Comparison of levosimendan and nitroglycerine in patients undergoing coronary artery bypass graft surgery

Prophylactic use of inotropic agents for the prevention of low cardiac output syndrome and mortality in adults undergoing cardiac surgery

BACKGROUND

As the burden of cardiovascular disease grows, so does the number of cardiac surgeries. Surgery is increasingly performed on older people with comorbidities who are at higher risk of developing perioperative complications such as low cardiac output state (LCOS). Surgery-associated LCOS represents a serious pathology responsible for substantial morbidity and mortality. Prevention of LCOS is a critical and worthwhile aim to further improve the outcome and effectiveness of cardiac surgery. However, guidelines consistently report a lack of evidence for pharmacological LCOS prophylaxis.

OBJECTIVES

To assess the benefits and harms of the prophylactic use of any inotropic agent to prevent low cardiac output and associated morbidity and mortality in adults undergoing cardiac surgery.

SEARCH METHODS

We identified trials (without language restrictions) via systematic searches of CENTRAL, MEDLINE, Embase, and CPCI-S Web of Science in October 2022. We checked reference lists from primary studies and review articles for additional references. We also searched two registers of ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) enrolling adults who underwent cardiac surgery and were prophylactically treated with one or multiple inotropic agent(s) in comparison to any type of control (i.e. standard cardiac care, placebo, other inotropic agents).

DATA COLLECTION AND ANALYSIS

We used established methodological procedures according to Cochrane standards. Two review authors independently extracted data and assessed risk of bias according to a pre-defined protocol. On request, we obtained a reply and additional information from only one of the included study authors. We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the certainty of evidence from the studies that contributed data to the meta-analyses for the pre-specified outcomes. Based on the identified studies, there were seven comparison groups: amrinone versus placebo, dopamine versus placebo, milrinone versus placebo, levosimendan versus dobutamine, levosimendan versus milrinone, levosimendan versus standard cardiac care, and levosimendan versus placebo.

MAIN RESULTS

We identified 29 eligible studies, including 3307 individuals, and four ongoing studies. In general, confidence in the results of the analysed studies was reduced due to relevant study limitations, imprecision, or inconsistency. Domains of concern encompassed inadequate methods of sequence generation and lack of blinding. The majority of trials were small, with only a few included participants, and investigated the prophylactic use of levosimendan. Our meta-analyses showed that levosimendan as compared to placebo may reduce the risk of LCOS (risk ratio (RR) 0.43, 95% confidence interval (CI) 0.25 to 0.74; I2 = 66%; 1724 participants, 6 studies; GRADE: low) and probably reduces all-cause mortality (RR 0.65, 95% CI 0.43 to 0.97; I2 = 11%; 2347 participants, 14 studies; GRADE: moderate). This translates into a number needed to treat for an additional beneficial outcome (NNTB) of 8 to prevent one event of LCOS post surgery and of 44 to prevent one death at 30 days. Subgroup analyses revealed that the beneficial effects of levosimendan were predominantly observed in preoperative drug administration. Our meta-analyses further indicated that levosimendan as compared to placebo may shorten the length of intensive care unit (ICU) stay (mean difference -1.00 days, 95% CI -1.63 to -0.37; 572 participants, 7 studies; GRADE: very low) and the duration of mechanical ventilation (mean difference -8.03 hours, 95% CI -13.17 to -2.90; 572 participants, 7 studies; GRADE: very low) but the evidence is very uncertain. The risk of adverse events did not clearly differ between levosimendan and placebo groups (cardiogenic shock: RR 0.65, 95% CI 0.40 to 1.05; I2 = 0%; 1212 participants, 3 studies; GRADE: high; atrial fibrillation: RR 1.02, 95% CI 0.82 to 1.27; I2 = 60%; 1934 participants, 11 studies; GRADE: very low; perioperative myocardial infarction: RR 0.89, 95% CI 0.61 to 1.31; I2 = 13%; 1838 participants, 8 studies; GRADE: moderate; non-embolic stroke or transient ischaemic attack: RR 0.89, 95% CI 0.58 to 1.38; I2 = 0%; 1786 participants, 8 studies; GRADE: moderate). However, levosimendan as compared to placebo might reduce the number of participants requiring mechanical circulatory support (RR 0.47, 95% CI 0.24 to 0.91; I2 = 74%; 1881 participants, 10 studies; GRADE: low). There was no conclusive evidence on the effect of levosimendan compared to standard cardiac care on LCOS (RR 0.49, 95% CI 0.14 to 1.73; I2 = 59%; 208 participants, 3 studies; GRADE: very low), all-cause mortality (RR 0.37, 95% CI 0.13 to 1.04; I2 = 0%; 208 participants, 3 studies; GRADE: low), adverse events (cardiogenic shock: RR 0.62, 95% CI 0.22 to 1.81; 128 participants, 1 study; GRADE: very low; atrial fibrillation: RR 0.40, 95% CI 0.11 to 1.41; I2 = 60%; 188 participants, 2 studies; GRADE: very low; perioperative myocardial infarction: RR 0.62, 95% CI 0.22 to 1.81; 128 participants, 1 study; GRADE: very low; non-embolic stroke or transient ischaemic attack: RR 0.56, 95% CI 0.27 to 1.18; 128 participants, 1 study; GRADE: very low), length of ICU stay (mean difference 0.33 days, 95% CI -1.16 to 1.83; 80 participants, 2 studies; GRADE: very low), the duration of mechanical ventilation (mean difference -3.40 hours, 95% CI -11.50 to 4.70; 128 participants, 1 study; GRADE: very low), and the number of participants requiring mechanical circulatory support (RR 0.88, 95% CI 0.50 to 1.55; I2 = 0%; 208 participants, 3 studies; GRADE: low).

