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Kempsell-Smith M, Fitzsimons C. Managing the deteriorating child with suspected group A Streptococcus infection. Nurs Child Young People 2023; 35:35-42. [PMID: 37599641 DOI: 10.7748/ncyp.2023.e1467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 08/22/2023]
Abstract
Group A Streptococcus bacteria can cause various pyogenic infections such as tonsillitis, pharyngitis, scarlet fever, impetigo, erysipelas, cellulitis and pneumonia. Most group A Streptococcus infections in children are mild and respond positively to treatment with antibiotics. However, some children develop severe infection accompanied by complications such as sepsis and will require urgent treatment, which may include non-invasive or invasive ventilation and the administration of fluids and vasoactive agents. In some instances, for example if there are no beds available in the paediatric intensive care unit, these interventions may be undertaken in a ward setting. This article gives an overview of group A Streptococcus infection, including two rare but severe complications, streptococcal toxic shock syndrome and necrotising fasciitis. It uses a fictionalised case study to examine the management of the deteriorating child with suspected group A Streptococcus infection, including respiratory support, haemodynamic support and symptom management.
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Affiliation(s)
| | - Claire Fitzsimons
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, England
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Pagliara C, Zambaiti E, Brooks G, Bonadies L, Tognon C, Salvadori S, Sgrò A, Leon FF. Congenital Diaphragmatic Hernia: Perinatal Prognostic Factors and Short-Term Outcomes in a Single-Center Series. Children (Basel) 2023; 10. [PMID: 36832444 DOI: 10.3390/children10020315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/11/2023] [Accepted: 01/26/2023] [Indexed: 02/11/2023]
Abstract
Background: Many prognostic factors for CDH patients are described and validated in the current literature: the size of diaphragmatic defects, need for patch repair, pulmonary hypertension and left ventricular dysfunction are recognized as the most influencing outcomes. The aim of this study is to analyze the influence of these parameters in the outcome of CDH patients in our department and identify any further prognostic factors. Methods: An observational retrospective single-center study was conducted including all patients treated at our centre with posterolateral CDH between 01.01.1997 and 12.31.2019. The main outcomes evaluated were mortality and length of hospital stay. A univariate and multivariate analysis was performed. Results: We identified 140 patients with posterolateral CDH; 34.8% died before discharge. The overall median length of stay was 24 days. A univariate analysis confirmed that both outcomes are associated with the size of diaphragmatic defects, need for patch repair and presence of spleen-up (p < 0.05). A multivariate analysis identified that the need for patch repair and maximum dopamine dose used for cardiac dysfunction are independent parameters associated with the length of stay only (p < 0.001). Conclusions: In our series, the duration of hospitalization is longer for newborns with CDH treated with higher doses of dopamine for left ventricular dysfunction or needing patch repair in large diaphragmatic defects.
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Forzano I, Mone P, Mottola G, Kansakar U, Salemme L, De Luca A, Tesorio T, Varzideh F, Santulli G. Efficacy of the New Inotropic Agent Istaroxime in Acute Heart Failure. J Clin Med 2022; 11:7503. [PMID: 36556120 PMCID: PMC9786901 DOI: 10.3390/jcm11247503] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
Current therapeutic strategies for acute heart failure (AHF) are based on traditional inotropic agents that are often associated with untoward effects; therefore, finding new effective approaches with a safer profile is dramatically needed. Istaroxime is a novel compound, chemically unrelated to cardiac glycosides, that is currently being studied for the treatment of AHF. Its effects are essentially related to its inotropic and lusitropic positive properties exerted through a dual mechanism of action: activation of the sarcoplasmic reticulum Ca2+ ATPase isoform 2a (SERCA2a) and inhibition of the Na+/K+-ATPase (NKA) activity. The advantages of istaroxime over the available inotropic agents include its lower arrhythmogenic action combined with its capability of increasing systolic blood pressure without augmenting heart rate. However, it has a limited half-life (1 hour) and is associated with adverse effects including pain at the injection site and gastrointestinal issues. Herein, we describe the main mechanism of action of istaroxime and we present a systematic overview of both clinical and preclinical trials testing this drug, underlining the latest insights regarding its adoption in clinical practice for AHF.
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Affiliation(s)
- Imma Forzano
- Division of Cardiology, Department of Advanced Biomedical Sciences, “Federico II” University, 80131 Naples, Italy
| | - Pasquale Mone
- Division of Cardiology, Department of Medicine, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Gaetano Mottola
- Casa di Cura “Montevergine”, Mercogliano, 83013 Avellino, Italy
| | - Urna Kansakar
- Division of Cardiology, Department of Advanced Biomedical Sciences, “Federico II” University, 80131 Naples, Italy
| | - Luigi Salemme
- Casa di Cura “Montevergine”, Mercogliano, 83013 Avellino, Italy
| | - Antonio De Luca
- Department of Mental and Physical Health and Preventive Medicine, University of Campania “Vanvitelli”, 81100 Caserta, Italy
| | - Tullio Tesorio
- Casa di Cura “Montevergine”, Mercogliano, 83013 Avellino, Italy
| | - Fahimeh Varzideh
- Division of Cardiology, Department of Advanced Biomedical Sciences, “Federico II” University, 80131 Naples, Italy
| | - Gaetano Santulli
- Division of Cardiology, Department of Advanced Biomedical Sciences, “Federico II” University, 80131 Naples, Italy
- Division of Cardiology, Department of Medicine, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York, NY 10461, USA
- Department of Molecular Pharmacology, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Einstein Institute for Neuroimmunology and Inflammation (INI), Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY 10461, USA
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Wang J, Trinh TN, Vu ATV, Kim JC, Hoang ATN, Ohk CJ, Zhang YH, Nguyen CM, Woo SH. Chrysosplenol-C increases contraction by augmentation of sarcoplasmic reticulum Ca 2+ loading and release via protein kinase C in rat ventricular myocytes. Mol Pharmacol 2021; 101:13-23. [PMID: 34764211 DOI: 10.1124/molpharm.121.000365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/11/2021] [Indexed: 11/22/2022] Open
Abstract
Naturally found chrysosplenol-C (4',5,6-trihydroxy-3,3',7-trimethoxyflavone) increases the contractility of cardiac myocytes independent of b-adrenergic signaling. We investigated the cellular mechanism for chrysosplenol-C-induced positive inotropy. Global and local Ca2+ signals, L-type Ca2+ current (ICa), and contraction were measured from adult rat ventricular myocytes using two-dimensional confocal Ca2+ imaging, the whole-cell patch clamp technique, and video-edge detection, respectively. Application of chrysosplenol-C reversibly increased Ca2+ transient magnitude with a maximal increase of ~55% within 2-3-min-exposures (EC50 =~21 mM). This chemical did not alter ICa and slightly increased diastolic Ca2+ level. The frequency and size of resting Ca2+ sparks were increased by chrysosplenol-C. Chrysosplenol-C significantly increased sarcoplasmic reticulum (SR) Ca2+ content but not fractional release. Pretreatment of protein kinase C (PKC) inhibitor, but not Ca2+/calmodulin-dependent protein kinase II (CaMKII) inhibitor, abolished the stimulatory effects of chrysosplenol-C on Ca2+ transients and Ca2+ sparks. Chrysosplenol-C-induced positive inotropy was removed by the inhibition of PKC, but not CaMKII or phospholipase C. Western blotting assessment revealed that PKC-δ protein level in the membrane fractions significantly increase within 2 min after chrysosplenol-C exposure with a delayed (5 min) increase in PKC-α levels in insoluble membrane. These results suggest that chrysosplenol-C enhances contractility via PKC (most likely PKC-δ)-dependent enhancement of SR Ca2+ releases in ventricular myocytes. Significance Statement We show that chrysosplenol-C, a natural flavone showing a positive inotropic effect, increases sarcoplasmic reticulum (SR) Ca2+ releases on depolarizations and Ca2+ sparks with an increase of SR Ca2+ loading, but not L-type Ca2+ current, in ventricular myocytes. Chrysosplenol-C-induced enhancement in contraction is eliminated by protein kinase C (PKC) inhibition, and it is associated with redistributions of PKC to the membrane. These indicate that chrysosplenol-C enhances contraction via PKC-dependent augmentations of SR Ca2+ release and Ca2+ loading during action potentials.
