Beneficial effects of levosimendan to wean patients from VA-ECMO: a systematic review and meta-analysis

BERTINI, Pietro; Paternoster, Gianluca; LANDONI, Giovanni; FALCONE, Marco; NOCCI, Matteo; COSTANZO, Diego; BRIZZI, Giulia; ROMANI, Matteo; ESPOSITO, Andrea; Guarracino, Fabio

doi:10.23736/s2724-5683.22.06054-9

Cited by 4 publications

(3 citation statements)

References 39 publications

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“…Our findings are in line with the existing literature, which hints towards a positive effect of preconditioning patients with Levosimendan, but fails to find such an effect when Levosimendan is given only in the postoperative phase (8,9,13,16). Additionally, a recent meta-analysis was able to demonstrate beneficial effects of Levosimendan in weaning patients from veno-arterial ECMO support (31), which is in line with our hypothesis that benefits of Levosimendan administration present themselves with a significant delay in onset.…”

Section: Discussionsupporting

confidence: 89%

Influence of timing of Levosimendan administration on outcomes in cardiac surgery

Schiefenhövel

Berger

Penkova

et al. 2023

Front. Cardiovasc. Med.

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PurposeThough a subgroup analysis has shown improved survival for patients suffering severely reduced ventricular function undergoing coronary artery bypass grafting, RCTs were not able to demonstrate overall beneficial effects of perioperative Levosimendan in cardiac surgery. This might be due to Levosimendan’s pharmacokinetics reaching a steady-state concentration only 4–8 h after administration. Thus, this study now analysed the influence of timing of Levosimendan administration on perioperative outcome in cardiac surgery patients preoperatively presenting with severely reduced ventricular function and therefore considered at high-risk for intra- or postoperative low cardiac output syndrome. We hypothesized that prolonged preoperative Levosimendan administration (“preconditioning”) would reduce mortality.MethodsAll adult patients undergoing cardiac surgery between 2006 and 2018 perioperatively receiving Levosimendan were included in this retrospective, observational cohort study (n = 498). Patients were stratified into 3 groups: Levosimendan started on the day prior to surgery (“preop”), Levosimendan started on the day of surgery (“intraop”) or post ICU admission (“postop”). After propensity score matching (PSM) was performed, outcomes defined according to proposed standard definitions for perioperative outcome research were compared between groups.ResultsAfter PSM, there were no significant differences in patients’ characteristics, comorbidities and type/priority of surgery between groups. Compared to intraop or postop Levosimendan treatment, preop treated patients had significantly lower in-hospital-mortality (preop vs. intraop. vs. postop = 16,7% vs. 33,3% vs. 42,3%), duration of mechanical ventilation and rate of continuous renal replacement therapy.ConclusionsProlonged preoperative treatment with Levosimendan of cardiac surgery patients preoperatively presenting with severely reduced left ventricular function might be beneficial in terms of postoperative outcome. Our results are in line with recent experts’ recommendations concerning the prolonged perioperative use of Levosimendan. We strongly recommend that future randomized trials include this “preconditioning” treatment as an experimental arm.

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Section: Discussionsupporting

confidence: 89%

Influence of timing of Levosimendan administration on outcomes in cardiac surgery

Schiefenhövel

Berger

Penkova

et al. 2023

Front. Cardiovasc. Med.

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“…This data is countercurrent compared to our recently published meta-analysis: we analyzed 10 observational retrospective studies, including 987 patients. We demonstrated more successful weaning from VA-ECMO in the levosimendan group, 2 data in line with the previous meta-analysis. 3,4 We also performed again a random effect meta-analysis adding Hau et al’s data and including information from another recent study by Chen et al, 5 and our results were not significantly altered (Figures 1 and 2).…”

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confidence: 91%

Levosimendan’s ability on veno-arterial extracorporeal membrane oxygenation weaning: Evidence says yes!

et al. 2023

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“…The findings of a recent substudy of the LEVO-CTS trial showing that levosimendan significantly reduced both 90day mortality and the rate of LCOS in patients undergoing isolated CABG, but not in those undergoing valve surgery or combined CABG/valve procedures suggest that subgroups of patients can benefit from levosimendan in terms of survival [22]. Moreover, it has been recently suggested that levosimendan may improve the weaning success rate and survival in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) [23,24], who undoubtedly represent a subgroup of patients with severe myocardial dysfunction and LCOS. The currently ongoing WEANILEVO trial aims at investigating the effectiveness of levosimendan in improving the weaning success rate (and mortality among other secondary outcomes) in adult patients who are eligible for VA-ECMO withdrawal [25].…”

Section: Outcomes After Cardiothoracic Surgerymentioning

confidence: 99%

Old issues and new challenges in cardiothoracic anesthesiology: Work in progress…

Pisano

Angelini

Vlasakov

et al. 2023

Front. Anesthesiol.

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Present and future of cardiothoracic anesthesia: An overviewCardiothoracic anesthesia may seem one of the most "traditionalist" subspecialties among anesthesia: cardiothoracic anesthesiologists intubate almost everyone, do very little locoregional anesthesia (especially in cardiac surgery), are still a long way from the fashionable "opioid-free anesthesia" concept [1], and are among the few who still use (and appreciate) the pulmonary artery catheter [2,3]. Some would say it is an old dinosaur destined for extinction just like cardiac surgery itself [4], but (s)he couldn't be further from the truth. First, cardiothoracic anesthesiology has a long tradition of continuous research and innovation to improve the outcome of complex procedures, which are often associated with marked hemodynamic impairment, major bleeding, and life-threatening complications. Moreover, not rarely cardiac surgery is performed in high risk patients due to age, frailty, comorbidities, or critical status. Hence, an increasingly refined and extensive monitoring, specific pharmacological and non-pharmacological perioperative interventions, and defined organ-protection strategies may be pivotal in improving clinically relevant outcomes and increasing survival after cardiothoracic surgery. Second, cardiothoracic surgery is a constantly and rapidly evolving field. On the one hand, improvements in perioperative hemodynamic management and intensive care procedures, as well as the availability of increasingly sophisticated and effective mechanical circulatory support devices allow complex invasive cardiothoracic surgery procedures to be performed relatively safely in elderly patients [5] and in patients with poor myocardial systolic function [6]. On the other hand, minimally invasive and hybrid cardiothoracic procedures are becoming increasingly more common. Cardiothoracic surgery of the future will no longer be considered as opposed to interventional cardiology, but rather it will become part (or one of the options) of a dynamic multidisciplinary approach [7] involving cardiologists, cardiothoracic surgeons, cardiac anesthesiologists, and dedicated intensive care practitioners (the last two now already often belonging to a single team of anesthesiologists/intensivists who deal with both perioperative and intensive care management). Accordingly, cardiothoracic anesthesiologists and intensivists will have to keep up with all this in order to face, at the same time, both less invasivity and greater complexity and level of risk.

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Beneficial effects of levosimendan to wean patients from VA-ECMO: a systematic review and meta-analysis

Cited by 4 publications

References 39 publications

Influence of timing of Levosimendan administration on outcomes in cardiac surgery

Influence of timing of Levosimendan administration on outcomes in cardiac surgery

Levosimendan’s ability on veno-arterial extracorporeal membrane oxygenation weaning: Evidence says yes!

Old issues and new challenges in cardiothoracic anesthesiology: Work in progress…

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