AUTHORS' CONCLUSIONS

Prophylactic treatment with levosimendan may reduce the incidence of LCOS and probably reduces associated mortality in adult patients undergoing cardiac surgery when compared to placebo only. Conclusions on the benefits and harms of other inotropic agents cannot be drawn due to limited study data. Given the limited evidence available, there is an unmet need for large-scale, well-designed randomised trials. Future studies of levosimendan ought to be designed to derive potential benefit in specific patient groups and surgery types, and the optimal administration protocol.

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

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

Levosimendan Prevents Memory Impairment Induced by Diabetes in Rats: Role of Oxidative Stress

BACKGROUND

Levosimendan is a calcium sensitizer and phosphodiesterase inhibitor that has potent antioxidant and anti-inflammatory activities.

OBJECTIVES

The aim of the current study is to investigate the potential protective effect of levosimendan on learning and memory impairment induced by diabetes.

METHODS

Adult Wister rats were randomly divided into four groups (n=15 rats/group): control, levosimendan, streptozotocin (STZ) induced diabetes, and levosimendan-STZ diabetes. Upon confirmation of the success of the STZ diabetic model, intraperitoneal levosimendan (100µg/kg/week) was administrated to the assigned groups for 4 weeks. Then, the radial arm water maze was used to evaluate spatial learning and memory. Oxidative stress biomarkers and brain-derived neurotrophic factor were evaluated in hippocampal tissues.

RESULTS

The results showed that Diabetes Mellitus (DM) impaired both short- and long- term memory (P<0.01), while levosimendan protected the animals from memory impairment. In addition, levosimendan prevented DM-induced reduction in the hippocampal levels of superoxide dismutase and glutathione peroxidase (P<0.05). Moreover, the administration of levosimendan prevented DM-induced increases in hippocampal thiobarbituric acid reactive substances level (P<0.05). Furthermore, levosimendan restored the ratio of reduced/oxidized glutathione (GSH/GSSG) in DM rats to that observed in the control group (P<0.05).

