology, University Clinical Centre Ljubljana, Slovenia
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Cheshire C, Bhagra CJ, Bhagra SK. A review of the management of patients with advanced heart failure in the intensive care unit. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:828. [PMID: 32793673 PMCID: PMC7396251 DOI: 10.21037/atm-20-1048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Despite progress in the medical and device therapy for heart failure (HF), the prognosis for those with advanced HF remains poor. Acute heart failure (AcHF) is the rapid development of, or worsening of symptoms and signs of HF typically leading to hospitalization. Whilst many HF decompensations are managed at a ward-based level, a proportion of patients require higher acuity care in the intensive care unit (ICU). Admission to ICU is associated with a higher risk of in-hospital mortality, and in those who fail to respond to standard supportive and medical therapy, a proportion maybe suitable for mechanical circulatory support (MCS). The optimal pre-operative management of advanced HF patients awaiting durable MCS or cardiac transplantation (CTx) is vital in improving both short and longer-term outcomes. This review will summarize the clinical assessment, hemodynamic profiling and management of the patient with AcHF in the ICU. The general principles of pre-surgical optimization encompassing individual systems (the kidneys, the liver, blood and glycemic control) will be discussed. Other factors impacting upon post-operative outcomes including nutrition and sarcopenia and pre-surgical skin decolonization have been included. Issues specific to durable MCS including the assessment of the right ventricle and strategies for optimization will also be discussed.
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Affiliation(s)
- Caitlin Cheshire
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Catriona Jane Bhagra
- Department of Cardiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sai Kiran Bhagra
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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18
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Papp Z, Agostoni P, Alvarez J, Bettex D, Bouchez S, Brito D, Černý V, Comin-Colet J, Crespo-Leiro MG, Delgado JF, Édes I, Eremenko AA, Farmakis D, Fedele F, Fonseca C, Fruhwald S, Girardis M, Guarracino F, Harjola VP, Heringlake M, Herpain A, Heunks LMA, Husebye T, Ivancan V, Karason K, Kaul S, Kivikko M, Kubica J, Masip J, Matskeplishvili S, Mebazaa A, Nieminen MS, Oliva F, Papp JG, Parissis J, Parkhomenko A, Põder P, Pölzl G, Reinecke A, Ricksten SE, Riha H, Rudiger A, Sarapohja T, Schwinger RHG, Toller W, Tritapepe L, Tschöpe C, Wikström G, von Lewinski D, Vrtovec B, Pollesello P. Levosimendan Efficacy and Safety: 20 Years of SIMDAX in Clinical Use. J Cardiovasc Pharmacol 2020; 76:4-22. [PMID: 32639325 PMCID: PMC7340234 DOI: 10.1097/fjc.0000000000000859] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022]
Abstract
Levosimendan was first approved for clinical use in 2000, when authorization was granted by Swedish regulatory authorities for the hemodynamic stabilization of patients with acutely decompensated chronic heart failure (HF). In the ensuing 20 years, this distinctive inodilator, which enhances cardiac contractility through calcium sensitization and promotes vasodilatation through the opening of adenosine triphosphate-dependent potassium channels on vascular smooth muscle cells, has been approved in more than 60 jurisdictions, including most of the countries of the European Union and Latin America. Areas of clinical application have expanded considerably and now include cardiogenic shock, takotsubo cardiomyopathy, advanced HF, right ventricular failure, pulmonary hypertension, cardiac surgery, critical care, and emergency medicine. Levosimendan is currently in active clinical evaluation in the United States. Levosimendan in IV formulation is being used as a research tool in the exploration of a wide range of cardiac and noncardiac disease states. A levosimendan oral form is at present under evaluation in the management of amyotrophic lateral sclerosis. To mark the 20 years since the advent of levosimendan in clinical use, 51 experts from 23 European countries (Austria, Belgium, Croatia, Cyprus, Czech Republic, Estonia, Finland, France, Germany, Greece, Hungary, Italy, the Netherlands, Norway, Poland, Portugal, Russia, Slovenia, Spain, Sweden, Switzerland, the United Kingdom, and Ukraine) contributed to this essay, which evaluates one of the relatively few drugs to have been successfully introduced into the acute HF arena in recent times and charts a possible development trajectory for the next 20 years.