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Affiliation(s)
- Jun Wang
- Parmacy, Chungnam National University, Korea, Republic of
| | - Tran N Trinh
- Chungnam National University, Korea, Republic of
| | | | | | | | - Celine J Ohk
- Physiology, Seoul National University College of Medicine, Korea, Republic of
| | - Yin Hua Zhang
- Physiology, Seoul National University College of Medicine, Korea, Republic of
| | | | - Sun-Hee Woo
- Pharmacy, Chungnam National University, Korea, Republic of
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Oh J, Lee BA, Shin WJ, Jeong D, Yun TJ, Park CS, Choi ES, Song IK. Clinical implication of intraoperative ventricular-arterial coupling in pediatric patients undergoing ventricular septal defects repair: A retrospective cohort study. Paediatr Anaesth 2021; 31:1216-1224. [PMID: 34398480 DOI: 10.1111/pan.14277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 05/29/2021] [Accepted: 08/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ventricular-arterial coupling is the ratio of arterial elastance to ventricular end-systolic elastance. AIMS The objective of this study was to determine the clinical implication of intraoperative ventricular-arterial coupling derived from the pressure-area relationship using transesophageal echocardiography. METHODS This retrospective study reviewed the medical records of 72 pediatric patients with ventricular septal defects who underwent corrective surgery with cardiopulmonary bypass. The single-beat modified method was used to assess ventricular-arterial coupling. Logistic regression analyses were performed to determine the correlation between ventricular-arterial coupling and early postoperative outcomes, including the maximum vasoactive-inotropic score, length of mechanical ventilation, and length of hospital stay. RESULTS Ventricular-arterial coupling after cardiopulmonary bypass significantly increased (from 1.0 ± 0.4 to 1.4 ± 0.8, p < .001), indicating a disproportionate increase in the arterial elastance index (from 11.5 ± 5.1 to 19.8 ± 7.5 mmHg/cm2 /m2 , p < .001) compared with the ventricular end-systolic elastance index (from 13.0 ± 6.9 to 16.9 ± 9.0 mmHg/cm2 /m2 , p < .001). Logistic regression analyses revealed that high postoperative ventricular-arterial coupling was independently associated with higher postoperative maximum vasoactive-inotropic score (>10; odds ratio [OR], 8.04; 95% confidence interval [CI], 1.38-46.85, p = .020), longer postoperative mechanical ventilation (>15 h; OR: 11.00; 95% CI: 1.26-96.45, p = .030), and longer postoperative hospital stay (>7 days; OR: 2.98; 95% CI: 1.04-8.58, p = .043). CONCLUSIONS Ventricular-arterial coupling can be easily obtained from the intraoperative transesophageal echocardiography in pediatric patients undergoing ventricular septal defects repair. High postoperative ventricular-arterial coupling is strongly associated with worse early postoperative outcomes. Ventricular-arterial coupling shows promise as an intraoperative analysis tool that can provide insight into the impact of interventions on cardiovascular performance and identify potential targets for treatment in this population.
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Affiliation(s)
- Jimi Oh
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Byungdoo Andrew Lee
- Laboratory for Cardiovascular Dynamics, Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won-Jung Shin
- Laboratory for Cardiovascular Dynamics, Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - DaUn Jeong
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Jin Yun
- Department of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chun Soo Park
- Department of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Seok Choi
- Department of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Kyung Song
- Laboratory for Cardiovascular Dynamics, Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Di Filippo C, Giovannini M, Gentile S, Mori F, Porcedda G, Manfredi M, Calabri GB, De Simone L, Favilli S, Kounis NG. Kounis Syndrome Associated With Takotsubo Syndrome in an Adolescent With Peutz-Jeghers Syndrome. JACC Case Rep 2021; 3:1602-1606. [PMID: 34729510 PMCID: PMC8543138 DOI: 10.1016/j.jaccas.2021.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/07/2021] [Accepted: 07/13/2021] [Indexed: 12/02/2022]
Abstract
We describe the case of a 15-year-old female patient with Peutz-Jeghers syndrome who presented with vomiting and abdominal pain secondary to ileoileal invagination. Initial analgesic treatment was not effective, and subsequent tramadol infusion resulted in clinical manifestations compatible with Kounis and Takotsubo syndromes. However, the patient had an excellent recovery. (Level of Difficulty: Advanced.)
