1
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Demailly Z, Besnier E, Tamion F, Lesur O. Ventriculo-arterial (un)coupling in septic shock: Impact of current and upcoming hemodynamic drugs. Front Cardiovasc Med 2023; 10:1172703. [PMID: 37324631 PMCID: PMC10266274 DOI: 10.3389/fcvm.2023.1172703] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/08/2023] [Indexed: 06/17/2023] Open
Abstract
Sepsis is an archetype of distributive shock and combines different levels of alterations in preload, afterload, and often cardiac contractility. The use of hemodynamic drugs has evolved over the past few years, along with the invasive and non-invasive tools used to measure these components in real time. However, none of them is impeccable, which is why the mortality of septic shock remains too high. The concept of ventriculo-arterial coupling (VAC) allows for the integration of these three fundamental macroscopic hemodynamic components. In this mini review, we discuss the knowledge, tools, and limitations of VAC measurement, along with the evidence supporting ventriculo-arterial uncoupling in septic shock. Finally, the impact of recommended hemodynamic drugs and molecules on VAC is detailed.
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Affiliation(s)
- Zoé Demailly
- Medical Intensive Care Unit, UNIROUEN, INSERM U1096, CHU Rouen, Normandie Université, Rouen, France
- Department of Anesthesiology and Critical Care, UNIROUEN, INSERM U1096, CHU Rouen, Normandie Université, Rouen, France
| | - Emmanuel Besnier
- Department of Anesthesiology and Critical Care, UNIROUEN, INSERM U1096, CHU Rouen, Normandie Université, Rouen, France
| | - Fabienne Tamion
- Medical Intensive Care Unit, UNIROUEN, INSERM U1096, CHU Rouen, Normandie Université, Rouen, France
| | - Olivier Lesur
- Centre de Recherche Clinique du CHU Sherbrooke, Sherbrooke, QC, Canada
- Départements de Soins Intensifs et de Médecine et Service de Pneumologie, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
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2
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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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3
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Antohi EL, Chioncel O, Mihaileanu S. Overcoming the Limits of Ejection Fraction and Ventricular-Arterial Coupling in Heart Failure. Front Cardiovasc Med 2022; 8:750965. [PMID: 35127846 PMCID: PMC8813963 DOI: 10.3389/fcvm.2021.750965] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 12/21/2021] [Indexed: 12/25/2022] Open
Abstract
Left ventricular ejection fraction (LVEF) and ventricular-arterial coupling (VAC) [VAC = Ea/Ees; Ea: effective arterial elastance; Ees: left ventricle (LV) elastance] are both dimensionless ratios with important limitations, especially in heart failure setting. The LVEF to VAC relationship is a divergent non-linear function, having a point of intersection at the specific value of 0.62, where V0 = 0 ml (V0: the theoretical extrapolated value of the volume-axis intercept at end-systolic pressure 0 mmHg). For the dilated LV, both LVEF and VAC are highly dependent on V0 which is inconclusive when derived from single-beat Ees formulas. VAC simplification should be avoided. Revisiting the relationship between systolic time intervals (STI), pressure, and volumes could provide simple-to-use guiding formulas, affordable for daily clinical practice. We have analyzed by echocardiography the hemodynamics of 21 patients with severe symptomatic heart failure with reduced ejection (HFrEF) compared to 12 asymptomatic patients (at risk of heart failure with mild structural disease). The groups were unequivocally separated by ‘classic’ measures (LVEF, LV end-systolic volume (ESV), LV mass, STI). Chen's Ees formula was weakly correlated with LVEF and indexed ESV (ESVi) but better correlated to the pre-ejection period (PEP); PEP/total ejection time (PEP/TET); systolic blood pressure/PEP (SBP/PEP) (P < 0.001). Combining the predictability of the LVEF to the determinant role of SBP/PEP on the Ees variations, we obtained: (SBP*LVEF)/PEP mm Hg/ms, with an improved R2 value (R2 = 0.848; P < 0.001). The strongest correlations to VAC were for LVEF (R = −0.849; R2 = 0.722) and PEP/TET (R = 0.925; R2 = 0.857). By multiple regression, the VAC was strongly predicted (N = 33): (R = 0.975; R2 = 0.95): VAC = 0.553–0.009*LVEF + 3.463*PEP/TET, and natural logarithm: Ln (VAC) = 0.147–1.4563*DBP/SBP*0.9–0.010*LVEF + 4.207*PEP/TET (R = 0.987; R2 = 0.975; P = 0) demonstrating its exclusive determinants: LVEF, PEP/TET, and DBP/SBP. Considering Ea as a known value, the VAC-derived Ees formula: Ees_d ≈ Ea/(0.553–0.009*LVEF+3.463*PEP/TET) was strongly correlated to Chen's Ees formula (R = 0.973; R2 = 0.947) being based on SBP, ESV, LVEF, and PEP/TET and no exponential power. Thus, the new index supports our hypothesis, in the limited sample of patients with HFrEF. Indices like SBP/PEP, (SBP*LVEF)/PEP, PEP/TET, and DBP/SBP deserve further experiments, underlining the major role of the forgotten STI.