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Affiliation(s)
- Zoltán Papp
- Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Piergiuseppe Agostoni
- Department of Clinical Sciences and Community Health, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Julian Alvarez
- Department of Surgery, School of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Dominique Bettex
- Institute of Anaesthesiology, University Hospital of Zurich, Zurich, Switzerland
| | - Stefan Bouchez
- Department of Anaesthesiology, University Hospital, Ghent, Belgium
| | - Dulce Brito
- Cardiology Department, Centro Hospitalar Universitario Lisboa Norte, CCUI, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Vladimir Černý
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, Usti nad Labem, Czech Republic
| | - Josep Comin-Colet
- Heart Diseases Institute, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Marisa G. Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), CIBERCV, Instituto de Investigacion Biomedica A Coruña (INIBIC), Universidad de a Coruña (UDC), La Coruña, Spain
| | - Juan F. Delgado
- Heart Failure and Transplant Program, Cardiology Department, University Hospital 12 Octubre, Madrid, Spain
| | - István Édes
- Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Alexander A. Eremenko
- Department of Cardiac Intensive Care, Petrovskii National Research Centre of Surgery, Sechenov University, Moscow, Russia
| | - Dimitrios Farmakis
- Department of Cardiology, Medical School, University of Cyprus, Nicosia, Cyprus
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, La Sapienza University of Rome, Rome, Italy
| | - Cândida Fonseca
- Heart Failure Clinic, São Francisco Xavier Hospital, CHLO, Lisbon, Portugal
| | - Sonja Fruhwald
- Department of Anaesthesiology and Intensive Care Medicine, Division of Anaesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Massimo Girardis
- Struttura Complessa di Anestesia 1, Policlinico di Modena, Modena, Italy
| | - Fabio Guarracino
- Dipartimento di Anestesia e Terapie Intensive, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Veli-Pekka Harjola
- Emergency Medicine, Meilahti Central University Hospital, University of Helsinki, Helsinki, Finland
| | - Matthias Heringlake
- Department of Anaesthesiology and Intensive Care Medicine, University of Lübeck, Lübeck, Germany
| | - Antoine Herpain
- Department of Intensive Care, Hôpital Erasme, Brussels, Belgium
| | - Leo M. A. Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Amsterdam, the Netherlands
| | - Tryggve Husebye
- Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway
| | - Višnja Ivancan
- Department of Anaesthesiology, Reanimatology and Intensive Care, University Hospital Centre, Zagreb, Croatia
| | - Kristjan Karason
- Departments of Cardiology and Transplantation, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sundeep Kaul
- Intensive Care Unit, National Health Service, Leeds, United Kingdom
| | - Matti Kivikko
- Global Medical Affairs, R&D, Orion Pharma, Espoo, Finland
| | - Janek Kubica
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Torun, Poland
| | - Josep Masip
- Intensive Care Department, Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain
| | | | - Alexandre Mebazaa
- Department of Anaesthesiology and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, Paris, France
| | | | - Fabrizio Oliva
- Department of Cardiology, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Julius G. Papp
- MTA-SZTE Research Group of Cardiovascular Pharmacology, Hungarian Academy of Sciences, University of Szeged, Szeged, Hungary
| | - John Parissis
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexander Parkhomenko
- Emergency Cardiology Department, National Scientific Centre MD Strazhesko Institute of Cardiology, Kiev, Ukraine
| | - Pentti Põder
- Department of Cardiology, North Estonia Medical Centre, Tallinn, Estonia
| | - Gerhard Pölzl
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alexander Reinecke
- Klinik für Innere Medizin III, Kardiologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Sven-Erik Ricksten
- Department of Anaesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hynek Riha
- Department of Anaesthesiology and Intensive Care Medicine, Cardiothoracic Anaesthesiology and Intensive Care, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Alain Rudiger
- Department of Medicine, Spittal Limmattal, Schlieren, Switzerland
| | | | - Robert H. G. Schwinger
- Medizinische Klinik II, Klinikum Weiden, Teaching Hospital of University of Regensburg, Weiden, Germany
| | - Wolfgang Toller
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Luigi Tritapepe
- Anaesthesia and Intensive Care Division, San Camillo-Forlanini Hospital, Rome, Italy
| | - Carsten Tschöpe
- Department of Cardiology, Campus Virchow Klinikum, Charité—University Medicine Berlin, Berlin, Germany
| | - Gerhard Wikström
- Institute of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Dirk von Lewinski
- Department of Cardiology, Myokardiale Energetik und Metabolismus Research Unit, Medical University of Graz, Graz, Austria
| | - Bojan Vrtovec
- Department of Cardiology, Advanced Heart Failure and Transplantation Centre, University Clinical Centre, Ljubljana, Slovenia
| | - Piero Pollesello
- Critical Care Proprietary Products, Orion Pharma, Espoo, Finland.