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Affiliation(s)
- Chiara Di Filippo
- Cardiology Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Silvia Gentile
- Cardiology Unit, Santa Maria Nuova Hospital, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Giulio Porcedda
- Cardiology Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Mariangela Manfredi
- Immunology and Allergy Laboratory, San Giovanni di Dio Hospital, Florence, Italy
| | | | - Luciano De Simone
- Cardiology Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Silvia Favilli
- Cardiology Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
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Venema CS, Erasmus ME, Mariani M, Voors AA, Damman K. Post-transplant inotrope score is associated with clinical outcomes after adult heart transplantation. Clin Transplant 2021; 35:e14347. [PMID: 33969543 PMCID: PMC8519078 DOI: 10.1111/ctr.14347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 04/28/2021] [Accepted: 05/02/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Inotrope score has been proposed as a marker of clinical outcome after adult heart transplantation (HTx) but is rarely used in practice. METHODS Inotrope score during the first 48 h after HTx was calculated in 81 patients as: dopamine + dobutamine + amrinone + milrinone (dose × 15) + epinephrine (dose × 100) + norepinephrine (dose × 100) + enoximone + isoprenaline (dose × 100), with each drug in µg/kg/min. Determinants of inotrope score were identified with linear regression. Cox regression was used to determine the association of inotrope score with mortality. RESULTS The mean recipient age was 52 ± 11 years, and 32 (39.5%) patients were female. Determinants of inotrope score were preoperative C-reactive protein, serum urea, congenital heart disease, and donor cardiac arrest (R2 = .30). Inotrope score was associated with 5-year mortality, independent of recipient age and gender (HR 1.03, 95% CI 1.00-1.07). This association was attenuated when adjusting for female-to-male transplant and ischemia time. Inotrope score was also strongly associated with continuous veno-venous hemofiltration (OR 1.07, 95% CI 1.03-1.12). CONCLUSION High inotrope score post-HTx was observed in recipient congenital heart disease and was associated with a higher risk of mortality and acute kidney injury.
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Affiliation(s)
- Constantijn S. Venema
- Department of Cardiothoracic SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
- Department of CardiologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Michiel E. Erasmus
- Department of Cardiothoracic SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Massimo Mariani
- Department of Cardiothoracic SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Adriaan A. Voors
- Department of CardiologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Kevin Damman
- Department of CardiologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
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Gottlieb SS, Psotka MA, Desai N, Lindenfeld J, Russo P, Allen LA. Use of Outpatient Intravenous Calcitropes for Heart Failure in the United States. J Card Fail 2021; 27:1276-1279. [PMID: 34265464 DOI: 10.1016/j.cardfail.2021.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Outpatient calcitrope infusions-that is, the cardiac inotropes milrinone and dobutamine-are often used for bridge to transplantation and palliation in advanced heart failure, but few data exist about the real-world use of these agents. METHODS AND RESULTS We used the Symphony Integrated DataVerse of commercial, managed Medicare, and Medicaid insurance claims of approximately 280 million people (2012-2020) to determine the incidence and characteristics of ambulatory calcitrope use. Demographics were calculated, including geographic densities at the metropolitan statistical area level. A population projection normalized for age, sex, and location was extrapolated to the total US population. Ambulatory dispensing of milrinone was found in 10,533 outpatients, 1867 in 2019. Ambulatory dobutamine use was found in 4967 outpatients, 836 in 2019. The 2019 total US projection was 3411 for milrinone and 1281 for dobutamine. The mean age was 62 years for milrinone and 68 for dobutamine. Males represented 70% of use. There were differences between drugs in geographic distribution, with more milrinone use in the Northeast and South and more dobutamine use in the Midwest. Duration of use was 4.6 ± 7.2 months for milrinone and 1.8 ± 4.0 months for dobutamine. Of the patients receiving milrinone, 30.6% subsequently underwent cardiac transplantation or left ventricular assist device placement, whereas 10% receiving dobutamine went on to advanced therapies. Less than 0.5% of patients received calcitropes while enrolled in hospice care. CONCLUSIONS More than 4000 patients receive outpatient infusion of calcitropes annually in the outpatient setting. Men are much more likely to receive these medications. A minority of the use is as a bridge to advanced therapies. Geographic variability in use suggests better evidence and consistent guidelines may be helpful.
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Affiliation(s)
- Stephen S Gottlieb
- University of Maryland School of Medicine and Baltimore VAMC, Baltimore, Maryland.
| | | | | | | | - Pierantonio Russo
- Spring Hills-Population Health, Edison, NJ and Eversana Analytics, Milwaukee, WI
| | - Larry A Allen
- University of Colorado School of Medicine, Aurora, Colorado
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Nanasi P, Komaromi I, Gaburjakova M, Almassy J. Omecamtiv Mecarbil: A Myosin Motor Activator Agent with Promising Clinical Performance and New in vitro Results. Curr Med Chem 2019; 25:1720-1728. [PMID: 29278207 DOI: 10.2174/0929867325666171222164320] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 09/26/2017] [Accepted: 11/29/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Clinical treatment of heart failure is still suffering from limited efficacy and unfavorable side effects. The recently developed group of agents, the myosin motor activators, act directly on cardiac myosin resulting in an increased force generation and prolongation of contraction. The lead molecule, omecamtiv mecarbil is now in human 3 stage. In addition to the promising clinical data published so far, there are new in vitro results indicating that the effect of omecamtiv mecarbil on contractility is rate-dependent. Furthermore, omecamtiv mecarbil was shown to activate cardiac ryanodine receptors, an effect that may carry proarrhythmic risk. METHODS These new results, together with the controversial effects of the drug on cardiac oxygen consumption, are critically discussed in this review in light of the current literature on omecamtiv mecarbil. RESULTS In therapeutically relevant concentrations the beneficial inotropic effect of the agent is not likely affected by these new results - in accordance with the good clinical data. At supratherapeutic concentrations, however, activation of cardiac ryanodine receptors may increase arrhythmia propensity, and the stronger effect on diastolic than systolic cell shortening, observed at higher pacing frequencies, may decrease or offset the inotropic effect of omecamtiv mecarbil. CONCLUSION Further studies with definitely supratherapeutical concentrations of omecamtiv mecarbil should be designed to map the actual risk of these potentially harmful side-effects.