CONCLUSIONS

In summary, DM induced learning and memory impairment, and treatment with levosimendan impeded this impairment probably through preventing alterations in the antioxidant system in the hippocampus.

The effect of levosimendan on postoperative bleeding and blood transfusion in cardiac surgical patients: a PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Levosimendan (LEVO), is an inotropic agent which has been shown to be associated with better myocardial performance, and higher survival rate in cardiac surgical patients. However, preliminary clinical evidence suggested that LEVO increased the risk of post-operative bleeding in patients undergoing valve surgery. Currently, there has been no randomized controlled trials (RCTs) designed specifically on this issue. Therefore, we performed present systemic review and meta-analysis.

METHODS

Electronic databases were searched to identify all RCTs comparing LEVO with Control (placebo, blank, dobutamine, milrinone, etc). Primary outcomes include post-operative blood loss and re-operation for bleeding. Secondary outcomes included post-operative transfusion of red blood cells (RBC), fresh frozen plasma (FFP) and platelet concentrates (PC). For continuous variables, treatment effects were calculated as weighted mean difference (WMD) and 95% confidential interval (CI). For dichotomous data, treatment effects were calculated as odds ratio (OR) and 95% CI.

RESULTS

Search yielded 15 studies including 1,528 patients. Meta-analysis suggested that, LEVO administration was not associated with increased risk of reoperation for bleeding post-operatively (OR = 1.01; 95%CI: 0.57 to 1.79; p = 0.97) and more blood loss volume (WMD = 28.25; 95%CI: -19.21 to 75.72; p = 0.24). Meta-analysis also demonstrated that, LEVO administration did not increase post-operative transfusion requirement for RBC (rate: OR = 0.97; 95%CI: 0.72 to 1.30; p = 0.83 and volume: WMD = 0.34; 95%CI: -0.55 to 1.22; p = 0.46), FFP (volume: WMD = 0.00; 95%CI: -0.10 to 0.10; p = 1.00) and PC (rate: OR = 1.01; 95%CI: 0.41 to 2.50; p = 0.98 and volume: WMD = 0.00; 95%CI: -0.05 to 0.04; p = 0.95).

CONCLUSION

This meta-analysis suggested that, peri-operative administration of LEVO was not associated with increased risks of post-operative bleeding and blood transfusion requirement in cardiac surgical patients.

Modulating the Bioactivity of Nitric Oxide as a Therapeutic Strategy in Cardiac Surgery

Cardiac surgery, including cardioplegic arrest and extracorporeal circulation, causes endothelial dysfunction, which can lead to no-reflow phenomenon and reduction of myocardial pump function. Nitric oxide (NO) deficiency is involved in this pathologic process, thereby providing a fundamental basis for the use of NO replacement therapy. Presently used drugs and additives to cardioplegic and heart preservation solutions are not able to reliably protect endothelial cells and cardiomyocytes from ischemia-reperfusion injury. This review discusses promising NO-releasing compounds of various chemical classes for cardioplegia and reperfusion, which effectively maintain NO homeostasis under experimental conditions, and presents the mechanisms of their action on the cardiovascular system. Incomplete preclinical studies and a lack of toxicity assessment, however, hinder translation of these drug candidates into the clinic. Perspectives for modulation of endothelial function using NO-mediated mechanisms are discussed. They are based on the cardioprotective potential of targeting vascular gap junctions and endothelial ion channels, intracoronary administration of progenitor cells, and endothelial-specific microRNAs. Some of these strategies may provide important therapeutic benefits for human cardiovascular interventions.

Impact of Perioperative Levosimendan Administration on Risk of Bleeding After Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Levosimendan, a calcium sensitizer and potassium channel opener, has been demonstrated to improve myocardial function without increasing oxygen consumption and to show protective effects in other organs. Recently, a prospective, randomized controlled trial (RCT) revealed an association between levosimendan use and a possible increased risk of bleeding postoperatively. Levosimendan's anti-platelet effects have been shown in in vitro studies. Current studies do not provide sufficient data to support a relation between perioperative levosimendan administration and increased bleeding risk.