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Schlachtenberger G, Deppe AC, Gerfer S, Choi YH, Zeriouh M, Liakopoulos O, Wahlers TCW. Major Bleeding after Surgical Revascularization with Dual Antiplatelet Therapy. Thorac Cardiovasc Surg 2020; 68:714-722. [PMID: 32593177 DOI: 10.1055/s-0040-1710508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Patients with acute coronary syndrome are treated with dual antiplatelet therapy containing acetylsalicylic acid (ASA) and P2Y12 antagonists. In case of urgent coronary artery bypass grafting this might be associated with increasing risks of bleeding complications. METHODS Data from 1200 consecutive urgent operations between 2010 and 2018 were obtained from our institutional patient database. For this study off-pump surgery was excluded. The primary composite end point major bleeding consisted of at least one end point: transfusion ≥ 5 packed red blood cells within 24 hours, rethoracotomy due to bleeding, chest tube output >2000 mL within 24 hours. Demographic data, peri-, and postoperative variables and outcomes were compared between patients treated with mono antiplatelet therapy, ASA + clopidogrel (ASA-C) +ticagrelor (ASA-T) or +prasugrel (ASA-P) < 72 hours before surgery. Furthermore, we compared patients with dual antiplatelet therapy with ASA monotherapy. RESULTS From 1,086 patients, 475 (44%) received dual antiplatelet therapy. Three-hundred seventy-two received ASA-C (77.7%), 72 ASA-T (15%), and 31 ASA-P (6.5%). Major bleeding (44 vs. 23%, p < 0.0001) was more frequently in patients receiving dual therapy with higher rates of massive drainage loss within 24 hours (23 vs. 11%, p < 0.0001) of mass transfusion (34 vs. 16%, p < 0.0001) and rethoracotomy (10 vs. 5%, p = 0.002) when compared with ASA. In this analysis, ASA-T and ASA-P were not associated with higher bleeding complications compared with ASA-C. CONCLUSION Dual antiplatelet therapy is associated with higher rates of major bleeding. Further studies should examine the difference in the prevalence of major bleeding complications in the different dual antiplatelet therapy regimes in patients requiring urgent surgery.
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Affiliation(s)
- Georg Schlachtenberger
- Department of Cardiothoracic Surgery, Klinikum der Universitat zu Koln Klinik und Poliklinik fur Herz- und Thoraxchirurgie, Köln, Nordrhein-Westfalen, Germany
| | - Antje Christin Deppe
- Department of Cardiothoracic Surgery, Klinikum der Universitat zu Koln Klinik und Poliklinik fur Herz- und Thoraxchirurgie, Köln, Nordrhein-Westfalen, Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, Klinikum der Universitat zu Koln Klinik und Poliklinik fur Herz- und Thoraxchirurgie, Köln, Nordrhein-Westfalen, Germany
| | - Yeong-Hoon Choi
- Department of Cardiac Surgery, Kerckhoff Vascular Centre Bad Nauheim, Bad Nauheim, Hessen, Germany
| | - Mohamed Zeriouh
- Department of Cardiac Surgery, Kerckhoff Vascular Centre Bad Nauheim, Bad Nauheim, Hessen, Germany
| | - Oliver Liakopoulos
- Department of Cardiothoracic Surgery, Klinikum der Universitat zu Koln Klinik und Poliklinik fur Herz- und Thoraxchirurgie, Köln, Nordrhein-Westfalen, Germany
| | - Thorsten C W Wahlers
- Department of Cardiothoracic Surgery, Klinikum der Universitat zu Koln Klinik und Poliklinik fur Herz- und Thoraxchirurgie, Köln, Nordrhein-Westfalen, Germany
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20
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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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21
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Jiménez-Rivera JJ, Álvarez-Castillo A, Ferrer-Rodríguez J, Iribarren-Sarrías JL, García-González MJ, Jorge-Pérez P, Lacalzada-Almeida J, Pérez-Hernández R, Montoto-López J, Martínez-Sanz R. Preconditioning with levosimendan reduces postoperative low cardiac output in moderate-severe systolic dysfunction patients who will undergo elective coronary artery bypass graft surgery: a cost-effective strategy. J Cardiothorac Surg 2020; 15:108. [PMID: 32448319 PMCID: PMC7245898 DOI: 10.1186/s13019-020-01140-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/04/2020] [Indexed: 11/17/2022] Open
Abstract
Background Patients with moderate-severe systolic dysfunction undergoing coronary artery bypass graft have a higher incidence of postoperative low cardiac output. Preconditioning with levosimendan may be a useful strategy to prevent this complication. In this context, design cost-effective strategies like preconditioning with levosimendan may become necessary. Methods In a sequential assignment of patients with Left Ventricle Ejection Fraction less than 40%, two strategies were compared in terms of cost-effectiveness: standard care (n = 41) versus preconditioning with Levosimendan (n = 13). The adverse effects studied included: postoperative new-onset atrial fibrillation, low cardiac output, renal failure and prolonged mechanical ventilation. The costs were evaluated using deterministic and probabilistic sensitivity analysis, and Monte Carlo simulations were performed. Results Preconditioning with levosimendan in moderate to severe systolic dysfunction (Left Ventricle Ejection Fraction < 40%), was associated with a lower incidence of postoperative low cardiac output in elective coronary artery bypass graft surgery 2(15.4%) vs 25(61%) (P < 0.01) and lesser intensive care unit length of stay 2(1–4) vs 4(3–6) days (P = 0.03). Average cost on levosimendan group was 14,792€ while the average cost per patient without levosimendan was 17,007€. Patients with no complications represented 53.8% of the total in the levosimendan arm, as compared to 31.7% in the non-levosimendan arm. In all Montecarlo simulations for sensitivity analysis, use of levosimendan was less expensive and more effective. Conclusions Preconditioning with levosimendan, is a cost-effective strategy preventing postoperative low cardiac output in patients with moderate-severe left ventricular systolic dysfunction undergoing elective coronary artery bypass graft surgery.