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Affiliation(s)
- Peter Nanasi
- Department of Biophysics and Cell Biology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Istvan Komaromi
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Marta Gaburjakova
- Institute of Molecular Physiology and Genetics, Centre of Biosciences, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Janos Almassy
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Rønning L, Bakkehaug JP, Rødland L, Kildal AB, Myrmel T, How O. Opposite diastolic effects of omecamtiv mecarbil versus dobutamine and ivabradine co-treatment in pigs with acute ischemic heart failure. Physiol Rep 2018; 6:e13879. [PMID: 30311442 PMCID: PMC6182250 DOI: 10.14814/phy2.13879] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 08/30/2018] [Accepted: 09/03/2018] [Indexed: 02/01/2023] Open
Abstract
Acute ischemic cardiogenic shock is associated with poor prognosis, and the impact of inotropic support on diastolic function in this context is unclear. We assessed two suggested new inotropic strategies in a clinically relevant pig model of ischemic acute heart failure (AHF): treatment with the myosin activator omecamtiv mecarbil (OM) or dobutamine and ivabradine (D+I). Left ventricular (LV) ischemia was induced in anesthetized pigs by coronary microembolization (n = 12). The animals then received OM (bolus 0.75 mg/kg, followed by 0.5 mg/kg per h) (n = 6) or D+I (5 μg/kg per min + 0.29 ± 0.16 mg/kg) (n = 6), respectively. Ischemia reduced the stroke volume (SV), despite the increased left atrial pressure associated with impaired LV early relaxation, systolic dilatation, and LV late diastolic stiffness. Both treatments improved systolic ejection, but only D+I increased the SV from 26 ± 5 to 33 ± 5 mL. D+I enhanced LV early relaxation (Tau; from 45 ± 11 to 29 ± 4 msec) and prolonged the diastolic time (DT) from 338 ± 60 to 352 ± 40 msec. In contrast, OM prolonged Tau (42 ± 5 to 62 ± 10 msec) and shortened the DT (from 326 ± 68 to 248 ± 84 msec). Our data suggest that enhanced early relaxation by D+I improves LV pump function in postischemic acute heart failure. In contrast, OM worsened lusitropy in this model.
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Affiliation(s)
- Leif Rønning
- Cardiovascular Research GroupInstitute of Medical BiologyFaculty of Health SciencesUiT The Arctic University of NorwayTromsøNorway
| | - Jens P. Bakkehaug
- Cardiovascular Research GroupInstitute of Medical BiologyFaculty of Health SciencesUiT The Arctic University of NorwayTromsøNorway
| | - Lars Rødland
- Cardiovascular Research GroupInstitute of Medical BiologyFaculty of Health SciencesUiT The Arctic University of NorwayTromsøNorway
| | - Anders B. Kildal
- Cardiovascular Research GroupInstitute of Medical BiologyFaculty of Health SciencesUiT The Arctic University of NorwayTromsøNorway
| | - Truls Myrmel
- Cardiovascular Research GroupInstitute of Clinical MedicineFaculty of Health SciencesUiT The Arctic University of NorwayTromsøNorway
- Department of Cardiothoracic and Vascular Surgery, Heart and Lung ClinicUniversity Hospital of North NorwayTromsøNorway
| | - Ole‐Jakob How
- Cardiovascular Research GroupInstitute of Medical BiologyFaculty of Health SciencesUiT The Arctic University of NorwayTromsøNorway
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11
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Abstract
Clinical treatment of heart failure is still not fully solved. A novel class of agents, the myosin motor activators, acts directly on cardiac myosin resulting in an increased force generation and prolongation of contraction. Omecamtiv mecarbil, the lead molecule of this group, is now in human phase 3 displaying promising clinical performance. However, omecamtiv mecarbil is not selective to myosin, because it readily binds to and activates cardiac ryanodine receptors (RyR-2), an effect that may cause complications in case of overdose. In this study, in silico analysis was performed to investigate the docking of omecamtiv mecarbil and other structural analogues to cardiac myosin heavy chain and RyR-2 to select the structure that has a higher selectivity to myosin over RyR-2. In silico docking studies revealed that omecamtiv mecarbil has comparable affinity to myosin and RyR-2: the respective Kd values are 0.60 and 0.87 μmol/L. Another compound, CK-1032100, has much lower affinity to RyR-2 than omecamtiv mecarbil, while it still has a moderate affinity to myosin. It was concluded that further research starting from the chemical structure of CK-1032100 may result a better myosin activator burdened probably less by the RyR-2 binding side effect. It also is possible, however, that the selectivity of omecamtiv mecarbil to myosin over RyR-2 cannot be substantially improved, because similar moieties seem to be responsible for the high affinity to both myosin and RyR-2.
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Affiliation(s)
- Péter Nánási
- a Department of Biophysics and Cell Biology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - István Komáromi
- b Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - János Almássy
- c Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Pappalardo F, Ajello S, Greco M, Celińska-Spodar M, De Bonis M, Zangrillo A, Montisci A. Contemporary applications of intra-aortic balloon counterpulsation for cardiogenic shock: a "real world" experience. J Thorac Dis 2018; 10:2125-2134. [PMID: 29850116 DOI: 10.21037/jtd.2018.04.20] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Intra-aortic balloon pump (IABP) had a pivotal role in the therapy of cardiogenic shock (CS), but recent studies have questioned its effects on patients' outcome. Aim of this study is the description of a "real world" series of patients in which IABP was used as a primary mechanical circulatory support (MCS). Methods All patients who received IABP in our institution during 1 year were prospectively enrolled in our study. The outcomes were: ICU mortality, length of ICU stay, factors associated with mortality and complications of IABP. A logistic regression model was developed to estimate the effect of several risk factors on mortality. Results A total of 119 patients were enrolled, 54 patients underwent IABP placement for CS unrelated to cardiac surgery (medical CS) and 65 after open-heart surgery. There was no significant difference for mortality between medical CS [12/54 (22.2%)] and cardiac surgery [7/65 (10.8%)] (P=0.09). The morbidity rate related to IABP was 11.3%. Multivariable analysis identified AKI (OR =9.3; 95% CI, 2.0-40.0; P=0.004), inotropic score at the time of IABP implantation (OR =1.06; 95% CI, 1.01-1.11; P=0.009) and history of myocardial revascularization (OR =4.7; 95% CI, 1.1-20.2; P=0.036) as independent predictors for early death (P<0.05). A ROC curve analysis for inotropic score at time of implantation and mortality was performed in the overall population [AUC=0.78 (95% CI, 0.66-0.90)]. A cutoff of 20 has a specificity =72% and sensitivity=74% in this population. Conclusions Mortality is similar in medical and postcardiotomy CS. The benefits of IABP are limited if the amount of inotropes and the severity of shock are too high.