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Affiliation(s)
- Elena-Laura Antohi
- Emergency Institute for Cardiovascular Diseases “Prof. Dr. C.C. Iliescu”, Bucharest, Romania
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- *Correspondence: Elena-Laura Antohi
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases “Prof. Dr. C.C. Iliescu”, Bucharest, Romania
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
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4
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Liu DH, Ning YL, Lei YY, Chen J, Liu YY, Lin XF, Yang ZQ, Xian SX, Chen WT. Levosimendan versus dobutamine for sepsis-induced cardiac dysfunction: a systematic review and meta-analysis. Sci Rep 2021; 11:20333. [PMID: 34645892 PMCID: PMC8514594 DOI: 10.1038/s41598-021-99716-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/27/2021] [Indexed: 12/14/2022] Open
Abstract
Levosimendan and dobutamine are extensively used to treat sepsis-associated cardiovascular failure in ICU. Nevertheless, the role and mechanism of levosimendan in patients with sepsis-induced cardiomyopathy remains unclear. Moreover, previous studies on whether levosimendan is superior to dobutamine are still controversial. More importantly, these studies did not take changes (before-after comparison to the baseline) in quantitative parameters such as ejection fraction into account with the baseline level. Here, we aimed to determine the pros and cons of the two medicines by assessing the changes in cardiac function and blood lactate, mortality, with the standardized mean difference used as a summary statistic. Relevant studies were obtained by a thorough and disciplined literature search in several notable academic databases, including Google Scholar, PubMed, Cochrane Library and Embase until November 2020. Outcomes included changes in cardiac function, lactic acid, mortality and length of hospital stay. A total of 6 randomized controlled trials were included in this study, including 192 patients. Compared with dobutamine, patients treated with levosimendan had a greater improvement of cardiac index (ΔCI) (random effects, SMD = 0.90 [0.20,1.60]; I2 = 76%, P < 0.01) and left ventricular stroke work index (ΔLVSWI) (random effects, SMD = 1.56 [0.90,2.21]; I2 = 65%, P = 0.04), a significant decrease of blood lactate (Δblood lactate) (random effects, MD = - 0.79 [- 1.33, - 0.25]; I2 = 68%, P < 0.01) at 24-h after drug intervention, respectively. There was no significant difference between levosimendan and dobutamine on all-cause mortality in ICU (fixed effect, OR = 0.72 [0.39,1.33]; I2 = 0%, P = 0.99). We combine effect sizes related to different measurement parameters to evaluate cardiac function, which implied that septic patients with myocardial dysfunction might have a better improvement of cardiac function by levosimendan than dobutamine (random effects, SMD = 1.05 [0.69,1.41]; I2 = 67%, P < 0.01). This study suggested a significant improvement of CI, LVSWI, and decrease of blood lactate in septic patients with myocardial dysfunction in ICU after 24-h administration of levosimendan than dobutamine. However, the administration of levosimendan has neither an impact on mortality nor LVEF. Septic patients with myocardial dysfunction may partly benefit from levosimendan than dobutamine, mainly embodied in cardiac function improvement.
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Affiliation(s)
- Dong-Hua Liu
- Department of Critical Care Medicine, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China
- The First Clinical School, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Yi-Le Ning
- Department of Critical Care Medicine, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China
- Ling-Nan Medical Research Center, Guangzhou University of Chinese Medicine, No. 12, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China
| | - Yan-Yan Lei
- Department of Critical Care Medicine, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China
| | - Jing Chen
- Department of Critical Care Medicine, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China
- The First Clinical School, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Yan-Yan Liu
- Department of Critical Care Medicine, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China
| | - Xin-Feng Lin
- Department of Critical Care Medicine, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China
| | - Zhong-Qi Yang
- Ling-Nan Medical Research Center, Guangzhou University of Chinese Medicine, No. 12, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China.
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China.
| | - Shao-Xiang Xian
- Ling-Nan Medical Research Center, Guangzhou University of Chinese Medicine, No. 12, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China.
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China.
| | - Wei-Tao Chen
- Department of Critical Care Medicine, The First Affiliated Hospital, Guangzhou University of Chinese Medicine, No. 16, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China.
- The First Clinical School, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
- Ling-Nan Medical Research Center, Guangzhou University of Chinese Medicine, No. 12, Jichang Road, Baiyun District, Guangzhou, 510405, Guangdong Province, China.
