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De Luca L, Mistrulli R, Scirpa R, Thiele H, De Luca G. Contemporary Management of Cardiogenic Shock Complicating Acute Myocardial Infarction. J Clin Med 2023; 12:2184. [PMID: 36983185 PMCID: PMC10051785 DOI: 10.3390/jcm12062184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/26/2023] [Accepted: 03/03/2023] [Indexed: 03/16/2023] Open
Abstract
Despite an improvement in pharmacological therapies and mechanical reperfusion, the outcome of patients with acute myocardial infarction (AMI) is still suboptimal, especially in patients with cardiogenic shock (CS). The incidence of CS accounts for 3-15% of AMI cases, with mortality rates of 40% to 50%. In contrast to a large number of trials conducted in patients with AMI without CS, there is limited evidence-based scientific knowledge in the CS setting. Therefore, recommendations and actual treatments are often based on registry data. Similarly, knowledge of the available options in terms of temporary mechanical circulatory support (MCS) devices is not equally widespread, leading to an underutilisation or even overutilisation in different regions/countries of these treatment options and nonuniformity in the management of CS. The aim of this article is to provide a critical overview of the available literature on the management of CS as a complication of AMI, summarising the most recent evidence on revascularisation strategies, pharmacological treatments and MCS use.
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Affiliation(s)
- Leonardo De Luca
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, Division of Cardiology, A.O. San Camillo-Forlanini, 00152 Rome, Italy
- Faculty of Medicine and Dentistry, UniCamillus-Saint Camillus International University of Health Sciences, 00131 Rome, Italy
| | - Raffaella Mistrulli
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, Division of Cardiology, A.O. San Camillo-Forlanini, 00152 Rome, Italy
| | - Riccardo Scirpa
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, Division of Cardiology, A.O. San Camillo-Forlanini, 00152 Rome, Italy
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig, University of Leipzig, 04289 Leipzig, Germany
| | - Giuseppe De Luca
- Division of Cardiology, AOU “Policlinico G. Martino”, Department of Clinical and Experimental Medicine, University of Messina, 98166 Messina, Italy
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant’Ambrogio, 20161 Milan, Italy
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Bruno RR, Wolff G, Kelm M, Jung C. Pharmacological treatment of cardiogenic shock - A state of the art review. Pharmacol Ther 2022; 240:108230. [PMID: 35697151 DOI: 10.1016/j.pharmthera.2022.108230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 12/14/2022]
Abstract
Cardiogenic shock is a clinical syndrome of impaired tissue perfusion caused by primary cardiac dysfunction and inadequate cardiac output. It represents one of the most lethal clinical conditions in intensive care medicine with mortality >40%. Management of different clinical presentations of cardiogenic shock includes guidance of cardiac preload, afterload, heart rate and contractility by differential pharmacological modulation of volume, systemic and pulmonary vascular resistance and cardiac output besides reversing the triggering cause. Data from large registries and randomized controlled trials on optimal diagnostic guidance as well as choice of pharmacological agents has accrued significantly in recent years. This state-of-the-art review summarizes the basic concepts of cardiogenic shock, the diagnostic work-up and currently available evidence and guideline recommendations on pharmacological treatment of cardiogenic shock.
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Affiliation(s)
- Raphael Romano Bruno
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany
| | - Georg Wolff
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany
| | - Malte Kelm
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Duesseldorf, Germany
| | - Christian Jung
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany.
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Chen YW, Lee WC, Wu PJ, Fang HY, Fang YN, Chen HC, Tong MS, Sung PH, Lee CH, Chung WJ. Early Levosimendan Administration Improved Weaning Success Rate in Extracorporeal Membrane Oxygenation in Patients With Cardiogenic Shock. Front Cardiovasc Med 2022; 9:912321. [PMID: 35845047 PMCID: PMC9279688 DOI: 10.3389/fcvm.2022.912321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/08/2022] [Indexed: 12/28/2022] Open
Abstract
Background Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly used in patients with refractory cardiogenic shock (CS) or out-of-hospital cardiac arrest. It is difficult to perform VA-ECMO weaning, which may cause circulatory failure and death. Levosimendan is an effective inotropic agent used to maintain cardiac output, has a long-lasting effect, and may have the potential benefit for VA-ECMO weaning. The study aimed to explore the relationship between the early use of levosimendan and the rate of VA-ECMO weaning failure in patients on VA-ECMO support for circulatory failure. Methods All patients who underwent VA-ECMO in our hospital for CS between January 2017 and December 2020 were recruited in this cohort study and divided into two groups: without and with levosimendan use. Levosimendan was used as an add-on to other inotropic agents as early as possible after VA-ECMO setting. The primary endpoint was VA-ECMO weaning success, which was defined as survival without events for 24 h after VA-ECMO withdrawl. The secondary outcomes were cardiovascular and all-cause mortality at the 30-day and 180-day follow-up periods post-VA-ECMO initialization. Results A total of 159 patients were recruited for our study; 113 patients were enrolled in the without levosimendan-use group and 46 patients were enrolled in the levosimendan-use group. In levosimendan-use group, the patients received levosimendan infusion within 24 h after VA-ECMO initialization. Similar hemodynamic parameters were noted between the two groups. Poorer left ventricular ejection fraction and a higher prevalence of intra-aortic balloon pumping were observed in the levosimendan group. An improved weaning rate (without vs. with: 48.7 vs. 82.6%; p < 0.001), lower in-hospital mortality rate (without vs. with: 68.1 vs. 43.5%; p = 0.007), and 180-day cardiovascular mortality (without vs. with: 75.3 vs. 43.2%; p < 0.001) were also noted. Patients administered with levosimendan also presented a lower rate of 30-day (without vs. with: 75.3 vs. 41.3%; p = 0.034) and 180-day (without vs. with: 77.0 vs. 43.2%; p < 0.001) all-cause mortality. Conclusion Early levosimendan administration may contribute to increasing the success rate of VA-ECMO weaning and may help to decrease CV and all-cause mortality.