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Affiliation(s)
- Federico Pappalardo
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Massimiliano Greco
- Department of Anesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy
| | | | - Michele De Bonis
- Department of Cardiac Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Montisci
- Department of Anesthesia and Intensive Care, Cardiothoracic Centre, Istituto Clinico Sant'Ambrogio, Gruppo Ospedaliero San Donato, Milan, Italy
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13
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Abstract
OBJECTIVES To assess the validity of Vasoactive-Inotropic Score as a scoring system for cardiovascular support and surrogate outcome in pediatric sepsis. DESIGN Secondary retrospective analysis of a single-center sepsis registry. SETTING Freestanding children's hospital and tertiary referral center. PATIENTS Children greater than 60 days and less than 18 years with sepsis identified in the emergency department between January 2012 and June 2015 treated with at least one vasoactive medication within 48 hours of admission to the PICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Vasoactive-Inotropic Score was abstracted at 6, 12, 24, and 48 hours post ICU admission. Primary outcomes were ventilator days and ICU length of stay. The secondary outcome was a composite outcome of cardiac arrest/extracorporeal membrane oxygenation/in-hospital mortality. One hundred thirty-eight patients met inclusion criteria. Most common infectious sources were pneumonia (32%) and bacteremia (23%). Thirty-three percent were intubated and mortality was 6%. Of the time points assessed, Vasoactive-Inotropic Score at 48 hours showed the strongest correlation with ICU length of stay (r = 0.53; p < 0.0001) and ventilator days (r = 0.52; p < 0.0001). On multivariable analysis, Vasoactive-Inotropic Score at 48 hours was a strong independent predictor of primary outcomes and intubation. For every unit increase in Vasoactive-Inotropic Score at 48 hours, there was a 13% increase in ICU length of stay (p < 0.001) and 8% increase in ventilator days (p < 0.01). For every unit increase in Vasoactive-Inotropic Score at 12 hours, there was a 14% increase in odds of having the composite outcome (p < 0.01). CONCLUSIONS Vasoactive-Inotropic Score in pediatric sepsis patients is independently associated with important clinically relevant outcomes including ICU length of stay, ventilator days, and cardiac arrest/extracorporeal membrane oxygenation/mortality. Vasoactive-Inotropic Score may be a useful surrogate outcome in pediatric sepsis.
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14
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Affiliation(s)
| | - Sumit Singh
- University of California Los Angeles, CA, USA
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15
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Abstract
Heart failure became a leading cause of mortality in the past few decades with a progressively increasing prevalence. Its current therapy is restricted largely to the suppression of the sympathetic activity and the renin-angiotensin system in combination with diuretics. This restrictive strategy is due to the potential long-term adverse effects of inotropic agents despite their effective influence on cardiac function when employed for short durations. Positive inotropes include inhibitors of the Na+/K+ pump, β-receptor agonists, and phosphodiesterase inhibitors. Theoretically, Ca2+ sensitizers may also increase cardiac contractility without resulting in Ca2+ overload; nevertheless, their mechanism of action is frequently complicated by other pleiotropic effects. Recently, a new positive inotropic agent, the myosin activator omecamtiv mecarbil, has been developed. Omecamtiv mecarbil binds directly to β-myosin heavy chain and enhances cardiac contractility by increasing the number of the active force-generating cross-bridges, presumably without major off-target effects. This review focuses on recent in vivo and in vitro results obtained with omecamtiv mecarbil, and discusses its mechanism of action at a molecular level. Based on clinical data, omecamtiv mecarbil is a promising new tool in the treatment of systolic heart failure.
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Affiliation(s)
- Péter Nánási
- a Department of Biophysics and Cell Biology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Krisztina Váczi
- b Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Papp
- c Division of Clinical Physiology, Department of Cardiology, Research Center for Molecular Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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16
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Lovett ME, Estrada M, Sargel C, Tobias JD. Augmentation of the Inotropic Effects of Dopamine Following Linezolid Administration in an Infant. J Intensive Care Med 2016; 31:490-2. [PMID: 26864168 DOI: 10.1177/0885066615627777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 12/30/2015] [Indexed: 11/15/2022]
Abstract
Although generally safe and effective, one of the unique properties of linezolid is its weak inhibitory effect on monoamine oxidase. As such, it may interact with other medications that act through the adrenergic or serotonergic systems, including selective-serotonin reuptake inhibitors and vasoactive agents. We present a 3-month-old infant who was being treated with dopamine to maintain mean arterial pressure during mechanical ventilation following viral-induced respiratory failure. Hypertension and tachycardia developed during the administration of linezolid on two separate occasions. The physiology of catecholamine metabolism is reviewed including the role of the monoamine oxidase system. The potential interaction between linezolid and vasoactive agents such as dopamine is discussed.
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Affiliation(s)
- Marlina E Lovett
- Division of Pediatric Critical Care, Nationwide Children's Hospital, Columbus, OH, USA
| | - Maria Estrada
- Division of Pediatric Critical Care, Nationwide Children's Hospital, Columbus, OH, USA Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Cheryl Sargel
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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17
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Denault AY, Couture P, Beaulieu Y, Haddad F, Deschamps A, Nozza A, Pagé P, Tardif JC, Lambert J. Right Ventricular Depression After Cardiopulmonary Bypass for Valvular Surgery. J Cardiothorac Vasc Anesth 2015; 29:836-44. [PMID: 25976606 DOI: 10.1053/j.jvca.2015.01.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To assess if right ventricular (RV) dysfunction is associated with increased mortality after cardiac surgery. DESIGN Post-hoc analysis of a single-center double-blind randomized controlled trial. SETTING University hospital. PARTICIPANTS A total of 120 patients undergoing simple or complex valvular surgery. INTERVENTIONS Patients were randomized to receive intravenous amiodarone or placebo intraoperatively. As secondary analysis, patients were divided into those requiring or not requiring postoperative inotropic agents. MEASUREMENTS AND MAIN RESULTS After cardiopulmonary bypass (CPB), there were significant increases in heart rate, cardiac index, systolic and mean arterial pressures, central venous pressure and pulmonary capillary wedge pressure with reduction in systemic vascular resistance (p<0.05). Right ventricular end-systolic area became larger in those without inotropes and tricuspid annular plane systolic excursion was reduced in all patients; mitral annular systolic velocities were higher in patients receiving inotropes. Both right- and left-sided Doppler signals were altered significantly after CPB, which may be attributed to increased filling pressure. Inotropic agents were required in 56 patients after CPB (47%). The use of inotropic agents was associated with increased left and right atrial velocities (p<0.05). There were no differences in postoperative complications between groups; however, the number of deaths at 6 years was increased in patients who received inotropes after CPB (p = 0.0247). CONCLUSIONS The increases in right-sided dimensions after CPB are associated with reduction in RV function and increased biventricular filling pressure, suggesting worsening biventricular function and interventricular dependence. Inotropic medications were associated with unaltered RV dimensions and increased biatrial activity.