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Affiliation(s)
- Juan José Jiménez-Rivera
- Department of Intensive Care, Hospital Universitario de Canarias, La Laguna Tenerife, S.C.Tenerife, Canary Islands, Spain.
| | - Andrea Álvarez-Castillo
- Department of Intensive Care, Hospital Universitario de Canarias, La Laguna Tenerife, S.C.Tenerife, Canary Islands, Spain
| | - Jorge Ferrer-Rodríguez
- Health Economist, University of La Laguna, La Laguna, Tenerife, S.C.Tenerife, Canary Islands, Spain
| | - José Luis Iribarren-Sarrías
- Department of Intensive Care, Hospital Universitario de Canarias, La Laguna Tenerife, S.C.Tenerife, Canary Islands, Spain
| | - Martín Jesús García-González
- Department of Cardiology, Hospital Universitario de Canarias, La Laguna, Tenerife, S.C.Tenerife, Canary Islands, Spain
| | - Pablo Jorge-Pérez
- Department of Cardiology, Hospital Universitario de Canarias, La Laguna, Tenerife, S.C.Tenerife, Canary Islands, Spain
| | - Juan Lacalzada-Almeida
- Department of Cardiology, Hospital Universitario de Canarias, La Laguna, Tenerife, S.C.Tenerife, Canary Islands, Spain
| | - Rosalía Pérez-Hernández
- Department of Intensive Care, Hospital Universitario de Canarias, La Laguna Tenerife, S.C.Tenerife, Canary Islands, Spain
| | - Javier Montoto-López
- Department of Cardiovascular Surgery, Hospital Universitario de Canarias, La Laguna, Tenerife, S.C.Tenerife, Canary Islands, Spain
| | - Rafael Martínez-Sanz
- Department of Cardiovascular Surgery, Hospital Universitario de Canarias, La Laguna, Tenerife, S.C.Tenerife, Canary Islands, Spain
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Abstract
Levosimendan is an inodilator that promotes cardiac contractility primarily through calcium sensitization of cardiac troponin C and vasodilatation via opening of adenosine triphosphate–sensitive potassium (KATP) channels in vascular smooth muscle cells; the drug also exerts organ-protective effects through a similar effect on mitochondrial KATP channels. This pharmacological profile identifies levosimendan as a drug that may have applications in a wide range of critical illness situations encountered in intensive care unit medicine: hemodynamic support in cardiogenic or septic shock; weaning from mechanical ventilation or from extracorporeal membrane oxygenation; and in the context of cardiorenal syndrome. This review, authored by experts from 9 European countries (Austria, Belgium, Czech republic, Finland, France, Germany, Italy, Sweden, and Switzerland), examines the clinical and experimental data for levosimendan in these situations and concludes that, in most instances, the evidence is encouraging, which is not the case with other cardioactive and vasoactive drugs routinely used in the intensive care unit. The size of the available studies is, however, limited and the data are in need of verification in larger controlled trials. Some proposals are offered for the aims and designs of these additional studies.