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5
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Cosentino N, Niccoli G, Fracassi F, Rebuzzi A, Agostoni P, Marenzi G. Rationale, experimental data, and emerging clinical evidence on early and preventive use of levosimendan in patients with ventricular dysfunction. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 6:310-316. [PMID: 31688906 DOI: 10.1093/ehjcvp/pvz065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/18/2019] [Accepted: 11/01/2019] [Indexed: 12/13/2022]
Abstract
Acute ventricular dysfunction (AVD) is a complex condition with substantial morbidity and mortality, still featuring unique therapeutic challenges. Levosimendan is a calcium sensitizer and ATP-dependent potassium channel opener that was developed as an inodilating drug for the treatment of acute heart failure and cardiogenic shock. Differently from other more widely used inotropic agents, levosimendan has some exclusive characteristics, in terms of mechanisms of action, pharmacodynamic profile, and haemodynamic effects. This may have important clinical implications. In particular, in patients with AVD or in patients with pre-existing severe ventricular impairment undergoing planned myocardial stress, the administration of levosimendan before the onset of overt symptoms or before cardiovascular therapeutic procedures may have the potential to bridge the patient through the critical phase. In this review, we will focus on the rationale, the existing experimental data, and the emerging clinical experience supporting an early, even preventive use of levosimendan in severe ventricular dysfunction, beyond its recognized indications.
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Affiliation(s)
- Nicola Cosentino
- Centro Cardiologico Monzino, I.R.C.C.S, Via Parea 4, 20138 Milan, Italy
| | - Giampaolo Niccoli
- Department of Cardiovascular & Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli, I.R.C.C.S, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Fracassi
- Department of Cardiovascular & Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli, I.R.C.C.S, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Rebuzzi
- Department of Cardiovascular & Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli, I.R.C.C.S, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, I.R.C.C.S, Via Parea 4, 20138 Milan, Italy.,Department of Clinical Sciences and Community Health - Cardiovascular Section, Università degli Studi di Milano, Milan, Italy
| | - Giancarlo Marenzi
- Centro Cardiologico Monzino, I.R.C.C.S, Via Parea 4, 20138 Milan, Italy
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6
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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: 32] [Impact Index Per Article: 8.0] [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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7
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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: 22] [Impact Index Per Article: 5.5] [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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Abstract
In the late 19th century, Otto Frank published the first description of a ventricular pressure-volume diagram, thus laid the foundation for modern cardiovascular physiology. Since then, the analysis of the pressure-volume loops became a reference tool for the study of the ventricular pump properties. However, understanding cardiovascular performance requires both the evaluation of ventricular properties and the modulating effects of the arterial system, since the heart and the arterial tree are anatomically and functionally related structures. The study of the coupling between the cardiac function and the properties of the arterial system, or ventriculo-arterial (VA) coupling, provides then a comprehensive characterization of the performance of the cardiovascular system in both health and disease. The assessment of cardiovascular function is an essential element of the hemodynamic evaluation of critically ill patients. Both left and right ventricular dysfunction and arterial system disturbances are frequent in these patients. Since VA coupling ultimately defines de performance and efficiency of the cardiovascular system, the analysis of the interaction between the heart and the arterial system could offer a broader perspective of the hemodynamic disorders associated with common conditions, such as septic shock, heart failure, or right ventricular dysfunction. Moreover, this analysis could also provide valuable information about their pathophysiological mechanisms and may help to determine the best therapeutic strategy to correct them. In this review, we will describe the basic principles of the VA coupling assessment, its limitations, and the most common methods for its estimation at the bedside. Then, we will summarize the current knowledge of the application of VA coupling in critically ill patients and suggest some recommendations for further research.
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Affiliation(s)
| | - Arnoldo Santos
- Centro de Investigación Biomédica en Red (CIBER). Madrid, España.,ITC Ingeniería y Técnicas Clínicas SA, Madrid, España
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Guarracino F, Zima E, Pollesello P, Masip J. Short-term treatments for acute cardiac care: inotropes and inodilators. Eur Heart J Suppl 2020; 22:D3-D11. [PMID: 32431568 PMCID: PMC7225903 DOI: 10.1093/eurheartj/suaa090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute heart failure (AHF) continues to be a substantial cause of illness and death, with in-hospital and 3-month mortality rates of 5% and 10%, respectively, and 6-month re-admission rates in excess of 50% in a range of clinical trials and registry studies; the European Society of Cardiology (ESC) Heart Failure Long-Term Registry recorded a 1-year death or rehospitalization rate of 36%. As regards the short-term treatment of AHF patients, evidence was collected in the ESC Heart Failure Long-Term Registry that intravenous (i.v.) treatments are administered heterogeneously in the critical phase, with limited reference to guideline recommendations. Moreover, recent decades have been characterized by a prolonged lack of successful innovation in this field, with a plethora of clinical trials generating neutral or inconclusive findings on long-term mortality effects from a multiplicity of short-term interventions in AHF. One of the few exceptions has been the calcium sensitizer and inodilator levosimendan, introduced 20 years ago for the treatment of acutely decompensated chronic heart failure. In the present review, we will focus on the utility of this agent in the wider context of i.v. inotropic and inodilating therapies for AHF and related pathologies.
