Impact of the perioperative inotropic support in grown-up congenital heart patients undergoing cardiac surgery: a propensity score adjusted analysis

Abstract

Background: Grown-up congenital heart (GUCH) patients represent a growing population with a high morbidity risk when undergoing reparative surgery. A main preoperative feature is right ventricular failure, which represents a risk factor for postoperative low cardiac output syndrome. Levosimendan has a potentially beneficial effect. This retrospective study included consecutive GUCH patients with surgeries in a tertiary cardiothoracic centre between 01-01-2013 and 01-10-2017, to test the hypothesis that the postoperative use of levosimendan might be associated with shorter time of mechanical ventilation, when compared with the use of milrinone. To adjust for bias related to the probability of treatment assignment, it uses the inverse propensity score weighting methodology. Results: Overall 363 patients had GUCH surgeries during the study period, their mean age was 31.39 ± 15.31 years, 87 patients were eligible for analysis in the Levosimendan group and 117 in the Milrinone group. The propensity score used pre-and intraoperative variables and resulted in a good balance between covariates. The Levosimendan group included patients with higher preoperative risk scores, a higher prevalence of left and right ventricular failure, who required more often the addition of epinephrine, renal replacement therapy, prolonged mechanical ventilation and intensive care stay. However, after propensity score weighting, patients in the Levosimendan group had shorter durations of mechanical ventilation (average treatment effect − 37.59 h IQR [− 138.85 to − 19.13], p = 0.01) and intensive care stay (average treatment effect − 3.11 days IQR [− 10.03 to − 1.48], p = 0.009). The number of days of additional epinephrine support was shorter and the vasoactive inotropic scores lower. Conclusion: We report a beneficial effect in terms of duration of mechanical ventilation and intensive care stay, and on inotropic requirements of the use of levosimendan following GUCH surgeries. The use of levosimendan in this setting requires validation at a larger scale.

Levosimendan in intensive care and emergency medicine: literature update and expert recommendations for optimal efficacy and safety

“…One study in grown-up congenital heart disease (GUCH) has been identified since 2019. In that retrospective work, Mauriat and colleagues compared outcomes in 87 patients undergoing cardiac surgery who received postoperative levosimendan (0.2 μg/kg/min/24 h) with those in 117 patients who received milrinone (0.5–1.0 μg/kg/min) [ 17 ]. Patients in either group could also receive low-dose (0.02–0.05 μg/kg/min) epinephrine or norepinephrine, as required.…”

“…In this context, Mauriat et al [ 17 ] suggested that when levosimendan was used following surgery in GUCH patients with a high prevalence of RVF and PH, a beneficial impact on the durations of MV and ICU stay was noticed.…”

Dobutamine-sparing strategy in managing patients with impaired ejection fraction undergoing coronary artery bypass grafting: less is more?

“…In many centers worldwide, inotropic therapy has been used routinely in managing patients undergoing cardiovascular surgery and is considered a standard of care. However, few high-quality randomized controlled trials (RCTs) have verified its efficacy, and there is no consensus on how inotropes should be used in cardiac surgery patients (1,2). Recently, an RCT has shown that the 30-day mortality and major cardiovascular complication risks were similar between the dobutamine-sparing and the dobutamine-toall strategy groups in patients with normal left ventricular ejection fraction (LVEF) (i.e., LVEF >50%) who underwent coronary artery bypass grafting (CABG) (3).…”