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Affiliation(s)
- Yu-Wen Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wei-Chieh Lee
- College of Medicine, Institute of Clinical Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Cardiovascular Medicine, Chi-Mei Medical Center, Tainan, Taiwan
- *Correspondence: Wei-Chieh Lee,
| | - Po-Jui Wu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsiu-Yu Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yen-Nan Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Huang-Chung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Meng-Shen Tong
- Division of Cardiology, Department of Internal Medicine, Fangliao General Hospital, Pingtung, Taiwan
| | - Pei-Hsun Sung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chieh-Ho Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wen-Jung Chung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Kaddoura R, Elmoheen A, Badawy E, Eltawagny MF, Seif MA, Bashir K, Salam AM. Vasoactive pharmacologic therapy in cardiogenic shock: a critical review. J Drug Assess 2021; 10:68-85. [PMID: 34350058 PMCID: PMC8293961 DOI: 10.1080/21556660.2021.1930548] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background Cardiogenic shock (CS) is an acute complex condition leading to morbidity and mortality. Vasoactive medications, such as vasopressors and inotropes are considered the cornerstone of pharmacological treatment of CS to improve end-organ perfusion by increasing cardiac output (CO) and blood pressure (BP), thus preventing multiorgan failure. Objective A critical review was conducted to analyze the currently available randomized studies of vasoactive agents in CS to determine the indications of each agent and to critically appraise the methodological quality of the studies. Methods PubMed database search was conducted to identify randomized controlled trials (RCTs) on vasoactive therapy in CS. After study selection, the internal validity of the selected studies was critically appraised using the three-item Jadad scale. Results Nine studies randomized 2388 patients with a mean age ranged between 62 and 69 years, were identified. Seven of studies investigated CS in the setting of acute myocardial infarction (AMI). The studies evaluated the comparisons of norepinephrine (NE) vs. dopamine, epinephrine vs. NE, levosimendan vs. dobutamine, enoximone or placebo, and nitric oxide synthase inhibitors (NOSi) vs. placebo. The mean Jadad score of the nine studies was 3.33, with only three studies of a score of 5. Conclusions The evidence from the studies of vasoactive agents in CS carries uncertainties. The methodological quality between the studies is variable due to the inherent difficulties to conduct a study in CS. Vasopressors and inotropes continue to have a fundamental role given the lack of pharmacological alternatives.
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Affiliation(s)
- Rasha Kaddoura
- Heart Hospital Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Amr Elmoheen
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Ehab Badawy
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Mohamed A Seif
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Khalid Bashir
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Amar M Salam
- College of Medicine, QU Health, Qatar University, Doha, Qatar.,Adult Cardiology, Hamad Medical Corporation, Doha, Qatar
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Comparison of Circulatory Unloading Techniques for Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J 2021; 67:623-631. [PMID: 33074863 DOI: 10.1097/mat.0000000000001268] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Left ventricular (LV) distention and pulmonary congestion are major complications inherent to venoarterial extracorporeal membrane oxygenation (ECMO). This study aimed to quantitatively compare the hemodynamic differences between common circulatory unloading methods for ECMO. Ten circulatory unloading techniques were evaluated on a mock circulatory loop simulating acute LV failure supported by ECMO. Simulated unloading techniques included: surgical and percutaneous pulmonary artery (PA) venting, surgical left atrial venting, surgical and percutaneous LV venting, atrial septal defect, partial support ventricular assist device, intraaortic balloon pump, and temporary VAD with inline oxygenator (tVAD). The most LV unloading occurred with the surgically placed LV vent and tVAD, which reduced LV end-diastolic volume from 295 to 167 ml and 82 ml, respectively. Meanwhile, the PA surgical vent was the most effective at reducing mean PA pressure from 21.0 to 10.6 mm Hg, and the tVAD was most effective at reducing left atrial pressure from 13.3 to 4.4 mm Hg. The major limitation of this study was the use of a mock circulatory loop, which simulated lower left atrial pressure than is typically seen clinically. This study identified clinically significant hemodynamic variability between the different circulatory unloading techniques evaluated. However, the applicability of these techniques will vary with different patient disease etiology. Further studies on ECMO unloading will help to quantify hemodynamic benefits and establish treatment guidelines.
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[Cardiogenic shock]. Wien Klin Wochenschr 2020; 132:333-348. [PMID: 32095880 DOI: 10.1007/s00508-020-01612-1] [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: 10/24/2022]
Abstract
Cardiogenic shock (CS) is defined as end-organ hypoperfusion as the consequence of primary myocardial dysfunction. Among the diagnostic criteria are a systolic blood pressure < 90 mmHg, acute renal failure (oligoanuria), ischemic hepatitis, cyanosis and cold, clammy skin. Accepted hemodynamic cutoffs are a cardiac index < 2,2 (l/min)/m2 and a pulmonary capillary wedge pressure > 15 mmHg. It should be acknowledged, that a normal blood pressure does not rule out CS; there is a nonhypotensive variant of CS demonstrating all the signs mentioned above (including elevated lactate levels) while the blood pressure is compensated due to vasoconstriction.The single most frequent cause of CS is pump failure in the setting of an acute myocardial infarction and its mortality rate has been lowered to 40-50%, owing to the widespread availability of primary PCI. Regarding PCI, it has been demonstrated recently that a "culprit-lesion only strategy" should be followed in the setting of CS. Other important causes of CS to take into account are mechanical complications of myocardial infarction (papillary and ventricular septal rupture as well as rupture of the myocardial free wall leading to tamponade), valvular heart disease (mostly decompensated aortic stenosis) as well as myocarditis and end stage cardiomyopathy.The diagnosis of CS is made by patient history, physical examination, ECG, echocardiography and coronary angiography. Echocardiography should always be performed before coronary angiography because, in the case of mechanical complications, it significantly alters the management of the patients. Patients with clinical signs of CS but paradoxically preserved ejection fraction must be thoroughly evaluated for the presence of a papillary muscle rupture, particularly in the setting of a lateral wall infarction.Noradrenaline and dobutamine are the first-line agents for medical stabilization. When such conventional measures fail, extracorporeal support devices such as ECMO or Impella© may be used. Currently, trials are underway to assess wheter these devices confer a survival benefit in this high-risk population.
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Grossini E, Farruggio S, Pierelli D, Bolzani V, Rossi L, Pollesello P, Monaco C. Levosimendan Improves Oxidative Balance in Cardiogenic Shock/Low Cardiac Output Patients. J Clin Med 2020; 9:jcm9020373. [PMID: 32019057 PMCID: PMC7073614 DOI: 10.3390/jcm9020373] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/22/2020] [Accepted: 01/25/2020] [Indexed: 12/16/2022] Open
Abstract
The beneficial effects exerted by levosimendan against cardiac failure could be related to the modulation of oxidative balance. We aimed to examine the effects of levosimendan in patients with cardiogenic shock or low cardiac output on cardiac systo-diastolic function and plasma oxidants/antioxidants (glutathione, GSH; thiobarbituric acid reactive substances, TBARS). In four patients undergoing coronary artery bypass grafting or angioplasty, cardiovascular parameters and plasma GSH and TBARS were measured at T0 (before levosimendan infusion), T1 (1 h after the achievement of the therapeutic dosage of levosimendan), T2 (end of levosimendan infusion), T3 (72 h after the end of levosimendan infusion), and T4 (end of cardiogenic shock). We found an improvement in the indices of systolic (ejection fraction, cardiac output, cardiac index) and diastolic (E to early diastolic mitral annular tissue velocity, E/'; early to late diastolic transmitral flow velocity, EA) cardiac function at early T2. A reduction of central venous pressure and pulmonary wedge pressure was also observed. Plasma levels of GSH and TBARS were restored by levosimendan at T1, as well. The results obtained indicate that levosimendan administration can regulate oxidant/antioxidant balance as an early effect in cardiogenic shock/low cardiac output patients. Modulation of oxidative status on a mitochondrial level could thus play a role in exerting the cardio-protection exerted by levosimendan in these patients.