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Wang A, Cui C, Fan Y, Zi J, Zhang J, Wang G, Wang F, Wang J, Tan Q. Prophylactic use of levosimendan in pediatric patients undergoing cardiac surgery: a prospective randomized controlled trial. Crit Care 2019; 23:428. [PMID: 31888711 PMCID: PMC6937718 DOI: 10.1186/s13054-019-2704-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 12/13/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The administration of levosimendan prophylactically to patients undergoing cardiac surgery remains a controversial practice, and few studies have specifically assessed the value of this approach in pediatric patients. This study therefore sought to explore the safety and efficacy of prophylactic levosimendan administration to pediatric patients as a means of preventing low cardiac output syndrome (LCOS) based upon hemodynamic, biomarker, and pharmacokinetic readouts. METHODS This was a single-center, double-blind, randomized, placebo-controlled trial. Patients ≤ 48 months old were enrolled between July 2018 and April 2019 and were randomly assigned to groups that received either placebo or levosimendan infusions for 48 h post-surgery, along with all other standard methods of care. LCOS incidence was the primary outcome of this study. RESULTS A total of 187 patients were enrolled, of whom 94 and 93 received levosimendan and placebo, respectively. LCOS incidence did not differ significantly between the levosimendan and placebo groups (10 [10.6%] versus 18 [19.4%] patients, respectively; 95% confidence interval [CI] 0.19-1.13; p = 0.090) nor did 90-day mortality (3 [3.2%] versus 4 [4.3%] patients, CI 0.14-3.69, p = 0.693), duration of mechanical ventilation (median, 47.5 h and 39.5 h, respectively; p = 0.532), ICU stay (median, 114.5 h and 118 h, respectively; p = 0.442), and hospital stay (median, 20 days and 20 days, respectively; p = 0.806). The incidence of hypotension and cardiac arrhythmia did not differ significantly between the groups. Levels of levosimendan fell rapidly without any plateau in plasma concentrations during infusion. A multiple logistic regression indicated that randomization to the levosimendan group was a predictor of LCOS. CONCLUSIONS Prophylactic levosimendan administration was safe in pediatric patients and had some benefit to postoperative hemodynamic parameters, but failed to provide significant benefit with respect to LCOS or 90-day mortality relative to placebo. TRIAL REGISTRATION Name of the registry: Safety evaluation and therapeutic effect of levosimendan on the low cardiac output syndrome in patients after cardiopulmonary bypass. TRIAL REGISTRATION NUMBER ChiCTR1800016594. Date of registration: 11 June 2018. URL of trial registry record: http://www.chictr.org.cn/index.aspx.
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Affiliation(s)
- Anbiao Wang
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Chaomei Cui
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Yiou Fan
- Department of Toxicological and Functional Test, Centers for Disease Control and Prevention of Shandong, Jinan, 250014 China
| | - Jie Zi
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Jie Zhang
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Guanglai Wang
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Fang Wang
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Jun Wang
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, 250021 China
| | - Qi Tan
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong University, No. 9677 Jingshi Road, Jinan, 250021 China
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021 China
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Habicher M, Zajonz T, Heringlake M, Böning A, Treskatsch S, Schirmer U, Markewitz A, Sander M. [S3 guidelines on intensive medical care of cardiac surgery patients : Hemodynamic monitoring and cardiovascular system-an update]. Anaesthesist 2019; 67:375-379. [PMID: 29644444 DOI: 10.1007/s00101-018-0433-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
An update of the S3- guidelines for treatment of cardiac surgery patients in the intensive care unit, hemodynamic monitoring and cardiovascular system was published by the Association of Scientific Medical Societies in Germany (AWMF) in January 2018. This publication updates the guidelines from 2006 and 2011. The guidelines include nine sections that in addition to different methods of hemodynamic monitoring also reviews the topic of volume therapy as well as vasoactive and inotropic drugs. Furthermore, the guidelines also define the goals for cardiovascular treatment. This article describes the most important innovations of these comprehensive guidelines.
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Affiliation(s)
- M Habicher
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Gießen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Deutschland
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité - Universitätsmedizin Berlin, Charité Campus Mitte und Campus Virchow Klinikum, Berlin, Deutschland
| | - T Zajonz
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Gießen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Deutschland
| | - M Heringlake
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Lübeck, Deutschland
| | - A Böning
- Klinik für Herz- und Gefäßchirurgie, Universitätsklinikum Gießen, Gießen, Deutschland
| | - S Treskatsch
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité - Universitätsmedizin Berlin, Charité Campus Mitte und Campus Virchow Klinikum, Berlin, Deutschland
| | - U Schirmer
- Herz- und Diabeteszentrum NRW Institut für Anästhesiologie, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Deutschland
| | - A Markewitz
- Klinik für Herz- und Gefäßchirurgie, Bundeszentralwehrkrankenhaus Koblenz, Koblenz, Deutschland
| | - M Sander
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Gießen, Rudolf-Buchheim-Straße 7, 35392, Gießen, Deutschland.