PURPOSE

Our goal was to investigate the relation between perioperative levosimendan administration and increased bleeding risk using a meta-analysis study design.

METHODS

The PubMed, Ovid, EMBASE and Cochrane Library databases were searched for relevant RCTs before July 1, 2019. The outcome parameters included reoperation secondary to increased bleeding in the postoperative period, the amount of postoperative recorded blood loss, and the need for transfusion of packed red blood cells (RBCs) and other blood products.

RESULTS

A total of 1160 patients in nine RCTs (576 in the levosimendan group and 584 in the control group) were included according to our inclusion criteria. Analysis showed that perioperative levosimendan administration neither increased the rate of reoperation secondary to bleeding nor increased the amount of postoperative chest tube drainage when compared with the control group. In terms of blood product transfusion, levosimendan did not influence the requirement for RBC transfusion, platelet transfusion nor fresh frozen plasma (FFP) transfusion. Levosimendan also did not shorten or prolong the aortic cross-clamp time or the cardiopulmonary bypass time.

CONCLUSION

The analyzed parameters, including reoperations due to bleeding, postoperative chest drainage and the requirement for blood products, revealed that levosimendan did not increase postoperative bleeding risk. More studies with a larger sample size are needed to address a more reliable conclusion due to study limitations.

Levosimendan and systemic vascular resistance in cardiac surgery patients: a systematic review and meta-analysis

Levosimendan is a potent non-adrenergic inodilator agent. The net effect of hemodynamic changes may result in a hyperdynamic state with low systemic vascular resistance. We conducted a systematic review and meta-analysis assessing hemodynamics in cardiac surgery patients treated with levosimendan. English-language literature was searched systematically from 2006 until October 2018, including randomized controlled trials and case-matched or retrospective studies providing at least two sequentially measured hemodynamic variables in adult patients who underwent cardiac surgery with cardiopulmonary bypass and were treated with levosimendan in comparison to alternative drugs or devices. Cardiac index significantly increased in the levosimendan group by 0.74 (0.24 to 1.23) [standardized mean difference (95% CI); p = 0.003] from baseline to postoperative day (POD) 1, and by 0.75 (0.25 to 1.25; p = 0.003) from baseline to POD 7, when corrected for the standardized mean difference at baseline by a multivariate mixed effects meta-analysis model. With this correction for baseline differences, other hemodynamic variables including systemic vascular resistance did not significantly differ until POD 1 [−0.17 (−0.64 to 0.30), p = 0.48] and POD 7 [−0.13 (−0.61 to 0.34), p = 0.58] between the levosimendan and the comparator group. Levosimendan increases cardiac index in patients undergoing cardiac surgery. Although levosimendan has inodilator properties, this meta-analysis finds no clinical evidence that levosimendan produces vasopressor-resistant vasoplegic syndrome.

Perioperative Use of Levosimendan Improves Clinical Outcomes in Patients After Cardiac Surgery: A Systematic Review and Meta-Analysis