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Affiliation(s)
- Elena Grossini
- Laboratory of Physiology, Department of Translational Medicine, UPO, 28100 Novara, Italy;
- Correspondence: ; Tel.: +390321660526; Fax: +3903213733537
| | - Serena Farruggio
- Laboratory of Physiology, Department of Translational Medicine, UPO, 28100 Novara, Italy;
| | - Daniele Pierelli
- Cardiothoracic Intensive Care Unit, AOU, 28100 Novara, Italy; (D.P.); (C.M.)
| | | | - Lidia Rossi
- Cardiology Division, AOU, 28100 Novara, Italy; (V.B.); (L.R.)
| | | | - Carolina Monaco
- Cardiothoracic Intensive Care Unit, AOU, 28100 Novara, Italy; (D.P.); (C.M.)
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Schumann J, Henrich EC, Strobl H, Prondzinsky R, Weiche S, Thiele H, Werdan K, Frantz S, Unverzagt S. Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev 2018; 1:CD009669. [PMID: 29376560 PMCID: PMC6491099 DOI: 10.1002/14651858.cd009669.pub3] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cardiogenic shock (CS) and low cardiac output syndrome (LCOS) as complications of acute myocardial infarction (AMI), heart failure (HF) or cardiac surgery are life-threatening conditions. While there is a broad body of evidence for the treatment of people with acute coronary syndrome under stable haemodynamic conditions, the treatment strategies for people who become haemodynamically unstable or develop CS remain less clear. We have therefore summarised here the evidence on the treatment of people with CS or LCOS with different inotropic agents and vasodilative drugs. This is the first update of a Cochrane review originally published in 2014. OBJECTIVES To assess efficacy and safety of cardiac care with positive inotropic agents and vasodilator strategies in people with CS or LCOS due to AMI, HF or cardiac surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CPCI-S Web of Science in June 2017. We also searched four registers of ongoing trials and scanned reference lists and contacted experts in the field to obtain further information. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials in people with myocardial infarction, heart failure or cardiac surgery complicated by cardiogenic shock or LCOS. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We identified 13 eligible studies with 2001 participants (mean or median age range 58 to 73 years) and two ongoing studies. We categorised studies into eight comparisons, all against cardiac care and additional other active drugs or placebo. These comparisons investigated the efficacy of levosimendan versus dobutamine, enoximone or placebo, epinephrine versus norepinephrine-dobutamine, amrinone versus dobutamine, dopexamine versus dopamine, enoximone versus dopamine and nitric oxide versus placebo.All trials were published in peer-reviewed journals, and analysis was done by the intention-to-treat (ITT) principle. Twelve of 13 trials were small with few included participants. Acknowledgement of funding by the pharmaceutical industry or missing conflict of interest statements emerged in five of 13 trials. In general, confidence in the results of analysed studies was reduced due to serious study limitations, very serious imprecision or indirectness. Domains of concern, which show a high risk of more than 50%, include performance bias (blinding of participants and personnel) and bias affecting the quality of evidence on adverse events.Levosimendan may reduce short-term mortality compared to a therapy with dobutamine (RR 0.60, 95% CI 0.37 to 0.95; 6 studies; 1776 participants; low-quality evidence; NNT: 16 (patients with moderate risk), NNT: 5 (patients with CS)). This initial short-term survival benefit with levosimendan vs. dobutamine is not confirmed on long-term follow up. There is uncertainty (due to lack of statistical power) as to the effect of levosimendan compared to therapy with placebo (RR 0.48, 95% CI 0.12 to 1.94; 2 studies; 55 participants, very low-quality evidence) or enoximone (RR 0.50, 95% CI 0.22 to 1.14; 1 study; 32 participants, very low-quality evidence).All comparisons comparing other positive inotropic, inodilative or vasodilative drugs presented uncertainty on their effect on short-term mortality with very low-quality evidence and based on only one RCT. These single studies compared epinephrine with norepinephrine-dobutamine (RR 1.25, 95% CI 0.41 to 3.77; 30 participants), amrinone with dobutamine (RR 0.33, 95% CI 0.04 to 2.85; 30 participants), dopexamine with dopamine (no in-hospital deaths from 70 participants), enoximone with dobutamine (two deaths from 40 participants) and nitric oxide with placebo (one death from three participants). AUTHORS' CONCLUSIONS Apart from low quality of evidence data suggesting a short-term mortality benefit of levosimendan compared with dobutamine, at present there are no robust and convincing data to support a distinct inotropic or vasodilator drug-based therapy as a superior solution to reduce mortality in haemodynamically unstable people with cardiogenic shock or LCOS.Considering the limited evidence derived from the present data due to a generally high risk of bias and imprecision, it should be emphasised that there remains a great need for large, well-designed randomised trials on this topic to close the gap between daily practice in critical care medicine and the available evidence. It seems to be useful to apply the concept of 'early goal-directed therapy' in cardiogenic shock and LCOS with early haemodynamic stabilisation within predefined timelines. Future clinical trials should therefore investigate whether such a therapeutic concept would influence survival rates much more than looking for the 'best' drug for haemodynamic support.
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Affiliation(s)
- Julia Schumann
- Martin‐Luther‐University Halle‐WittenbergDepartment of Anaesthesiology and Surgical Intensive CareHalle/SaaleGermany
| | - Eva C Henrich
- Martin‐Luther‐University Halle‐WittenbergInstitute of Medical Epidemiology, Biostatistics and InformaticsHalle/SaaleGermany06112
| | - Hellen Strobl
- Martin‐Luther‐University Halle‐WittenbergInstitute of Medical Epidemiology, Biostatistics and InformaticsHalle/SaaleGermany06112
| | - Roland Prondzinsky
- Carl von Basedow Klinikum MerseburgCardiology/Intensive Care MedicineWeisse Mauer 42MerseburgGermany06217
| | - Sophie Weiche
- Martin‐Luther‐University Halle‐WittenbergDepartment of Internal Medicine IIIHalle/SaaleGermany
| | - Holger Thiele
- University Clinic Schleswig‐Holstein, Campus LübeckMedical Clinic II (Kardiology, Angiology, Intensive Care Medicine)Ratzeburger Allee 160LubeckD‐23538Germany
| | - Karl Werdan
- Martin‐Luther‐University Halle‐WittenbergDepartment of Internal Medicine IIIHalle/SaaleGermany
| | - Stefan Frantz
- Martin‐Luther‐University Halle‐WittenbergDepartment of Internal Medicine IIIHalle/SaaleGermany
| | - Susanne Unverzagt
- Martin‐Luther‐University Halle‐WittenbergInstitute of Medical Epidemiology, Biostatistics and InformaticsHalle/SaaleGermany06112
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Nuding S, Werdan K, Prondzinsky R. Optimal course of treatment in acute cardiogenic shock complicating myocardial infarction. Expert Rev Cardiovasc Ther 2018; 16:99-112. [PMID: 29310471 DOI: 10.1080/14779072.2018.1425141] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION About 5% of patients with myocardial infarction suffer from cardiogenic shock as a complication, with a mortality of ≥30%. Primary percutaneous coronary intervention as soon as possible is the most successful therapeutic approach. Prognosis depends not only on the extent of infarction, but also - and even more - on organ hypoperfusion with consequent development of multiple organ dysfunction syndrome. Areas covered: This review covers diagnostic, monitoring and treatment concepts relevant for caring patients with cardiogenic shock complicating myocardial infarction. All major clinical trials have been selected for review of the recent data. Expert commentary: For optimal care, not only primary percutaneous intervention of the occluded coronary artery is necessary, but also best intensive care medicine avoiding the development of multiple organ dysfunction syndrome and finally death. On contrary, intra-aortic balloon pump - though used for decades - is unable to reduce mortality of patients with cardiogenic shock complicating myocardial infarction.