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Affiliation(s)
- André Y Denault
- Departments of Anesthesiology; Division of Critical Care, Centre Hospitalier de l'Université de Montréaland Montreal Heart Institute.
| | | | - Yanick Beaulieu
- Department of Medicine, Sacré-Coeur de Montréal Hospital, Montreal, Quebec, Canada
| | - Francois Haddad
- Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | | | - Anna Nozza
- Montreal Heart Institute Coordinating Center
| | - Pierre Pagé
- Cardiac Surgery, Montreal Heart Institute and Université de Montréal
| | | | - Jean Lambert
- Department of Preventive and Social Medicine, Université de Montréal, Montreal, Quebec, Canada
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18
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Abstract
The ability to stimulate cardiac contractility is known as positive inotropy. Endogenous hormones, such as adrenaline and several natural or synthetic compounds possess this biological property, which is invaluable in the modern cardiovascular therapy setting, especially in acute heart failure or in cardiogenic shock. A number of proteins inside the cardiac myocyte participate in the molecular pathways that translate the initial stimulus, that is, the hormone or drug, into the effect of increased contractility (positive inotropy). Genetic variations (polymorphisms) in several genes encoding these proteins have been identified and characterized in humans with potentially significant consequences on cardiac inotropic function. The present review discusses these polymorphisms and their effects on cardiac inotropy, along with the individual pharmacogenomics of the most important positive inotropic agents in clinical use today. Important areas for future investigations in the field are also highlighted.
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Affiliation(s)
- Anastasios Lymperopoulos
- From the Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, 3200 S. University Drive, HPD (Terry) Bldg/Room 1338, Ft. Lauderdale, FL 33328-2018, USA
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19
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Shah B, Sharma P, Brahmbhatt A, Shah R, Rathod B, Shastri N, Patel J, Malhotra A. Study of levosimendan during off-pump coronary artery bypass grafting in patients with LV dysfunction: a double-blind randomized study. Indian J Pharmacol 2014; 46:29-34. [PMID: 24550581 PMCID: PMC3912803 DOI: 10.4103/0253-7613.125161] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 08/05/2013] [Accepted: 10/06/2013] [Indexed: 12/03/2022] Open
Abstract
Objectives: Levosimendan is a calcium sensitizer drug which has been used in cardiac surgery for the prevention of postoperative low cardiac output syndrome (LCOS) and in difficult weaning from cardiopulmonary bypass (CPB). This study aims to evaluate perioperative hemodynamic effects of levosimendan pretreatment in patients for off-pump coronary artery bypass graft (OPCABG) surgery with low left ventricular ejection fractions (LVEF < 30%). Materials and Methods: Fifty patients undergoing OPCABG surgery with low LVEF (<30%) were enrolled in the study. Patients were randomly divided in two groups: Levosimendan pretreatment (Group L) and placebo pretreatment (Group C) of 25 each. Group L, patients received levosimendan infusion 200 μg/kg over 24 h and in Group C Patients received placebo. The clinical parameters measured before and after the drug administration up to 48 h were heart rate (HR; for the hour after drug infusion), cardiac index (CI), and pulmonary capillary wedge pressure (PCWP). The requirement of inotropes, intraaortic balloon pump (IABP), CPB, intensive care unit (ICU) stay, and hospital stay were also measured. Results: The patients in group L exhibited higher CI and PCWP during operative in early postoperative period as compared to control group C. Group L also had a less requirement for inotropes, CPB support and IABP with shorter ICU stay as well as hospital stay. Conclusion: Levosimendan pretreatment (24 h infusion) in patient for OPCABG with poor LVEF shows better outcomes and hemodynamics in terms of inotropes, CPB and IABP requirements. It also reduces ICU stay.
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Affiliation(s)
- B Shah
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - P Sharma
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - A Brahmbhatt
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - R Shah
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - B Rathod
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - Naman Shastri
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - J Patel
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
| | - A Malhotra
- Chief Cardiac Anesthesiologist, SAL Hospital, Ahmadabad, Gujarat, India
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20
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Tzimas KN, Papadakos PJ. An updated review of sepsis for the anesthesiologist. Semin Cardiothorac Vasc Anesth 2013; 17:262-8. [PMID: 24013953 DOI: 10.1177/1089253213504141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Severe sepsis and septic shock continue to be among of the leading causes of death in intensive care unit patients, carrying an estimated mortality rate between 30% and 50%. This article provides an evidence-based focused review of sepsis, including an update on management strategies based on the most recent guidelines published by the Surviving Sepsis Campaign.
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21
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Andritsos MJ, Kozower BD, Kennedy JLW, Bergin JD, Blank RS. CASE 6-2014: anesthetic management of thoracoscopic lobectomy in a patient with severe biventricular dysfunction. J Cardiothorac Vasc Anesth 2013; 28:826-35. [PMID: 23992651 DOI: 10.1053/j.jvca.2013.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | | | - Randal S Blank
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA.
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22
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Packer M, Colucci W, Fisher L, Massie BM, Teerlink JR, Young J, Padley RJ, Thakkar R, Delgado-Herrera L, Salon J, Garratt C, Huang B, Sarapohja T; REVIVE Heart Failure Study Group. Effect of levosimendan on the short-term clinical course of patients with acutely decompensated heart failure. JACC Heart Fail. 2013;1:103-111. [PMID: 24621834 DOI: 10.1016/j.jchf.2012.12.004] [Citation(s) in RCA: 276] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 12/21/2012] [Accepted: 12/28/2012] [Indexed: 12/25/2022]
Abstract
BACKGROUND This study evaluated the efficacy and safety of levosimendan, a positive inotropic drug with vasodilator effects, given intravenously to patients with acutely decompensated heart failure (ADHF). METHODS We performed 2 sequential trials, the first to develop a new measure of efficacy in 100 patients, and the second to use this measure to evaluate levosimendan in an additional 600 patients. Patients admitted with ADHF received placebo or intravenous levosimendan for 24 h in addition to standard treatment. The primary endpoint was a composite that evaluated changes in clinical status during the first 5 days after randomization. RESULTS In the 600-patient trial, more levosimendan than placebo patients (58 vs. 44) were improved at all 3 pre-specified time points (6 h, 24 h, and 5 days), whereas fewer levosimendan patients (58 vs. 82) experienced clinical worsening (p = 0.015 for the difference between the groups). These differences were apparent, despite more frequent intensification of adjunctive therapy in the placebo group (79 vs. 45 patients). Improvements in patient self-assessment and declines in B-type natriuretic peptide levels with levosimendan persisted for 5 days and were associated with reduced length of stay (p = 0.009). Similar findings were present in the 100-patient pilot trial. Levosimendan was associated with more frequent hypotension and cardiac arrhythmias during the infusion period and a numerically higher risk of death across the 2 trials (49 of 350 on a regimen of levosimendan vs. 40 of 350 on a regimen of placebo at 90 days, p = 0.29). CONCLUSIONS In patients with ADHF, intravenous levosimendan provided rapid and durable symptomatic relief. As dosed in this trial, levosimendan was associated with an increased risk of adverse cardiovascular events. (Evaluation of Intravenous Levosimendan Efficacy in the Short Term Treatment of Decompensated Chronic Heart Failure; NCT00048425).