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Affiliation(s)
- Fabio Guarracino
- Dipartimento di Anestesia e Terapie Intensive, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Endre Zima
- Cardiac Intensive Care, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Piero Pollesello
- Critical Care Proprietary Products, CO, Orion Pharma, PO Box 65, FIN-02101 Espoo, Finland
| | - Josep Masip
- Intensive Care Department, Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain
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10
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Evaluation of ventriculo-arterial coupling in ST elevation myocardial infarction with left ventricular dysfunction treated with levosimendan. Int J Cardiol 2019; 288:1-4. [PMID: 31056414 DOI: 10.1016/j.ijcard.2019.04.052] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/10/2019] [Accepted: 04/16/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Acute heart failure (AHF) after ST-segment elevation myocardial infarction (STEMI) is usually treated with inotropic support or vasoactive medications. In this study, we aimed at investigating the role of levosimendan on cardiovascular determinants of contractility and afterload in patients with AHF following STEMI treated with percutaneous coronary intervention (PCI). METHODS Forty-eight consecutive STEMI patients were retrospectively enrolled. Non-invasive assessment of left ventricular elastance (Ees) and arterial elastance (Ea) and their relationship, ventriculo-arterial coupling (VAC) was performed before and after levosimendan infusion. RESULTS After infusion of levosimendan a significant increase in SV was detected in all patients (from 48 ± 17 to 60 ± 21 ml, p < 0.001). VAC slightly decreased from 1.74 ± 0.8 to 1.66 ± 0.7 (p = NS) as a result of a profound reduction in arterial elastance (Ea 2.34 ± 1.09 to 1.74 ± 0.5 mm Hg/ml, p < 0.001) and in ventricular elastance (Ees 1.57 ± 0.12 to 1.24 ± 0.09 mm Hg/ml, p = 0.021). Ejection fraction (EF) (from 0.29 ± 0.1 to 0.32 ± 0.1, p < 0.01) and WMSI, (from 2.16 ± 0.47 to 2.05 ± 0.54, p < 0.05) also, significantly improved. Finally, baseline VAC was able to predict the use of norepinephrine (NE) and early and one-year mortality of patients treated. CONCLUSION In STEMI patients with AHF the use of levosimendan significantly increases stroke volume after 24-hour treatment through Ea reduction. Baseline VAC seemed to predict early and late mortality and early and prolonged use of NE, however, this needs to be tested in larger series of patients and multivariate adjustments for other prognostic predictors.
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12
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Wang X, Long Y, He H, Shan G, Zhang R, Cui N, Wang H, Zhou X, Rui X, Liu W. Left ventricular-arterial coupling is associated with prolonged mechanical ventilation in severe post-cardiac surgery patients: an observational study. BMC Anesthesiol 2018; 18:184. [PMID: 30522447 PMCID: PMC6284290 DOI: 10.1186/s12871-018-0649-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 11/23/2018] [Indexed: 12/20/2022] Open
Abstract
Background Weaning post-cardiac surgery patients from mechanical ventilation (MV) poses a big challenge to these patients. Optimized left ventricular-arterial coupling (VAC) may be crucial for reducing the MV duration of these patients. However, there is no research exploring the relationship between VAC and the duration of MV. We performed this study to investigate the relationship between left ventricular-arterial coupling (VAC) and prolonged mechanical ventilation (MV) in severe post-cardiac surgery patients. Methods This was a single-center retrospective study of 56 severe post-cardiac surgery patients from January 2015 to December 2017 at the Department of Critical Care Medicine of Peking Union Medical College Hospital. Patients were divided into two groups according to the duration of MV (PMV group: prolonged mechanical ventilation group, MV > 6 days; Non-PMV group: non-prolonged mechanical ventilation group, MV ≤ 6 days). Hemodynamics and tissue perfusion data were collected or calculated at admission (T0) and 48 h after admission (T1) to the ICU. Results In terms of hemodynamic and tissue perfusion data, there were no differences between the two groups at admission (T0). Compared with the non-prolonged MV group after 48 h in the ICU (T1), the prolonged MV group had significantly higher values for heart rate (108 ± 13 vs 97 ± 12, P = 0.018), lactate (2.42 ± 1.24 vs.1.46 ± 0.58, P < 0.001), and Ea/Ees (5.93 ± 1.81 vs. 4.05 ± 1.20, P < 0.001). Increased Ea/Ees (odds ratio, 7.305; 95% CI, 1.181–45.168; P = 0.032) and lactate at T1 (odds ratio, 17.796; 95% CI, 1.377–229.988; P = 0.027) were independently associated with prolonged MV. There was a significant relationship between Ea/EesT1 and the duration of MV (r = 0.512, P < 0.01). The area under the receiver operating characteristic (AUC) of the left VAC for predicting prolonged MV was 0.801, and the cutoff value for Ea/Ees was 5.12, with 65.0% sensitivity and 90.0% specificity. Conclusions Left ventricular-arterial coupling was associated with prolonged mechanical ventilation in severe post-cardiac surgery patients. The assessment and optimization of left VAC might be helpful in reducing duration of MV in these patients.