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Affiliation(s)
- Sebastian Nuding
- a Department of Medicine III , University Hospital Halle (Saale) , Halle (Saale) , Germany
| | - Karl Werdan
- a Department of Medicine III , University Hospital Halle (Saale) , Halle (Saale) , Germany
| | - Roland Prondzinsky
- b Department of Medicine I , Carl-von-Basedow Hospital Merseburg , Germany
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Cornejo-Avendaño J, Azpiri-López J, Ramírez-Rosales A. Levosimendan in acute decompensated heart failure: Systematic review and meta-analysis. MEDICINA UNIVERSITARIA 2017. [DOI: 10.1016/j.rmu.2017.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Lemm H, Dietz S, Janusch M, Buerke M. Einsatz von Vasopressoren und Inotropika im kardiogenen Schock. Herz 2017; 42:3-10. [DOI: 10.1007/s00059-016-4525-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Onody P, Aranyi P, Turoczi Z, Stangl R, Fulop A, Dudas E, Lotz G, Szijarto A. Levosimendan Administration in Limb Ischemia: Multicomponent Signaling Serving Kidney Protection. PLoS One 2016; 11:e0163675. [PMID: 27684548 PMCID: PMC5042425 DOI: 10.1371/journal.pone.0163675] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/11/2016] [Indexed: 11/19/2022] Open
Abstract
Aims and Objectives Acute renal failure is a severe complication of lower extremity major arterial reconstructions, which could even be fatal. Levosimendan is a dual-acting positive inotropic and vasodilatory agent, which is suspected to have protective effects against cardiac ischemia. However, there is no data available on lower limb or remote organ ischemic injuries therefore the aim of the study was to investigate the effect of levosimendan on lower limb ischemia-reperfusion injury and the corollary renal dysfunction. Methods Male Wistar rats underwent 180 min bilateral lower limb ischemia followed by 4 or 24 hours of reperfusion. Intravenous Levosimendan was administered continuously (0.2μg/bwkg/min) throughout the whole course of ischemia and the first 3h of reperfusion. Results were compared with sham-operated and ischemia-reperfusion groups. Hemodynamic monitoring was performed by invasive arterial blood pressure measurement. Kidney and lower limb muscle microcirculation was registered by a laser Doppler flowmeter. After 4h and 24h of reperfusion, serum, urine and histological samples were collected. Results Systemic hemodynamic parameters and microcirculation of kidney and the lower limb significantly improved in the Levosimendan treated group. Muscle viability was significantly preserved 4 and 24 hours after reperfusion. At the same time, renal functional laboratory tests and kidney histology demonstrated significantly less expressive kidney injury in Levosimendan groups. TNF-α levels were significantly less elevated in the Levosimendan group 4 hours after reperfusion. Conclusion The results claim a protective role for Levosimendan administration during major vascular surgeries to prevent renal complications.
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Affiliation(s)
- Peter Onody
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Peter Aranyi
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Zsolt Turoczi
- 2 Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Rita Stangl
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Andras Fulop
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Emese Dudas
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Gabor Lotz
- 2 Department of Pathology, Semmelweis University, Budapest, Hungary
| | - Attila Szijarto
- 1 Department of Surgery, Semmelweis University, Budapest, Hungary
- * E-mail:
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Labbene I, Arrigo M, Tavares M, Hajjej Z, Brandão JL, Tolppanen H, Feliot E, Gayat E, Ferjani M, Mebazaa A. Decongestive effects of levosimendan in cardiogenic shock induced by postpartum cardiomyopathy. Anaesth Crit Care Pain Med 2016; 36:39-42. [PMID: 27436451 DOI: 10.1016/j.accpm.2016.02.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 02/22/2016] [Accepted: 02/24/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Catecholamines and/or levosimendan have been proposed for haemodynamic restoration during cardiogenic shock (CS). In CS induced by post-partum cardiomyopathy (PPCM), levosimendan might be particularly favourable. The aim of this study was to evaluate the haemodynamic and echocardiographic effects of levosimendan in patients with CS, in particular in patients with PPCM-induced CS. METHODS Twenty-eight patients with refractory CS were retrospectively included in the study. Among them, a cohort of 8 women with PPCM-induced CS was included. All patients were treated with levosimendan (loading dose followed by a continuous infusion for 24 h) and were invasively monitored, including a pulmonary artery catheter, for 48hours. Echocardiographic measurements were performed at baseline and during follow-up. RESULTS Significant improvements in haemodynamic parameters were observed 48 h after starting levosimendan. The cardiac index increased (+1.2±0.6L/min, P<0.001) and filling pressures decreased (pulmonary artery occlusion pressure, PAOP: -11.2±4.3mmHg, P<0.001; right-atrial pressure, RAP: -6.1±4.9mmHg, P<0.001). The left ventricular ejection fraction was significantly higher at 48 h compared to baseline (38% [34-46%] versus 27% [22-30%], P<0.001). Despite similar characteristics at baseline, in the subgroup of patients with PPCM, more profound decongestive effects at 48hours were observed: PAOP (13±2 versus 17±4mmHg, P=0.007) and RAP (12±4 versus 17±4mmHg, P=0.006) were significantly lower in the PPCM subgroup compared to the non-PPCM subgroup. CONCLUSIONS Haemodynamics and left-ventricular ejection fraction rapidly improved after treatment with levosimendan. In patients with PPCM-induced CS, a more profound reduction of congestion was observed.
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Affiliation(s)
- I Labbene
- University of Tunis El Manar, department of anaesthesiology and critical care medicine, military hospital of Tunis, Tunis, Tunisia.
| | - M Arrigo
- Inserm UMR-S 942, Paris, France.
| | - M Tavares
- Serviço de cuidados intensivos, departamento de anestesia cuidados intensivos e emergência, hospital de Santo António, centro hospitalar do Porto, Porto, Portugal.
| | - Z Hajjej
- University of Tunis El Manar, department of anaesthesiology and critical care medicine, military hospital of Tunis, Tunis, Tunisia.
| | - J L Brandão
- Serviço de cuidados intensivos, departamento de anestesia cuidados intensivos e emergência, hospital de Santo António, centro hospitalar do Porto, Porto, Portugal.
| | | | - E Feliot
- Inserm UMR-S 942, Paris, France.
| | - E Gayat
- Inserm UMR-S 942, Paris, France; Université Paris Diderot, PRES Sorbonne Paris Cité, department of anaesthesiology and critical care medicine, AP-HP, Saint-Louis Lariboisière university hospitals, 2, rue Ambroise-Paré, 75010 Paris, France.
| | - M Ferjani
- University of Tunis El Manar, department of anaesthesiology and critical care medicine, military hospital of Tunis, Tunis, Tunisia.
| | - A Mebazaa
- Inserm UMR-S 942, Paris, France; Université Paris Diderot, PRES Sorbonne Paris Cité, department of anaesthesiology and critical care medicine, AP-HP, Saint-Louis Lariboisière university hospitals, 2, rue Ambroise-Paré, 75010 Paris, France.