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Levosimendan: What Have We Learned So Far? CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00346-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Perioperative Use of Levosimendan Improves Clinical Outcomes in Patients After Cardiac Surgery: A Systematic Review and Meta-Analysis. J Cardiovasc Pharmacol 2019; 72:11-18. [PMID: 29672418 DOI: 10.1097/fjc.0000000000000584] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Severe postoperative complications can affect cardiac surgery patients. Levosimendan is a novel calcium sensitizer commonly administered after cardiac surgery. However, the patient benefits are controversial. PubMed, Embase, and the Cochrane library were systematically searched for randomized controlled trials comparing levosimendan with control in adult cardiac surgery patients. Twenty-five studies (3247 patients) were included. Pooled data indicated that levosimendan reduced mortality after cardiac surgery [odds ratio (OR) 0.63, 95% confidence interval (CI): 0.47-0.84, P = 0.001]. However, this reduction was restricted to patients with low (<50%) left ventricular ejection fraction (OR 0.49, 95% CI: 0.35-0.70, P = 0.0001). It significantly reduced the incidence of postoperative acute kidney injury (OR 0.55, 95% CI: 0.41-0.74, P < 0.0001) and renal replacement therapy use (OR 0.56, 95% CI: 0.39-0.80, P = 0.002). Moreover, levosimendan significantly shortened the duration of the intensive care unit stay (weighted mean differences -0.49 day, 95% CI: -0.75 to -0.24, P = 0.0002) and mechanical ventilation use (weighted mean differences -2.30 hours, 95% CI: -3.76 to -0.84, P = 0.002). In conclusion, levosimendan reduced the mortality in patients with low left ventricular ejection fraction and decreased the incidence of acute renal injury and renal replacement therapy use. In addition, it shortened the duration of the intensive care unit stay and mechanical ventilation use.
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Bouchez S, Fedele F, Giannakoulas G, Gustafsson F, Harjola VP, Karason K, Kivikko M, von Lewinski D, Oliva F, Papp Z, Parissis J, Pollesello P, Pölzl G, Tschöpe C. Levosimendan in Acute and Advanced Heart Failure: an Expert Perspective on Posology and Therapeutic Application. Cardiovasc Drugs Ther 2019; 32:617-624. [PMID: 30402660 PMCID: PMC6267661 DOI: 10.1007/s10557-018-6838-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Levosimendan, a calcium sensitizer and potassium channel-opener, is widely appreciated by many specialist heart failure practitioners for its effects on systemic and pulmonary hemodynamics and for the relief of symptoms of acute heart failure. The drug’s impact on mortality in large randomized controlled trials has been inconsistent or inconclusive but, in contrast to conventional inotropes, there have been no indications of worsened survival and some signals of improved heart failure-related quality of life. For this reason, levosimendan has been proposed as a safer inodilator option than traditional agents in settings, such as advanced heart failure. Positive effects of levosimendan on renal function have also been described. At the HEART FAILURE 2018 congress of the Heart Failure Association of the European Society of Cardiology, safe and effective use levosimendan in acute and advanced heart failure was examined in a series of expert tutorials. The proceedings of those tutorials are summarized in this review, with special reference to advanced heart failure and heart failure with concomitant renal dysfunction. Meta-analysis of clinical trials data is supportive of a renal-protective effect of levosimendan, while physiological observations suggest that this effect is exerted at least in part via organ-specific effects that may include selective vasodilation of glomerular afferent arterioles and increased renal blood flow, with no compromise of renal oxygenation. These lines of evidence require further investigation and their clinical significance needs to be evaluated in specifically designed prospective trials.
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Affiliation(s)
- S Bouchez
- Department of Anesthesiology, University Hospital, Ghent, Belgium
| | - F Fedele
- Policlinico "Umberto I," University "La Sapienza", Rome, Italy
| | - G Giannakoulas
- Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - V-P Harjola
- Cardiology Clinic, HUS Meilahti Hospital, Helsinki, Finland
| | - K Karason
- Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - M Kivikko
- Critical Care Proprietary Products Division, Orion Pharma, P.O. Box 65, FIN-02101, Espoo, Finland
- Department of Cardiology S7, Jorvi Hospital, Espoo, Finland
| | - D von Lewinski
- Myokardiale Energetik und Metabolismus Research Unit, Medical University, Graz, Austria
| | - F Oliva
- Niguarda Ca'Granda Hospital, Milan, Italy
| | - Z Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - J Parissis
- Second University Cardiology Clinic, Attiko Teaching Hospital, Athens, Greece
| | - Piero Pollesello
- Critical Care Proprietary Products Division, Orion Pharma, P.O. Box 65, FIN-02101, Espoo, Finland.