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Affiliation(s)
- Xu Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Huaiwu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Guangliang Shan
- Department of Epidemiology and Biostatistics, Institute of Basic Medicine Sciences, Chinese Academy of Medical Sciences (CAMS) & School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Rui Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Na Cui
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Hao Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Xiang Zhou
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Xi Rui
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Wanglin Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
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Measuring Contractility During Mechanical Circulatory Support Would Be a Strong Plus. ASAIO J 2017; 64:e139. [PMID: 29240629 DOI: 10.1097/mat.0000000000000738] [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] Open
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Gustafsson F, Guarracino F, Schwinger RHG. The inodilator levosimendan as a treatment for acute heart failure in various settings. Eur Heart J Suppl 2017; 19:C2-C7. [PMID: 29249904 PMCID: PMC5932561 DOI: 10.1093/eurheartj/sux001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Levosimendan is an inodilator developed for treatment of acute heart failure. It was shown to enhance cardiac contractility, and to exert a vasodilatory effect in all vascular beds. In some trials, the use of levosimendan was associated with cardioprotective effects. These distinctive qualities may be relevant to its use in a range of acute heart failure settings and/or complications, including acute coronary syndromes and cardiogenic shock. It is conjectured that part of the benefit of levosimendan may arise from restoration of ventriculo-arterial coupling via optimization of the ratio of arterial to ventricular elastance and the transfer of mechanical energy. Full confirmation of the effectiveness of levosimendan is still awaited in many of these scenarios; however, the range of potential applications highlights both the versatility of levosimendan and the relative lack of proven interventions in many of these situations.
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Affiliation(s)
- Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Fabio Guarracino
- Department of Cardiothoracic Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
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Zolty R. Pulmonary Hypertension in Left Ventricular Dysfunction: Still Numerous Unanswered Questions. J Card Fail 2017; 23:221-223. [DOI: 10.1016/j.cardfail.2017.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 01/20/2017] [Accepted: 01/20/2017] [Indexed: 11/26/2022]
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Belletti A, Benedetto U, Biondi-Zoccai G, Leggieri C, Silvani P, Angelini GD, Zangrillo A, Landoni G. The effect of vasoactive drugs on mortality in patients with severe sepsis and septic shock. A network meta-analysis of randomized trials. J Crit Care 2017; 37:91-98. [PMID: 27660923 DOI: 10.1016/j.jcrc.2016.08.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 07/04/2016] [Accepted: 08/08/2016] [Indexed: 02/05/2023]
Affiliation(s)
- Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Umberto Benedetto
- University of Bristol, School of Clinical Sciences, Bristol Heart Institute, Bristol, United Kingdom.
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy.
| | - Carlo Leggieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Paolo Silvani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Gianni D Angelini
- University of Bristol, School of Clinical Sciences, Bristol Heart Institute, Bristol, United Kingdom.
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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17
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Levosimendan beyond inotropy and acute heart failure: Evidence of pleiotropic effects on the heart and other organs: An expert panel position paper. Int J Cardiol 2016; 222:303-312. [PMID: 27498374 DOI: 10.1016/j.ijcard.2016.07.202] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/28/2016] [Indexed: 02/04/2023]
Abstract
Levosimendan is a positive inotrope with vasodilating properties (inodilator) indicated for decompensated heart failure (HF) patients with low cardiac output. Accumulated evidence supports several pleiotropic effects of levosimendan beyond inotropy, the heart and decompensated HF. Those effects are not readily explained by cardiac function enhancement and seem to be related to additional properties of the drug such as anti-inflammatory, anti-oxidative and anti-apoptotic ones. Mechanistic and proof-of-concept studies are still required to clarify the underlying mechanisms involved, while properly designed clinical trials are warranted to translate preclinical or early-phase clinical data into more robust clinical evidence. The present position paper, derived by a panel of 35 experts in the field of cardiology, cardiac anesthesiology, intensive care medicine, cardiac physiology, and cardiovascular pharmacology from 22 European countries, compiles the existing evidence on the pleiotropic effects of levosimendan, identifies potential novel areas of clinical application and defines the corresponding gaps in evidence and the required research efforts to address those gaps.