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Lemm H, Dietz S, Janusch M, Buerke M. [Modern drug therapy in cardiovascular intensive care medicine]. Internist (Berl) 2016; 56:702, 704-8, 710-2. [PMID: 26054838 DOI: 10.1007/s00108-015-3717-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Vasoactive drugs and inotropes are important in the hemodynamic management of patients with cardiogenic shock despite modest volume administration. Currently, the concept of cardiac relief is pursued in the treatment of acute heart failure. In this article we present the use of different drugs in the intensive care unit for acute heart failure and cardiogenic shock. In acute heart failure catecholamines are only used during the transition from heart failure to cardiogenic shock. Here, the therapeutic concept of ventricular unloading is more sought after. This can be achieved by the use of diuretics, nitrates, levosimendan (inodilatator), or in the future serelaxin. The hemodynamic management in cardiogenic shock occurs after moderate volume administration with dobutamine to increase inotropy. If no adequate perfusion pressures are achieved, norepinephrine can be administered as a vasopressor. If there is still no sufficient increase in cardiac output, the inodilatator levosimendan can be used. Levosimendan instead of phosphodiesterase inhibitors in this case is preferable. The maxim of hemodynamic management in cardiogenic shock is the transient use of inotropes and vasopressors in the lowest dose possible and only for as long as necessary. This means that one should continuously check whether the dose can be reduced. There are no mortality data demonstrating the utility of hemodynamic monitoring based on objective criteria—but it makes sense to use inotropes and vasopressors sparingly.
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Affiliation(s)
- H Lemm
- Medizinische Klinik II - Kardiologie, Angiologie, Internistische Intensivmedizin, St. Marienkrankenhaus Siegen, Kampenstr. 51, 57072, Siegen, Deutschland
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15
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Alvarez Escudero J, Calvo Vecino JM, Veiras S, García R, González A. Clinical Practice Guideline (CPG). Recommendations on strategy for reducing risk of heart failure patients requiring noncardiac surgery: reducing risk of heart failure patients in noncardiac surgery. ACTA ACUST UNITED AC 2015; 62:359-419. [PMID: 26164471 DOI: 10.1016/j.redar.2015.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/04/2015] [Indexed: 12/29/2022]
Affiliation(s)
- J Alvarez Escudero
- Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain
| | - J M Calvo Vecino
- Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain; Associated Professor and Head of the Department of Anesthesiology, Infanta Leonor University Hospital, Complutense University of Madrid, Madrid, Spain.
| | - S Veiras
- Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain
| | - R García
- Department of Anesthesiology, Puerta del Mar University Hospital. Cadiz, Spain
| | - A González
- Department of Anesthesiology, Puerta de Hierro University Hospital. Madrid, Spain
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16
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Li H, Ge J. Cardiovascular diseases in China: Current status and future perspectives. IJC HEART & VASCULATURE 2015; 6:25-31. [PMID: 28785622 PMCID: PMC5497168 DOI: 10.1016/j.ijcha.2014.10.002] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 10/01/2014] [Indexed: 01/04/2023]
Abstract
Despite revolutionary advancement in medicine over the past century, cardiovascular disease (CVD) remains the leading cause of death and disability in the world. Likewise, the morbidity and mortality of CVD in China are increasing persistently, although the government has taken an active part in the prevention and control of CVD. Here we present an overview regarding the current CVD status in China with respect to various disease phenotypes, as well as the anticipated future trend in accordance with the dynamics and distribution of pathogenesis in Chinese actual situations.
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Affiliation(s)
- Hua Li
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai 200032, China
- Institutes of Biomedical Sciences, Fudan University, Shanghai 200032, China
| | - Junbo Ge
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai 200032, China
- Institutes of Biomedical Sciences, Fudan University, Shanghai 200032, China
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17
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Fröhlich G, Pibernik A, Ferrari M. ["Bridge to recovery"- implantation of an Impella® CP in infarct-related cardiogenic shock]. Med Klin Intensivmed Notfmed 2014; 110:225-30. [PMID: 25366887 DOI: 10.1007/s00063-014-0426-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 09/04/2014] [Accepted: 09/08/2014] [Indexed: 10/24/2022]
Abstract
We present the case of a 43-year-old man with the diagnosis of a posterior and anterior wall infarction who was taken to our institution after prolonged cardioplumonary resuscitation. Cardiac catheterization showed thrombotic occlusion of the LAD and a subtotal stenosis of the right coronary artery. Both lesions were revascularized by PCI. Despite catecholamine infusion, the patient developed severe cardiogenic shock with multiorgan dysfunction syndrome under therapeutic hypothermia. Thus, an Impella® CP, a percutaneous left ventricular assist device (LVAD), was implanted. Due to effective LVAD support, it was possible to wean and remove the device after 75 h of support. The impaired left ventricular ejection fraction and wall-motion abnormalities which were present on day 1 achieved complete recuperation on day 14. The patient was discharged without any neurological deficits.
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Affiliation(s)
- G Fröhlich
- Medizinische Klinik I, Dr. Horst Schmidt Kliniken (HSK) Wiesbaden, Ludwig-Erhard-Str. 100, 65199, Wiesbaden, Deutschland,
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18
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[Treatment of cardiogenic shock complicating acute myocardial infarction]. Herz 2014; 39:702-10. [PMID: 25006075 DOI: 10.1007/s00059-014-4124-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
While the mortality rate of acute myocardial infarction has decreased drastically in the last decades, the outcome of patients with cardiogenic shock complicating acute myocardial infarction is still devastating. The effectiveness of supportive medicinal therapy of cardiogenic shock is often limited by undesired side effects (e.g. arrhythmia and increased myocardial oxygen consumption) or inadequate hemodynamic support. Mechanical circulatory support in cardiogenic shock failed to show beneficial effects on short-term and long-term survival; however, there are hints for a survival benefit in therapy refractory cardiogenic shock. Therefore, future trials need to evaluate further medicinal treatment options and also the best type of mechanical support as well as the optimal time of initiation to improve the success of therapeutic management.