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23
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Califf RM. Better late than never: a welcome publication of tardy clinical trial results. JACC Heart Fail 2013; 1:112-4. [PMID: 24621835 DOI: 10.1016/j.jchf.2013.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 02/01/2013] [Indexed: 11/25/2022]
Affiliation(s)
- Robert M Califf
- Duke Translational Medicine Institute and the Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
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24
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Abstract
INTRODUCTION Vasoactive drugs are routinely used in critically ill patients with shock to optimize the hemodynamic state while evaluating and treating potentially reversible causes. Limited data exist on the use of multiple vasoactive drugs in the intensive care unit. We hypothesize that the use of 3 or more vasoactive drugs is associated with worse outcomes. METHODS We retrospectively examined the outcome in patients, at least 18 years of age, in whom 3 or more vasoactive drugs were administered simultaneously. We included patients admitted between November 2007 and August 2009. Vasoactive drugs included dopamine, dobutamine, epinephrine, norepinephrine, phenylephrine, and vasopressin. The primary end point was survival to hospital discharge. RESULTS Sixty-six patients received 3 or more vasoactive drugs simultaneously. Nine patients (14%) survived to ICU discharge and 6 patients (9%) survived to hospital discharge. There was a significant difference in mean Simplified Acute Physiology Score II between survivors (32.3 ± 28.6) and nonsurvivors (72.1 ± 30.4), P = .003. Five of the 6 survivors had an acute cardiac procedure, either percutaneous cardiac intervention or heart transplantation. The 1 patient with septic shock who survived had surgery for a bowel perforation. All patients who survived received inotropic therapy (dobutamine). None of the patients who received 4 or more vasoactive drugs survived. CONCLUSION Patients requiring 3 or more vasoactive drugs rarely survive in the absence of an intervention aimed at correcting the underlying cause such as revascularization or source control surgery.
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Affiliation(s)
- Curig O Prys-Picard
- Division of Pulmonary and Critical Care Medicine, University of Texas Medical Branch, TX, USA
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25
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Omerovic E, Råmunddal T, Albertsson P, Holmberg M, Hallgren P, Boren J, Grip L, Matejka G. Levosimendan neither improves nor worsens mortality in patients with cardiogenic shock due to ST-elevation myocardial infarction. Vasc Health Risk Manag 2010; 6:657-63. [PMID: 20859537 PMCID: PMC2941779 DOI: 10.2147/vhrm.s8856] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Indexed: 01/13/2023] Open
Abstract
Background: The aim of this study was to evaluate the effect of levosimendan on mortality in cardiogenic shock (CS) after ST elevation myocardial infarction (STEMI). Methods and results: Data were obtained prospectively from the SCAAR (Swedish Coronary Angiography and Angioplasty Register) and the RIKS-HIA (Register of Information and Knowledge about Swedish Heart Intensive Care Admissions) about 94 consecutive patients with CS due to STEMI. Patients were classified into levosimendan-mandatory and levosimendan-contraindicated cohorts. Inotropic support with levosimendan was mandatory in all patients between January 2004 and December 2005 (n = 46). After the SURVIVE and REVIVE II studies were presented, levosimendan was considered contraindicated and was not used in consecutive patients between December 2005 and December 2006 (n = 48). The cohorts were similar with respect to pre-treatment characteristics and concomitant medications. There was no difference in the incidence of new-onset atrial fibrillation, in-hospital cardiac arrest and length of stay at the coronary care unit. There was no difference in adjusted mortality at 30 days and at one year. Conclusion: The use of levosimendan neither improves nor worsens mortality in patients with CS due to STEMI. Well-designed randomized clinical trials are needed to define the role of inotropic therapy in the treatment of CS.
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Affiliation(s)
- Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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26
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Teerlink JR, Metra M, Zacà V, Sabbah HN, Cotter G, Gheorghiade M, Cas LD. Agents with inotropic properties for the management of acute heart failure syndromes. Traditional agents and beyond. Heart Fail Rev 2009; 14:243-53. [PMID: 19876734 PMCID: PMC2772951 DOI: 10.1007/s10741-009-9153-y] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Treatment with inotropic agents is one of the most controversial topics in heart failure. Initial enthusiasm, based on strong pathophysiological rationale and apparent empirical efficacy, has been progressively limited by results of controlled trials and registries showing poorer outcomes of the patients on inotropic therapy. The use of these agents remains, however, potentially indicated in a significant proportion of patients with low cardiac output, peripheral hypoperfusion and end-organ dysfunction caused by heart failure. Limitations of inotropic therapy seem to be mainly related to their mechanisms of action entailing arrhythmogenesis, peripheral vasodilation, myocardial ischemia and damage, and possibly due to their use in patients without a clear indication, rather than to the general principle of inotropic therapy itself. This review will discuss the characteristics of the patients with a potential indication for inotropic therapy, the main data from registries and controlled trials, the mechanism of the untoward effects of these agents on outcomes and, lastly, perspectives with new agents with novel mechanisms of action.
