I read with great interest the paper by Angadi et al. regarding the current role of levosimendan in paediatric patients undergoing heart surgery [1]. In this well-conducted review of the literature, the authors demonstrated that there is insufficient data to advocate the liberal use of levosimendan in this patient population. Today, it remains a rescue drug when other vasoactive drugs are insufficient. I would like to add a brief comment concerning the use of this drug in adult patients during or after cardiac surgery.
Levosimendan is a pyridazinone-dinitrite derivate belonging to the latest drug class of calcium sensitizers [2]. By reducing the calcium-binding coefficient of troponin C in its active form, levosimendan enhances myocardial contraction similar to the effects of traditional inotropic agents without increasing the intracellular calcium concentration, and has a weak arrhythmogenic effect. Additionally, it increases coronary perfusion due to the opening of adenosine triphosphate-sensitive potassium channels [2]. Lusitropic effects of levosimendan, i.e. the improvement of left ventricular relaxation and filling, is another important property of this relatively new agent.
Recently, Landoni et al. [3] conducted a meta-analysis of randomized controlled trials to determine the effects of levosimendan on mortality and hospitalization in adult patients with low output syndrome and decompensated heart failure. They extracted data from 45 randomized clinical trials. The overall in-hospital mortality rate was 17.4% among levosimendan-treated patients and 23.3% in the control group (risk ratio 0.80 [0.72; 0.89]). Of note, reduction in mortality was established in studies performed in cardiac surgery settings. Length of hospital stay was reduced in the levosimendan group (weighted mean difference = -1.31 day). However, a higher percentage of patients experiencing hypotension and increased requirement of vasopressor agents postoperatively was observed in levosimendan vs the control group.
To date, the accepted clinical experience with levosimendan is restricted to weaning from cardiopulmonary bypass when catecholamines are insufficient [4]. Its superiority over other vasoactive drugs was largely demonstrated as a postoperative rescue drug for patients with post-cardiotomy ventricular dysfunction to facilitate weaning from extracorporeal support [5]. However, further investigations are warranted to evaluate the cost/benefit ratio in high-risk patients.
Conflict of interest: none declared
References
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