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Pierrakos C, Velissaris D, Franchi F, Muzzi L, Karanikolas M, Scolletta S. Levosimendan in critical illness: a literature review. J Clin Med Res 2014; 6:75-85. [PMID: 24578748 PMCID: PMC3935527 DOI: 10.14740/jocmr1702w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2013] [Indexed: 01/30/2023] Open
Abstract
Levosimendan, the active enantiomer of simendan, is a calcium sensitizer developed for treatment of decompensated heart failure, exerts its effects independently of the beta adrenergic receptor and seems beneficial in cases of severe, intractable heart failure. Levosimendan is usually administered as 24-h infusion, with or without a loading dose, but dosing needs adjustment in patients with severe liver or renal dysfunction. Despite several promising reports, the role of levosimendan in critical illness has not been thoroughly evaluated. Available evidence suggests that levosimendan is a safe treatment option in critically ill patients and may reduce mortality from cardiac failure. However, data from well-designed randomized controlled trials in critically ill patients are needed to validate or refute these preliminary conclusions. This literature review is an attempt to synthesize available evidence on the role and possible benefits of levosimendan in critically ill patients with severe heart failure.
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Affiliation(s)
- Charalampos Pierrakos
- Department of Intensive Care, Universite Catholique de Louvain, Mont-Godinne University Hospital, Yvoir 5530, Belgium
| | - Dimitrios Velissaris
- Department of Internal Medicine, University of Patras School of Medicine, Patras, Greece
| | - Federico Franchi
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Luigi Muzzi
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Menelaos Karanikolas
- Department of Anesthesiology, Washington University School of Medicine, Campus Box 8054, 660 S. Euclid Avenue, St. Louis, MO, USA
| | - Sabino Scolletta
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
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Husebye T, Eritsland J, Müller C, Sandvik L, Arnesen H, Seljeflot I, Mangschau A, Bjørnerheim R, Andersen GØ. Levosimendan in acute heart failure following primary percutaneous coronary intervention-treated acute ST-elevation myocardial infarction. Results from the LEAF trial: a randomized, placebo-controlled study. Eur J Heart Fail 2014; 15:565-72. [DOI: 10.1093/eurjhf/hfs215] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Trygve Husebye
- Department of Cardiology; Oslo University Hospital Ullevål; Norway
- Center for Heart Failure Research; University of Oslo; Norway
- Faculty of Medicine; University of Oslo; Norway
| | - Jan Eritsland
- Department of Cardiology; Oslo University Hospital Ullevål; Norway
- Center for Heart Failure Research; University of Oslo; Norway
| | - Carl Müller
- Section for Nuclear Medicine; Oslo University Hospital Ullevål; Norway
| | - Leiv Sandvik
- Biostatistic and Epidemiology Unit; Oslo University Hospital Ullevål; Norway
- Center for Clinical Heart Research; Oslo University Hospital Ullevål; Norway
| | - Harald Arnesen
- Center for Heart Failure Research; University of Oslo; Norway
- Faculty of Medicine; University of Oslo; Norway
- Center for Clinical Heart Research; Oslo University Hospital Ullevål; Norway
| | - Ingebjørg Seljeflot
- Center for Heart Failure Research; University of Oslo; Norway
- Faculty of Medicine; University of Oslo; Norway
- Center for Clinical Heart Research; Oslo University Hospital Ullevål; Norway
| | - Arild Mangschau
- Department of Cardiology; Oslo University Hospital Ullevål; Norway
- Center for Heart Failure Research; University of Oslo; Norway
| | - Reidar Bjørnerheim
- Department of Cardiology; Oslo University Hospital Ullevål; Norway
- Center for Heart Failure Research; University of Oslo; Norway
| | - Geir Øystein Andersen
- Department of Cardiology; Oslo University Hospital Ullevål; Norway
- Center for Heart Failure Research; University of Oslo; Norway
- Center for Clinical Heart Research; Oslo University Hospital Ullevål; Norway
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22
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Caetano F, Mota P, Barra S, Almeida I, Botelho A, Trigo J, Marques AL. Use of levosimendan in critically ill patients with severe aortic stenosis and left ventricular dysfunction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2013; 1:281-4. [PMID: 24062918 DOI: 10.1177/2048872612467294] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 10/18/2012] [Indexed: 11/15/2022]
Abstract
Congestive heart failure and left ventricular dysfunction in the setting of severe aortic stenosis are associated with a high mortality rate. Evidence on optimal medical therapy is scanty. Vasodilators were traditionally considered to be contraindicated in severe aortic stenosis, albeit this concept has recently been challenged. The use of levosimendan, which has positive inotropic, vasodilatory and cardioprotective properties seems attractive. We describe a small series of exceedingly ill patients with severe aortic stenosis and left ventricular dysfunction, in different clinical settings (acute heart failure, cardiogenic shock and difficult-to-wean ventilatory support), in which levosimendan was successfully used.
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Affiliation(s)
- Francisca Caetano
- Cardiology Department, Coimbra Hospital and University Centre, Portugal
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23
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Kardiogener Schock. Herz 2013; 38:173-86; quiz 187-8. [DOI: 10.1007/s00059-013-3770-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Cardiogenic shock is most commonly a complication of acute myocardial infarction. The ischemic loss of functional myocardium triggers distinct cardiovascular responses which can deteriorate to global pump failure with a mortality rate of more than 50%. Causes of cardiogenic shock beyond myocardial ischemia are very diverse. Decisive management with rapid evaluation, identification of the underlying disease and urgent initiation of supportive measures as well as definitive therapy is of prognostic value. Causal treatment of the cardiac disease is crucial but has to be weighed against the specific surgical circumstances of perioperative patients, particularly concerning anticoagulation, platelet inhibition and bleeding risks. Hemodynamic stabilization is achieved by pharmacological support of myocardial function, control of arrhythmia and volume load. Prevention and intensive care of shock-related multiorgan failure is of pivotal importance in the successful management of cardiogenic shock.
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Affiliation(s)
- S Rasche
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinik Dresden, Deutschland.
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25
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Deutsch-österreichische S3-Leitlinie „Infarktbedingter kardiogener Schock – Diagnose, Monitoring und Therapie“. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/s00390-011-0284-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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26
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Essential lessons in cardiogenic shock: epinephrine versus norepinephrine/dobutamine. Crit Care Med 2011; 39:583-4. [PMID: 21330855 DOI: 10.1097/ccm.0b013e318208e381] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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27
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Buerke M, Lemm H, Dietz S, Werdan K. Pathophysiology, diagnosis, and treatment of infarction-related cardiogenic shock. Herz 2011; 36:73-83. [DOI: 10.1007/s00059-011-3434-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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28
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Mathieu S, Craig G. Levosimendan in the Treatment of Acute Heart Failure, Cardiogenic and Septic Shock: A Critical Review. J Intensive Care Soc 2011. [DOI: 10.1177/175114371101200106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Levosimendan is a drug which increases the sensitivity of the heart to calcium and which opens potassium channels, resulting in inodilation. Clinical trial data from patients suffering from heart failure have demonstrated that it improves haemodynamics without increasing intra-cellular calcium or oxygen consumption. However, there is no consistent evidence of mortality reduction. This narrative review summarises the key trials of its use in acute heart failure, acute coronary syndrome, cardiogenic shock and septic shock.