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18
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Calcium sensitizers: What have we learned over the last 25years? Int J Cardiol 2016; 203:543-8. [DOI: 10.1016/j.ijcard.2015.10.240] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 10/30/2015] [Accepted: 10/31/2015] [Indexed: 01/10/2023]
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Mebazaa A, Longrois D, Metra M, Mueller C, Richards AM, Roessig L, Seronde MF, Sato N, Stockbridge NL, Gattis Stough W, Alonso A, Cody RJ, Cook Bruns N, Gheorghiade M, Holzmeister J, Laribi S, Zannad F. Agents with vasodilator properties in acute heart failure: how to design successful trials. Eur J Heart Fail 2015; 17:652-64. [PMID: 26040488 DOI: 10.1002/ejhf.294] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 04/17/2015] [Accepted: 04/22/2015] [Indexed: 01/08/2023] Open
Abstract
Agents with vasodilator properties (AVDs) are frequently used in the treatment of acute heart failure (AHF). AVDs rapidly reduce preload and afterload, improve left ventricle to aorta and right ventricle to pulmonary artery coupling, and may improve symptoms. Early biomarker changes after AVD administration have suggested potentially beneficial effects on cardiac stretch, vascular tone, and renal function. AVDs that reduce haemodynamic congestion without causing hypoperfusion might be effective in preventing worsening organ dysfunction. Existing AVDs have been associated with different results on outcomes in randomized clinical trials, and observational studies have suggested that AVDs may be associated with a clinical outcome benefit. Lessons have been learned from past AVD trials in AHF regarding preventing hypotension, selecting the optimal endpoint, refining dyspnoea measurements, and achieving early randomization and treatment initiation. These lessons have been applied to the design of ongoing pivotal clinical trials, which aim to ascertain if AVDs improve clinical outcomes. The developing body of evidence suggests that AVDs may be a clinically effective therapy to reduce symptoms, but more importantly to prevent end-organ damage and improve clinical outcomes for specific patients with AHF. The results of ongoing trials will provide more clarity on the role of AVDs in the treatment of AHF.
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Affiliation(s)
- Alexandre Mebazaa
- University Paris Diderot, Sorbonne Paris Cité, Paris, France.,U942 INSERM, AP-HP, Paris, France.,APHP, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisière, Paris, France
| | - Dan Longrois
- Département d'Anesthésie-Réanimation, Hôpital Bichat-Claude Bernard, University Paris Diderot, Sorbonne Paris Cité, Paris, U1148 INSERM, Paris, France
| | - Marco Metra
- Cardiology, University of Brescia, Brescia, Italy
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Arthur Mark Richards
- Cardiovascular Research Institute, National University of Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lothar Roessig
- Global Clinical Development, Bayer Pharma AG, Berlin, Germany
| | - Marie France Seronde
- Department of Cardiology, University Hospital of Besançon, U942 INSERM, Besançon, France
| | - Naoki Sato
- Internal Medicine, Cardiology, and Intensive Care Medicine, Nippon Medical School Musashi-Kosugi Hospital, Kanagawa, Japan
| | - Norman L Stockbridge
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | | | - Angeles Alonso
- Scientific Advice Working Party European Medicines Agency, Madrid, Spain
| | | | | | - Mihai Gheorghiade
- Department of Medicine, Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Said Laribi
- APHP, Department of Emergency Medicine, Hôpitaux Universitaires Saint Louis-Lariboisière, INSERM U942, Paris, France
| | - Faiez Zannad
- INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Université de Lorraine, Nancy, France
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Antonucci E, Fiaccadori E, Donadello K, Taccone FS, Franchi F, Scolletta S. Myocardial depression in sepsis: From pathogenesis to clinical manifestations and treatment. J Crit Care 2014; 29:500-11. [DOI: 10.1016/j.jcrc.2014.03.028] [Citation(s) in RCA: 171] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 03/27/2014] [Accepted: 03/29/2014] [Indexed: 12/28/2022]
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Guarracino F, Ferro B, Morelli A, Bertini P, Baldassarri R, Pinsky MR. Ventriculoarterial decoupling in human septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R80. [PMID: 24762124 PMCID: PMC4056562 DOI: 10.1186/cc13842] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Accepted: 04/03/2014] [Indexed: 12/20/2022]
Abstract