| | - G Pölzl
- Universitätsklinik für Innere Medizin III Innsbruck, Medizinsche Universität, Innsbruck, Austria
| | - C Tschöpe
- Berlin Center for Regenerative Therapies (BCRT), Campus Virchow Klinikum (CVK), Berlin, Germany
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28
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Prediction model for acute kidney injury after coronary artery bypass grafting: a retrospective study. Int Urol Nephrol 2019; 51:1605-1611. [DOI: 10.1007/s11255-019-02173-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 05/14/2019] [Indexed: 10/26/2022]
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Kundra TS, Nagaraja PS, Bharathi KS, Kaur P, Manjunatha N. Inhaled levosimendan versus intravenous levosimendan in patients with pulmonary hypertension undergoing mitral valve replacement. Ann Card Anaesth 2019; 21:328-332. [PMID: 30052230 PMCID: PMC6078018 DOI: 10.4103/aca.aca_19_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context: Inhaled levosimendan may act as selective pulmonary vasodilator and avoid systemic side effects of intravenous levosimendan, which include decrease in systemic vascular resistance (SVR) and systemic hypotension, but with same beneficial effect on pulmonary artery pressure (PAP) and right ventricular (RV) function. Aim: The aim of this study was to compare the effect of inhaled levosimendan with intravenous levosimendan in patients with pulmonary hypertension undergoing mitral valve replacement. Settings and Design: The present prospective randomized comparative study was conducted in a tertiary care hospital. Subjects and Methods: Fifty patients were randomized into two groups (n = 25). Group A: Levosimendan infusion was started immediately after coming-off of cardiopulmonary bypass and continued for 24 h at 0.1 mcg/kg/min. Group B: Total dose of levosimendan which would be given through intravenous route over 24 h was calculated and then divided into four equal parts and administered through inhalational route 6th hourly over 24 h. Hemodynamic profile (pulse rate, mean arterial pressure, pulmonary artery systolic pressure [PASP], SVR) and RV function were assessed immediately after shifting, at 1, 8, 24, and 36 h after shifting to recovery. Statistical Analysis Used: Intragroup analysis was done using paired student t-test, and unpaired student t-test was used for analysis between two groups. Results: PASP and RV-fractional area change (RV-FAC) were comparable in the two groups at different time intervals. There was a significant reduction in PASP and significant improvement in RV-FAC with both intravenous and inhalational levosimendan. SVR was significantly decreased with intravenous levosimendan, but no significant decrease in SVR was observed with inhalational levosimendan. Conclusions: Inhaled levosimendan is a selective pulmonary vasodilator. It causes decrease in PAP and improvement in RV function, without having a significant effect on SVR.
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Affiliation(s)
- Tanveer Singh Kundra
- Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - P S Nagaraja
- Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - K S Bharathi
- Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Parminder Kaur
- Department of Critical Care, Sir Ganga Ram Hospital, New Delhi, India
| | - N Manjunatha
- Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
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Fletcher N. CON: Levosimendan should be used in clinical practice for patients with significantly impaired left ventricular function undergoing cardiac surgery. Anaesth Crit Care Pain Med 2019; 38:213-214. [PMID: 30857925 DOI: 10.1016/j.accpm.2019.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Nick Fletcher
- St Georges Hospital NHS Trust, Blackshaw road, London SW17 0QT, London, UK; Cleveland Clinic, 33 Grosvenor Pl, Belgravia, London SW1X 7HY, London, UK.
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Vally S, Ferdynus C, Persichini R, Bouchet B, Braunberger E, Lo Pinto H, Martinet O, Vandroux D, Aujoulat T, Allyn J, Allou N. Impact of levosimendan on weaning from peripheral venoarterial extracorporeal membrane oxygenation in intensive care unit. Ann Intensive Care 2019; 9:24. [PMID: 30707314 PMCID: PMC6358626 DOI: 10.1186/s13613-019-0503-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/29/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Few data are available on the impact of levosimendan in refractory cardiogenic shock patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO). The aim of this study was to evaluate the impact of levosimendan on VA-ECMO weaning in patients hospitalized in intensive care unit (ICU). METHODS This retrospective cohort study was conducted in a French university hospital from 2010 to 2017. All patients hospitalized in ICU undergoing VA-ECMO were consecutively evaluated. RESULTS A total of 150 patients undergoing VA-ECMO were eligible for the study. Thirty-eight propensity-matched patients were evaluated in the levosimendan group and 65 in the non-levosimendan group. In patients treated with levosimendan, left ventricular ejection fraction had increased from 21.5 ± 9.1% to 30.7 ± 13.5% (P < 0.0001) and aortic velocity-time integral from 8.9 ± 4 cm to 12.5 ± 3.8 cm (P = 0.002) 24 h after drug infusion. After propensity score matching, levosimendan was the only factor associated with a significant reduction in VA-ECMO weaning failure rates (hazard ratio = 0.16; 95% confidence interval 0.04-0.7; P = 0.01). Kaplan-Meier survival curves showed that survival rates at 30 days were 78.4% for the levosimendan group and 49.5% for the non-levosimendan group (P = 0.02). After propensity score matching analysis, the difference in 30-day mortality between the two groups was not significant (hazard ratio = 0.55; 95% confidence interval 0.27-1.10; P = 0.09). CONCLUSIONS Our results suggest that levosimendan was associated with a beneficial effect on VA-ECMO weaning in ICU patients.