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Affiliation(s)
- Steve Mathieu
- Steve Mathieu Locum Consultant in Critical Care and Anaesthesia, The Royal Bournemouth Hospital
| | - Gordon Craig
- Gordon Craig Consultant in Critical Care and Anaesthesia, Queen Alexandra Hospital, Portsmouth
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Ouanes-Besbes L, Ouanes I, Dachraoui F, Dimassi S, Mebazaa A, Abroug F. Weaning difficult-to-wean chronic obstructive pulmonary disease patients: a pilot study comparing initial hemodynamic effects of levosimendan and dobutamine. J Crit Care 2010; 26:15-21. [PMID: 20381295 DOI: 10.1016/j.jcrc.2010.01.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 01/03/2010] [Accepted: 01/11/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE To compare the short-term hemodynamic effects of levosimendan and dobutamine in chronic obstructive pulmonary disease (COPD) patients experiencing weaning difficulties in relation with increased left ventricular filling pressure. MATERIALS AND METHODS This prospective, sequential, pilot study included 10 COPD patients experiencing weaning difficulties in relation with increased left ventricular filling pressure ascertained by an increase >10 mm Hg of pulmonary artery occlusion pressure (PAOP) at the shift from mechanical to spontaneous breathing (SB). Patients received 1 h infusion of 7 μg/kg per minute of dobutamine, followed by 24-hour infusion of 0.2 μg/kg per minute levosimendan. Hemodynamic variables were measured under MV and 15 to 30 minutes after SB at baseline, at the end of dobutamine infusion, at a washout period, and after levosimendan infusion. RESULTS At baseline, the shift from mechanical ventilation to spontaneous ventilation was associated with a significant increase in PAOP from a median of 15 (interquartile range [IQR], 6) to 29 (9) mm Hg. Both drugs reduced significantly the level of PAOP increase at SB, but levosimendan had a greater effect than dobutamine [median PAOP increase (IQR): 5 (2) vs 9 (4) mm Hg, respectively; P < .01]. CONCLUSIONS Both drugs reduced the magnitude of PAOP increase at SB in difficult-to-wean COPD patients. PAOP increase was reduced to a greater extent by levosimendan.
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31
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Tuseth V, Nordrehaug JE. Role of percutaneous left ventricular assist devices in preventing cerebral ischemia. Interv Cardiol 2009. [DOI: 10.2217/ica.09.27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Do it right? Crit Care Med 2009; 37:3168-9. [PMID: 19923936 DOI: 10.1097/ccm.0b013e3181b3a320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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den Uil CA, Lagrand WK, Valk SD, Spronk PE, Simoons ML. Management of Cardiogenic Shock: Focus on Tissue Perfusion. Curr Probl Cardiol 2009; 34:330-49. [DOI: 10.1016/j.cpcardiol.2009.04.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Greif M, Zwermann L, Reithmann C, Weis M. Levosimendan as rescue therapy in severe cardiogenic shock after ST-elevation myocardial infarction. ACTA ACUST UNITED AC 2009; 10:185-90. [DOI: 10.1080/17482940801935774] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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36
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Kurt IH. Use of levosimendan in patients with ischemic heart disease following mechanical reperfusion. Surg Today 2009; 39:381-6. [PMID: 19408074 DOI: 10.1007/s00595-008-3869-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Accepted: 10/29/2008] [Indexed: 11/30/2022]
Abstract
Cardiac failure is among the most significant conditions associated with acute coronary syndrome. In ischemic heart disease, serious hemodynamic problems are reported in patients with left ventricular dysfunction during the acute phase despite mechanical revascularization. Several positive inotropic agents in addition to intra-aortic balloon pump (IABP) are required to support patients with impaired left ventricular pump function during this phase. Intravenous inotropic agents, beta-mimetics, and phosphodiesterase inhibitors lead to increases in the incidence of arrhythmia and myocardial O(2) consumption owing to their effect of increasing intracellular calcium amount, although they produce rapid hemodynamic improvements in cardiac failure. This causes severe problems particularly in cardiac failure of ischemic origin. Recently, levosimendan, a calcium-sensitizing agent with cardioprotective properties, is being used alone or in combination with IABP in cases with severe left ventricular systolic dysfunction during mechanical revascularization procedures (percutaneous coronary interventions, coronary bypass surgery). This review includes studies with levosimendan in cases not recovering due to myocardial stunning in the acute phase despite mechanical approaches applied.
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Affiliation(s)
- Ibrahim Halil Kurt
- Department of Cardiology, Adana Numune Education and Research Hospital, Adana, Turkey
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37
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Rehberg S, Enkhbaatar P, Traber DL. Role of the Calcium Sensitizer, Levosimendan, in Perioperative Intensive Care Medicine. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Senz A, Nunnink L. Review article: inotrope and vasopressor use in the emergency department. Emerg Med Australas 2008; 21:342-51. [PMID: 19694785 DOI: 10.1111/j.1742-6723.2009.01210.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Shock is a common presentation to the ED, with the incidence of septic shock increasing in Australasia over the last decade. The choice of inotropic agent is likely dependent on previous experience and local practices of the emergency and other critical care departments. The relatively short duration of stay in the ED before transfer leaves little room for evaluating the appropriateness of and response to the agent chosen. Delays in transfer to inpatient facilities means that patients receive advanced critical care within the ED for longer, requiring initiation and titration of vasoactive agents in the ED. This article discusses the general concepts of shock and the indicators for inotrope and vasopressor use, revises the various agents available and reviews the current evidence for their use.
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Affiliation(s)
- Ainslie Senz
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD 4006, Australia.
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Levosimendan is superior to enoximone in refractory cardiogenic shock complicating acute myocardial infarction*. Crit Care Med 2008; 36:2257-66. [DOI: 10.1097/ccm.0b013e3181809846] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Soeding PE, Royse CF, Wright CE, Royse AG, Angus JA. Inoprotection: the perioperative role of levosimendan. Anaesth Intensive Care 2008; 35:845-62. [PMID: 18084975 DOI: 10.1177/0310057x0703500602] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Levosimendan is emerging as a novel cardioprotective inotrope. Levosimendan augments myocardial contractility by sensitising contractile myofilaments to calcium without increasing myosin adenosine triphosphatase activity or oxygen consumption. Levosimendan activates cellular adenosine triphosphate-dependent potassium channels, a mechanism which is postulated to protect cells from ischaemia in a manner similar to ischaemic preconditioning. Levosimendan may therefore protect the ischaemic myocardium during ischaemia-reperfusion as well as improve the contractile function of the heart. Adenosine triphosphate-dependent potassium channel activation by levosimendan may also be protective in other tissues, such as coronary vascular endothelium, kidney and brain. Clinical trials in patients with decompensated heart failure and myocardial ischaemia show levosimendan to improve haemodynamic performance and potentially improve survival. This paper reviews the known pharmacology of levosimendan, the clinical experience with the drug to date and the potential use of levosimendan as a cardioprotective agent during surgery.