Introduction Septic shock is the most severe manifestation of sepsis. It is characterized as a hypotensive cardiovascular state associated with multiorgan dysfunction and metabolic disturbances. Management of septic shock is targeted at preserving adequate organ perfusion pressure without precipitating pulmonary edema or massive volume overload. Cardiac dysfunction often occurs in septic shock patients and can significantly affect outcomes. One physiologic approach to detect the interaction between the heart and the circulation when both are affected is to examine ventriculoarterial coupling, which is defined by the ratio of arterial elastance (Ea) to left ventricular end-systolic elastance (Ees). In this study, we analyzed ventriculoarterial coupling in a cohort of patients admitted to ICUs who presented with vs without septic shock. Methods In this retrospective cross-sectional opportunity study, we measured routine hemodynamics using indwelling arterial and pulmonary arterial catheters and transthoracic echocardiograms in 25 septic patients (group S) and 25 non–septic shock patients (group C) upon ICU admission. Ees was measured by echocardiography using a single-beat (EesSB) method. Ea was calculated as 0.9 systolic arterial pressure/stroke volume, and then the Ea/EesSB ratio was calculated (normal value <1.36). Results In group S, 21 patients had an Ea/EesSB ratio >1.36 (uncoupled). The four patients with Ea/EesSB ratios ≤1.36 had higher EesSB values than patients with Ea/EesSB ratios >1.36 (P = 0.007), although Ea measurements were similar in both groups (P = 0.4). In group C, five patients had uncoupled Ea/EesSB ratios. No correlation was found between EesSB and left ventricular ejection fraction and between Ea/EesSB ratio and mixed venous oxygen saturation in septic shock patients. Conclusions Upon admission to the ICU, patients in septic shock often display significant ventriculoarterial decoupling that is associated with impaired left ventricular performance. Because Ea/Ees decoupling alters cardiovascular efficiency and cardiac energetic requirements independently of Ea or Ees, we speculate that septic patients with ventriculoarterial uncoupling may benefit from therapy aimed at normalizing the Ea/Ees ratio.
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Bertini P, Baldassarri R, Simone V, Amitrano D, Cariello C, Guarracino F. Perioperative non-invasive estimation of left ventricular elastance (Ees) is no longer a challenge; it is a reality. Br J Anaesth 2014; 112:578. [PMID: 24535511 DOI: 10.1093/bja/aeu023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Boly CA, Bouwman RA, Reesink KD. Reply from the authors. Br J Anaesth 2014; 112:579-80. [PMID: 24535512 DOI: 10.1093/bja/aeu030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Ventriculo-arterial decoupling in acutely altered hemodynamic states. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:213. [PMID: 23510336 PMCID: PMC3672525 DOI: 10.1186/cc12522] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Abstract
Acute cardiac failure caused by myocardial infarction or inadequate cardioprotection during heart surgery is associated with increased mortality and morbidity. Levosimendan is a new drug used in heart failure though it is limited by the systemic hypotension, which develops with intravenous administration. Intracoronary (IC) administration however should affect systemic circulation less while maintaining the beneficial cardiac effects of the drug. We herewith report the results from the first such clinical series. Levosimendan was administered IC in 33 consecutive patients who developed cardiogenic shock during heart surgery and were unable to wean off cardiopulmonary bypass despite maximal support. Preadministration/postadministration coronary graft flows, hemodynamic parameters, left ventricular function, and metabolic requirements were measured and compared. Levosimendan significantly increased graft flows and improved hemodynamic parameters. Systolic blood pressure (93 ± 26.4 vs. 106 ± 18.2 mm Hg, P < 0.05) and cardiac index (2.0 ± 0.5 vs. 3.1 ± 0.2, P < 0.001) were increased, whereas systemic vascular resistance (1470.7 ± 114 vs. 1195.8 ± 112, P < 0.01) was reduced. Better myocardial perfusion improved metabolic requirements, with myocardial oxygen extraction and glucose uptake increasing by 72% and 74%, respectively, whereas lactate production was reduced by 64%. Echocardiography demonstrated additional ventricular segment recruitment. Therefore, IC Levosimendan administration in acute heart failure is safe and efficacious producing improved cardiac function without significant detrimental hypotension.