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Affiliation(s)
- Shamir Vally
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - Cyril Ferdynus
- Unité de Soutien Méthodologique, CHU de La Réunion, Saint-Denis, France.,INSERM, CIC 1410, Saint-Pierre, France
| | - Romain Persichini
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - Bruno Bouchet
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - Eric Braunberger
- Chirurgie cardiaque, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - Hugo Lo Pinto
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - Olivier Martinet
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - David Vandroux
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - Thomas Aujoulat
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - Jérôme Allyn
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France
| | - Nicolas Allou
- Réanimation polyvalente, Centre Hospitalier Universitaire Félix Guyon, 97405, Saint-Denis, Allée des Topazes, France. .,Réanimation polyvalente, Hôpital Félix Guyon, Bellepierre, 97405, Saint-Denis, France.
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Levosimendan use in patients with preoperative low ejection fraction undergoing cardiac surgery: A systematic review with meta-analysis and trial sequential analysis. J Clin Anesth 2019; 52:37-47. [DOI: 10.1016/j.jclinane.2018.08.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/13/2018] [Accepted: 08/16/2018] [Indexed: 12/20/2022]
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Levosimendan in patients with low cardiac output syndrome undergoing cardiac surgery: A systematic review and meta-analysis. Anaesth Crit Care Pain Med 2018; 38:243-249. [PMID: 30342103 DOI: 10.1016/j.accpm.2018.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/28/2018] [Accepted: 08/10/2018] [Indexed: 12/30/2022]
Abstract
Levosimendan is an inotropic agent that has been shown in small studies to treat low cardiac output syndrome in cardiac surgery. However, large randomised controlled trials (RCTs) have been recently published and presented neutral results. We sought to determine the effect of levosimendan on mortality in adults with low ejection fraction undergoing cardiac surgery. We searched different databases: Medline, Embase, Cochrane Central Register of Controlled Trials, and clinical trial registries. We included RCTs comparing events in the levosimendan versus placebo in adult patients with ejection fraction ≤ 35% undergoing cardiac surgery. Outcomes were mortality at 30-day, mortality beyond 30-day, acute kidney injury and myocardial infarction. Five trials with a total of 1519 patients were selected. Four trials were rated as low risk of bias. Our meta-analysis showed no significant difference between levosimendan versus placebo mortality at 30-day [odds radio (OR): 0.62; 95% confidence intervals (CI): 0.32 to 1.20; I2 = 33%; high quality evidence] and mortality beyond 30-day (OR: 0.71; 95% CI: 0.46 to 1.11; I2 = 0%). Similarly, there were no significant differences between the levosimendan versus placebo in the incidence of acute kidney injury (OR: 0.61, 95% CI: 0.33-1.13) and myocardial infarction (OR: 0.41, 95% CI: 0.08 to 1.22). The current evidence suggests that levosimendan is not associated with significantly reduced mortality in patients with reduced ejection fraction undergoing cardiac surgery.
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S3-Leitlinie zur intensivmedizinischen Versorgung herzchirurgischer Patienten. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2018. [DOI: 10.1007/s00398-018-0242-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Levosimendan versus placebo in cardiac surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2018; 27:677-685. [DOI: 10.1093/icvts/ivy133] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 03/25/2018] [Indexed: 11/14/2022] Open
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Zangrillo A, Alvaro G, Belletti A, Pisano A, Brazzi L, Calabrò MG, Guarracino F, Bove T, Grigoryev EV, Monaco F, Boboshko VA, Likhvantsev VV, Scandroglio AM, Paternoster G, Lembo R, Frassoni S, Comis M, Pasyuga VV, Navalesi P, Lomivorotov VV. 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. J Cardiothorac Vasc Anesth 2018; 32:2152-2159. [PMID: 29580796 DOI: 10.1053/j.jvca.2018.02.039] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Gabriele Alvaro
- Department of Anesthesia and Intensive Care, AOU Mater Domini Germaneto, Catanzaro, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Antonio Pisano
- Division of Cardiac Anesthesia and Intensive Care Unit, AORN dei Colli - Monaldi Hospital, Naples, Italy
| | - Luca Brazzi
- Department of Anesthesia and Intensive Care, AOU Città della Salute e della Scienza, Turin, Italy; Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Maria G Calabrò
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Guarracino
- Division of Cardiothoracic Anesthesia and Intensive Care, Department of Anesthesia and Critical Care Medicine, AOU Pisana, Pisa, Italy
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evgeny V Grigoryev
- Department of Anesthesiology and Intensive Care, State Research Institute for Complex Issues of Cardiovascular Disease, Kemerovo, Russia
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vladimir A Boboshko
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Valery V Likhvantsev
- Department of Anesthesiology and Intensive Care, Moscow Regional Clinical and Research Institute, Moscow, Russia
| | - Anna M Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Samuele Frassoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Comis
- Department of Cardiovascular Anesthesia and Intensive Care, AO Ordine Mauriziano, Turin, Italy
| | - Vadim V Pasyuga
- Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan, Russia
| | - Paolo Navalesi
- Department of Anesthesia and Intensive Care, AOU Mater Domini Germaneto, Catanzaro, Italy; Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
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