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Affiliation(s)
- P E Soeding
- Cardiovascular Therapeutics Unit, Department of Pharmacology, University of Melbourne, Melbourne, Victoria, Australia
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Russ MA, Prondzinsky R, Christoph A, Schlitt A, Buerke U, Söffker G, Lemm H, Swyter M, Wegener N, Winkler M, Carter JM, Reith S, Werdan K, Buerke M. Hemodynamic improvement following levosimendan treatment in patients with acute myocardial infarction and cardiogenic shock*. Crit Care Med 2007; 35:2732-9. [PMID: 17893627 DOI: 10.1097/01.ccm.0000287524.17358.48] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Levosimendan, a novel inodilator, has been shown to improve hemodynamic function in patients with acute exacerbation of congestive heart failure. We wanted to determine the hemodynamic effects of levosimendan following ineffective conventional therapy (with catecholamines) in patients with cardiogenic shock following myocardial infarction. DESIGN Observational hemodynamic study. SETTING Tertiary care center university hospital. PATIENTS Fifty-six patients with cardiogenic shock secondary to myocardial infarction were treated with percutaneous revascularization (intra-aortic balloon pump where appropriate) and commenced on conventional inotropic therapy. INTERVENTIONS Patients with persisting cardiogenic shock 24 hrs after revascularization were additionally treated with levosimendan (rapid bolus of 12 microg/kg for 10 mins, then 0.05-0.2 mug/kg/min for 24 hrs) (n = 25). MEASUREMENTS AND MAIN RESULTS With conventional catecholamine therapy (norepinephrine and dobutamine), we observed only marginal improvement in mean arterial pressure or cardiac index. In contrast, the addition of levosimendan produced a significant increase in cardiac index (2.1 +/- 0.56 to 3.0 +/- 1.11 L/min/m2, p < .01) and cardiac power index (0.32 +/- 0.08 to 0.44 +/- 0.18 W, p < .01), whereas systemic vascular resistance decreased significantly (1208 +/- 333 to 858 +/- 299 dyne.sec.cm(-5), p < .01). There was no significant change in blood pressure during levosimendan treatment. Hemodynamic improvement was sustained after levosimendan infusion was stopped. CONCLUSIONS Levosimendan infusion in cardiogenic shock following acute myocardial infarction improved cardiovascular hemodynamics without leading to hypotension.
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Affiliation(s)
- Martin A Russ
- Department of Internal Medicine III, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
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Hemodynamic improvement following levosimendan treatment in patients with acute myocardial infarction and cardiogenic shock *. Crit Care Med 2007. [DOI: 10.1097/00003246-200712000-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Levosimendan in cardiogenic shock: The magic drug for every patient?*. Crit Care Med 2007. [DOI: 10.1097/00003246-200712000-00032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Buerke M, Russ M, Werdan K. [New pharmacological treatment approaches to cardiogenic shock]. Internist (Berl) 2007; 48:1442-9. [PMID: 18034221 DOI: 10.1007/s00108-007-1979-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Cardiogenic shock after acute myocardial infarction continues to exhibit a high mortality rate. The prognosis can be improved with acute revascularization. Use of the intra-aortic balloon pump is also an established treatment concept. Administration of catecholamines should be limited as far as possible; monitoring hemodynamic parameters based on cardiac power output or cardiac power index can be very helpful. New treatment approaches such as the calcium sensitizer levosimendan, NO synthase inhibition, complement inhibition, or vasopressin therapy have not yet yielded convincing results. Future therapies will likely address the anti-inflammatory aspect of cardiogenic shock.
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Affiliation(s)
- M Buerke
- Universitätsklinik und Poliklinik für Innere Medizin III, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Strasse 40, Halle, Germany.
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Rehberg S, Ertmer C, Van Aken H, Lange M, Bröking K, Morelli A, Westphal M. [Role of Levosimendan in intensive care treatment of myocardial insufficiency]. Anaesthesist 2007; 56:30-43. [PMID: 17131137 DOI: 10.1007/s00101-006-1108-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Levosimendan is a calcium sensitizer that is currently in the focus of intensive care medicine because it may be superior to standard inotropic agents in the treatment of acute myocardial insufficiency. The effects of levosimendan mainly depend on three predominant mechanisms: 1) positive inotropic effect by increasing the sensitivity of cardiac myofilaments to calcium ions, 2) vasodilatory effect by stimulation of adenosine triphosphate-sensitive potassium channels and 3) inhibition of phosphodiesterase-III. In a large number of experimental and clinical studies further possible indications for levosimendan have been described, e.g. cardioprotection during ischemia, cardiogenic shock, septic myocardial insufficiency and pulmonary hypertension. This review article critically summarizes the current scientific and clinical knowledge about levosimendan, its pharmacologic characteristics, mechanisms of action as well as indications and potential risks.
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Affiliation(s)
- S Rehberg
- Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum, Albert-Schweitzer-Strasse 33, 48149, Münster.
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Guarracino F, Cariello C, Danella A, Doroni L, Lapolla F, Stefani M, Baldassarri R, Vullo C. Effect of levosimendan on ventriculo-arterial coupling in patients with ischemic cardiomyopathy. Acta Anaesthesiol Scand 2007; 51:1217-24. [PMID: 17850562 DOI: 10.1111/j.1399-6576.2007.01428.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Levosimendan, a novel calcium sensitizer, enhances myocardial contractility without affecting intracellular calcium concentration. It also dilates peripheral arterial vessels by acting on ATP-dependent K(+) channels. Ventriculo-arterial coupling, the relationship between myocardial contractility and the arterial system, describes the efficiency of the cardiovascular system by analysing the relationship between myocardial contractility expressed by ventricular elastance (E(es)) and arterial elastance (E(a)). The aim of this prospective clinical investigation was to evaluate the effects of levosimendan on ventriculo-arterial coupling in patients with ischemic cardiomyopathy. METHODS Fifteen patients with stable angina and left ventricular dysfunction underwent elective coronary surgery. Before surgery started, ventriculo-arterial coupling and several variables of cardiovascular performance were assessed by invasive monitoring and transoesophageal echocardiography before and after administration of levosimendan (12 mug/kg bolus) in coronary patients under general anesthesia. RESULTS The cardiac index and ejection fraction increased significantly [from 1.92 +/- 0.4 to 2.1 +/- 0.4 l/min/m(2) (P = 0.0004) and from 31% +/- 6 to 40% +/- 9 (P = 0.001), respectively], while mean arterial pressure and systemic vascular resistances decreased significantly [from 83 +/- 10 to 72 +/- 5 mmHg (P = 0.0016) and from 997 +/- 341 to 855 +/- 324 dyne s/cm(5) (P = 0.0002), respectively]. After administration of levosimendan, E(a) decreased significantly (from 4.3 +/- 1.8 to 3.2 +/- 1.3 mmHg/ml/m(2), P= 0.005), while E(es) significantly increased (from 2.8 +/- 1.6 to 4.4 +/- 2.3 mmHg/ml/m(2), P= 0.05); as a result, E(a)/E(es) decreased significantly (from 1.76 +/- 1 to 0.83 +/- 0.2, P= 0.002). CONCLUSION Levosimendan improves ventriculo-arterial coupling and cardiovascular performance in coronary patients with left ventricular dysfunction by enhancing myocardial contractility and reducing arterial elastance.
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Affiliation(s)
- F Guarracino
- Cardiothoracic Anaesthesia and Intensive Care Unit, Cardiothoracic Department, University Hospital of Pisa, Italy.
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