Severe postoperative complications can affect cardiac surgery patients. Levosimendan is a novel calcium sensitizer commonly administered after cardiac surgery. However, the patient benefits are controversial. PubMed, Embase, and the Cochrane library were systematically searched for randomized controlled trials comparing levosimendan with control in adult cardiac surgery patients. Twenty-five studies (3247 patients) were included. Pooled data indicated that levosimendan reduced mortality after cardiac surgery [odds ratio (OR) 0.63, 95% confidence interval (CI): 0.47-0.84, P = 0.001]. However, this reduction was restricted to patients with low (<50%) left ventricular ejection fraction (OR 0.49, 95% CI: 0.35-0.70, P = 0.0001). It significantly reduced the incidence of postoperative acute kidney injury (OR 0.55, 95% CI: 0.41-0.74, P < 0.0001) and renal replacement therapy use (OR 0.56, 95% CI: 0.39-0.80, P = 0.002). Moreover, levosimendan significantly shortened the duration of the intensive care unit stay (weighted mean differences -0.49 day, 95% CI: -0.75 to -0.24, P = 0.0002) and mechanical ventilation use (weighted mean differences -2.30 hours, 95% CI: -3.76 to -0.84, P = 0.002). In conclusion, levosimendan reduced the mortality in patients with low left ventricular ejection fraction and decreased the incidence of acute renal injury and renal replacement therapy use. In addition, it shortened the duration of the intensive care unit stay and mechanical ventilation use.

Effects of levosimendan on mortality in patients undergoing cardiac surgery: A systematic review and meta-analysis

PURPOSE

We sought to determine the impact of levosimendan on mortality following cardiac surgery based on large-scale randomized controlled trials (RCTs).

METHODS

We searched PubMed, Web of Science, Cochrane databases, and ClinicalTrials.gov for RCTs published up to December 2017, on levosimendan for patients undergoing cardiac surgery.

RESULTS

A total of 25 RCTs enrolling 2960 patients met the inclusion criteria; data from 15 placebo-controlled randomized trials were included for meta-analysis. Pooled analysis showed that the all-cause mortality rate was 6.4% (71 of 1106) in the levosimendan group and 8.4% (93 of 1108) in the placebo group (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.55-1.04; P = 0.09). There were no significant differences between the two groups in the rates of myocardial infarction (OR: 0.91; 95% CI, 0.68-1.21; P = 0.52), serious adverse events (OR: 0.84; 95% CI, 0.66-1.07; P = 0.17), hypotension (OR: 1.69; 95% CI, 0.94-3.03; P = 0.08), and low cardiac output syndrome (OR: 0.47; 95% CI, 0.22-1.02; P = 0.05).

CONCLUSION

Levosimendan did not result in a reduction in mortality in adult cardiac surgery patients. Well designed, adequately powered, multicenter trials are necessary to determine the role of levosimendan in adult cardiac surgery.

Perioperative levosimendan in cardiac surgery: A systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Several studies suggested beneficial effects of perioperative levosimendan on postoperative outcome after cardiac surgery. However, three large randomized controlled trials (RCTs) have been recently published and presented neutral results. We performed a systematic review with meta-analysis and trial sequential analysis (TSA) to assess benefits and harms of perioperative levosimendan therapy in cardiac surgery.

METHODS

Electronic databases were searched up to September 2017 for RCTs on preoperative levosimendan versus any type of control. The Cochrane methodology was employed. We calculated odds ratio (OR) or Risk Ratio (OR) and 95% confidence interval (CI) using fixed-effects meta-analyses and we further performed TSA.

RESULTS

We included data from 40 RCTs and 4246 patients. Pooled analysis of 5 low risk of bias trials (1910 patients) showed no association between levosimendan and mortality (OR 0.86 [95% CI, 0.62, 1.18], p=0.34, TSA inconclusive), acute kidney injury, need of renal replacement therapy, myocardial infarction, ventricular arrhythmias, and serious adverse events, but an association with higher incidence of supraventricular arrhythmias (RR 1.11 [95% CI, 1.00, 1.24], p=0.05, TSA inconclusive) and hypotension (RR 1.15 [95% CI, 1.01, 1.30], p=0.04, TSA inconclusive). Analysis including all 40 trials found that levosimendan was associated with lower postoperative mortality (OR 0.56 [95% CI, 0.44, 0.71], p<0.00001, TSA conclusive), acute kidney injury, and renal replacement therapy, and higher incidence of hypotension.

CONCLUSIONS

There is not enough high-quality evidence to neither support nor discourage the systematic use of levosimendan in cardiac surgery.