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Rehberg S, Ertmer C, Vincent JL, Spiegel HU, Köhler G, Erren M, Lange M, Morelli A, Seisel J, Su F, Van Aken H, Traber DL, Westphal M. Effects of combined arginine vasopressin and levosimendan on organ function in ovine septic shock. Crit Care Med 2010; 38:2016-23. [PMID: 20657271 DOI: 10.1097/ccm.0b013e3181ef4694] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the effects of a first-line therapy of combined arginine vasopressin, levosimendan, and norepinephrine with arginine vasopressin + norepinephrine or norepinephrine alone in ovine septic shock. DESIGN Prospective, randomized, controlled laboratory experiment. SETTING University animal research facility. SUBJECTS Twenty-one chronically instrumented sheep. INTERVENTIONS After the onset of fecal peritonitis-induced septic shock (mean arterial pressure <60 mm Hg), sheep were randomly assigned to receive first-line treatment with arginine vasopressin (0.5 mU·kg·min), combined arginine vasopressin (0.5 mU·kg·min) and levosimendan (0.2 μg·kg·min), or normal saline (each n = 7) for 24 hrs. In all groups, open-label norepinephrine was additionally titrated to maintain mean arterial pressure at 70 ± 5 mm Hg, if necessary. MEASUREMENTS AND MAIN RESULTS Arginine vasopressin + levosimendan + norepinephrine improved left ventricular contractility (higher stroke work indices at similar or lower preload) and pulmonary function (Pao2/Fio2 ratio) when compared with the other groups (p < .05 each). Both nonadrenergic treatment strategies reduced open-label norepinephrine doses. However, only arginine vasopressin + levosimendan + norepinephrine limited fluid requirements and positive fluid balance vs. both other groups (p < .05 each). In addition, arginine vasopressin + levosimendan + norepinephrine increased mixed venous oxygen saturation as compared with arginine vasopressin + norepinephrine. Histologic tissue analyses and pulmonary hemeoxygenase-1 activity revealed no differences among groups. Notably, arginine vasopressin + levosimendan + norepinephrine therapy reduced pulmonary 3-nitrotyrosine levels (p = .028 vs. control animals) as well as urinary protein/creatinine ratio (p < .05 each) and slightly prolonged survival when compared with both other groups (4 hrs vs. arginine vasopressin + norepinephrine: p = .013; 7 hrs vs. norepinephrine alone: p = .003). CONCLUSIONS First-line cardiovascular support with combined arginine vasopressin and levosimendan supplemented with norepinephrine improves myocardial, vascular, pulmonary, and renal function as compared with arginine vasopressin + norepinephrine in septic shock.
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Affiliation(s)
- Sebastian Rehberg
- Department of Anesthesiology and Intensive Care, University of Muenster, Muenster, Germany.
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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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Levosimendan: A New Therapeutic Option in the Treatment of Primary Graft Dysfunction After Heart Transplantation. J Heart Lung Transplant 2009; 28:501-4. [DOI: 10.1016/j.healun.2009.01.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Revised: 11/11/2008] [Accepted: 01/14/2009] [Indexed: 11/19/2022] Open
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Leppikangas H, Tenhunen JJ, Lindgren L, Salenius JP, Ruokonen E. Effects of levosimendan on indocyanine green plasma disappearance rate and the gastric mucosal-arterial pCO2 gradient in abdominal aortic aneurysm surgery. Acta Anaesthesiol Scand 2008; 52:785-92. [PMID: 18477074 DOI: 10.1111/j.1399-6576.2008.01659.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Levosimendan has a dual mechanism of action: it improves myocardial contractility and causes vasodilatation without increasing myocardial oxygen demand. In a laboratory setting, it selectively increases gastric mucosal oxygenation in particular and splanchnic perfusion in general. The aim of our study was to describe the effects of levosimendan on systemic and splanchnic circulation during and after abdominal aortic surgery. METHODS Twenty abdominal aortic aneurysm surgery patients were randomized to receive either levosimendan (n=10) or placebo (n=10) in a double-blinded manner. Both the mode of anaesthesia and the surgical procedures were performed according to the local guidelines. Automatic gas tonometry was used to measure the gastric mucosal partial pressure of carbon dioxide. Systemic indocyanine green clearance plasma disappearance rate (ICG-PDR) was used to estimate the total splanchnic blood flow. RESULTS The immediate post-operative recovery was uneventful in the two groups with a comparable, overnight length of stay in the intensive care unit. Cumulative doses of additional vasoactive drugs were comparable between the groups, with a tendency towards a higher cumulative dose of noradrenaline in the levosimendan group. After aortic clamping, the cardiac index was higher [4(3.8-4.7) l/min/m(2) vs. 2.6(2.3-3.6) l/min/m(2); P<0.05] and the gastric mucosal-arterial pCO(2) gradient was lower in levosimendan-treated patients [0.9(0.6-1.2) kPa vs. 1.7(1.2-2.1) kPa; (P<0.05)]. However, the total splanchnic blood flow, estimated by ICG-PDR, was comparable [29(21-29)% vs. 20(19-25)%; NS]. Organ dysfunction scores (sequential organ dysfunction assessment) were similar between the groups on the fifth post-operative day. CONCLUSION Levosimendan favours gastric perfusion but appears not to have a major effect on total splanchnic perfusion in patients undergoing an elective aortic aneurysm operation.
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Affiliation(s)
- H Leppikangas
- Critical Care Medicine Research Group, Department of Intensive Care, Tampere University Hospital, Tampere, Finland.
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