Journal Article

Levosimendan for patients with severely reduced left ventricular systolic function and/or low cardiac output syndrome undergoing cardiac surgery: a systematic review and meta-analysis

Scolletta, Sabino, Sanfilippo, Filippo, Santonocito, Cristina, Tritapepe, Luigi, Pastore, Federico, Knight, Joshua B., Morelli, Andrea, Arcadipane, Antonio, Lorini, Ferdinando L.

2017

Overview

Background Previous studies have shown beneficial effects of levosimendan in high-risk patients undergoing cardiac surgery. Two large randomized controlled trials (RCTs), however, showed no advantages of levosimendan. Methods We performed a systematic review and meta-analysis (MEDLINE and Embase from inception until March 30, 2017), investigating whether levosimendan offers advantages compared with placebo in high-risk cardiac surgery patients, as defined by preoperative left ventricular ejection fraction (LVEF) ≤ 35% and/or low cardiac output syndrome (LCOS). The primary outcomes were mortality at longest follow-up and need for postoperative renal replacement therapy (RRT). Secondary postoperative outcomes investigated included myocardial injury, supraventricular arrhythmias, development of LCOS, acute kidney injury (AKI), duration of mechanical ventilation, intensive care unit and hospital lengths of stay, and incidence of hypotension during drug infusion. Results Six RCTs were included in the meta-analysis, five of which investigated only patients with LVEF ≤ 35% and one of which included predominantly patients with LCOS. Mortality was similar overall (OR 0.64 [0.37, 1.11], p  = 0.11) but lower in the subgroup with LVEF < 35% (OR 0.51 [0.32, 0.82], p  = 0.005). Need for RRT was reduced by levosimendan both overall (OR 0.63 [0.42, 0.94], p  = 0.02) and in patients with LVEF < 35% (OR 0.55 [0.31, 0.97], p  = 0.04). Among secondary outcomes, we found lower postoperative LCOS in patients with LVEF < 35% receiving levosimendan (OR 0.49 [0.27, 0.89], p  = 0.02), lower overall AKI (OR 0.62 [0.42, 0.92], p  = 0.02), and a trend toward lower mechanical support, both overall ( p  = 0.07) and in patients with LVEF < 35% ( p  = 0.05). Conclusions Levosimendan reduces mortality in patients with preoperative severely reduced LVEF but does not affect overall mortality. Levosimendan reduces the need for RRT after high-risk cardiac surgery.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Cardiac arrhythmia / Cardiac Output, Low - drug therapy / Cardiac Surgical Procedures - methods / Cardiology / Cardiotonic Agents - pharmacology / Cardiotonic Agents - therapeutic use / Cardiovascular agents / Cardiovascular surgery / Clinical trials / Complications and side effects / Coronary vessels / Critical care / Critical Care Medicine / Dosage and administration / Ejection fraction / Emergency Medicine / Evidence-based medicine / Heart failure / Heart surgery / Humans / Hydrazones - pharmacology / Hydrazones - therapeutic use / Intensive / Intensive care / Kidney diseases / Medical diagnosis / Medicine / Medicine & Public Health / Meta-analysis / Methods / Mortality / Patient outcomes / Physiological aspects / Population / Pyridazines - pharmacology / Pyridazines - therapeutic use / Renal replacement therapy / Simendan / Stroke Volume - drug effects / Systematic review / Task forces / Veins & arteries / Ventilators / Ventricular Function, Left - drug effects