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Affiliation(s)
- John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, San Francisco, CA USA
| | - Marco Metra
- Cardiology, Department of Experimental and Applied Medicine, University of Brescia, c/o Spedali Civili di Brescia, Piazza Spedali Civili 1, 25123 Brescia, Italy
| | - Valerio Zacà
- Division of Cardiology, Cardiovascular and Thoracic Department, Santa Maria alle Scotte Hospital, Siena, Italy
| | - Hani N. Sabbah
- Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Heart & Vascular Institute, Detroit, MI USA
| | | | - Mihai Gheorghiade
- Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Livio Dei Cas
- Cardiology, Department of Experimental and Applied Medicine, University of Brescia, c/o Spedali Civili di Brescia, Piazza Spedali Civili 1, 25123 Brescia, Italy
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27
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Abstract
Acute heart failure (AHF) is a major cause of hospitalizations. Severe dyspnea, pulmonary congestion and low cardiac output with peripheral vasoconstriction and renal hypoperfusion is a main form of clinical presentation. Most patients with acute worsening have a pre-existing decompensated chronic heart failure (ADCHF), but AHF may also occur as a first manifestation of a previously unknown heart disease. Myocardial ischemia, cardiac arrhythmias, non-compliance with medication and infections are frequent precipitating factors. Management of AHF depends on the underlying heart disease and cause of decompensation. In patients with ADCHF vasodilators and iv diuretics are first-line drugs for rapid reduction of dyspnea and congestion. In patients with signs of low cardiac output and oliguria, inotropic agents are also often administered to prevent further deterioration. Beta-adrenergic agents and phosphodiesterase inhibitors correct the hemodynamic disturbance, but may also induce arrhythmias and worsen myocardial ischemia. Inotropic therapy therefore remains controversial. A novel class of drugs, the calcium sensitizers, represent a new therapeutic option. Levosimendan was shown to improve myocardial contractility without increasing oxygen requirements and to produce peripheral and coronary vasodilation. Its therapeutic effects and tolerance have been tested in several trials. The present review focuses on the clinical pharmacology and therapeutic utility of levosimendan in patients with ADCHF.
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Affiliation(s)
- Ferenc Follath
- Steering Group Drug Therapy, University Hospital Zürich, Raemistrasse 100, Zürich, Switzerland.
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28
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Bollano E, Täng MS, Hjalmarson A, Waagstein F, Andersson B. Different responses to dobutamine in the presence of carvedilol or metoprolol in patients with chronic heart failure. Heart 2003; 89:621-4. [PMID: 12748215 PMCID: PMC1767680 DOI: 10.1136/heart.89.6.621] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine whether patients with congestive heart failure on different beta adrenoreceptor blocking drugs have similar haemodynamic responses to dobutamine. DESIGN Single centre, single blind, randomised, two period crossover study comparing carvedilol with metoprolol CR/XL. PATIENTS Ten patients with stable chronic congestive heart failure (ejection fraction < 40%) on chronic treatment with metoprolol CR/XL. METHODS Patients were treated with carvedilol or metoprolol CR/XL (target dose 50 mg twice daily and 200 mg once daily, respectively) for eight weeks. Stress echocardiography was undertaken at the end of each maintenance period, using dobutamine 5 and 15 microg/kg/min. RESULTS No significant haemodynamic differences were seen at rest on the two treatments. There was a more pronounced increase in heart rate and cardiac output during dobutamine infusion when the patients were on metoprolol than when they were on carvedilol. Mean arterial pressure increased significantly when the patients were on carvedilol, and cardiac output increased during low dose dobutamine, without further change during high dose dobutamine. During the dobutamine infusion, there was no significant difference in ejection fraction between carvedilol and metoprolol treatment. CONCLUSIONS Patients with congestive heart failure on a non-selective beta adrenoreceptor blocker or beta1 selective blocker responded differently to the inotropic drug dobutamine: the beta1 blockade caused by metoprolol could be counteracted by dobutamine, whereas with carvedilol a low dose of dobutamine increased cardiac output, and a higher dose of dobutamine caused a pressor effect. These findings may be clinically relevant when choosing an inotropic drug.
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Affiliation(s)
- E Bollano
- Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska University Hospital, Göteborg, Sweden
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Abstract
1. The resuscitating activity of melanocortin peptides (MSH-ACTH peptides) was tested in an experimental model of prolonged respiratory arrest. 2. Anaesthetized, endotracheally intubated rats subjected to a 5 min period of ventilation interruption, invariably died from cardiac arrest within 6-9 min of resumption of ventilation. 3. When resumption of ventilation was associated with the simultaneous intravenous (i.v.) injection of a melanocortin peptide (alpha-MSH or ACTH-(1-24)) (160 microg kg(-1) there was an almost immediate (within 1 min), impressive increase in cardiac output, heart rate, mean arterial pressure (+ 560% of the before-treatment value) and pulse pressure (+356% of the before-treatment value), with full recovery of electroencephalogram after 30-45 min. Blood gases and pH were normalized within 15-60 min after treatment, and all treated animals eventually recovered completely and survived indefinitely (= more than 15 days). 4. The same response was observed in adrenalectomized animals, as well as in animals pretreated with a beta1-adrenoceptor blocking agent (atenolol, 3 mg kg(-1), i.v.), or with an alpha1-adrenoceptor blocking agent (prazosin, 0.1 mg kg(-1), i.v.), or with an adrenergic neurone blocking agent (guanethidine, 10 mg kg(-1), intraperitoneally). 5. An effect quite similar to that produced by melanocortins was obtained with ouabain (0.1 mg kg(-1), i.v.); the antioxidant drug, glutathione (75 mg kg(-1), i.v.) also produced 100% resuscitation, but the effect was slower in onset. On the other hand, adrenaline (0.005 mg kg(-1), i.v.) was able to resuscitate only 1 out of 8 rats and dobutamine (0.02 mg kg(-1), i.v.) resuscitated 4 out of 8 rats; moreover, the effect of both catecholamines was much slower in onset than that of melanocortins and the initial, impressive stimulation of cardiovascular function was absent. 6. These results show that melanocortin peptides have a resuscitating effect in a pre-terminal condition produced in rats by prolonged asphyxia. This effect seems primarily due to the restoration of cardiac function, not mediated by catecholamines. These data also suggest that these peptides may have potential therapeutic value in conditions of transient cardiac hypoxia and re-oxygenation such as occur in coronary artery disease.
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Affiliation(s)
- S Guarini
- Department of Biomedical Sciences, University of Modena, Italy
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Goldstein RA, Levin DD. Pharmacologic therapy for patients with congestive cardiomyopathy. Tex Heart Inst J 1987; 14:341-5. [PMID: 15227287 PMCID: PMC324755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Treatment in congestive heart failure is directed at improving cardiac output and decreasing preload and afterload without significantly increasing the oxygen requirements of the heart. This paper reviews the current approach to heart failure with inotropic and vasodilator drugs in patients with heart failure.
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Affiliation(s)
- R A Goldstein
- Division of Cardiology, Department of Internal Medicine, School of Medicine, The University of Texas Health Science Center at Houston, USA
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