Desai Pushkar Mahendra, Sarkar Manjula S, Umbarkar Sanjeeta R
Department of Anesthesiology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India.
Ann Card Anaesth. 2018 Apr-Jun;21(2):123-128. doi: 10.4103/aca.ACA_178_17.
Off-pump coronary artery bypass surgery (OPCAB) is often complicated by hemodynamic instability, especially in patients with prior left ventricular (LV) dysfunction and appropriate choice of inotrope plays a vital role in perioperative management of these patients.
To study hemodynamic effects and immediate outcome of prophylactic infusion of levosimendan in patients with the LV dysfunction undergoing OPCAB surgery and whether this strategy helps in successful conduct of OPCAB surgery.
After Institutional Ethics Committee approval, 60 patients posted for elective OPCAB surgery were randomly divided into two groups (n = 30 each). Patients with the LV ejection fraction <30% were included. Study group was started on injection levosimendan (@ 0.1 μg/kg/min) in the previous night before surgery and continued for 24 h including intraoperative period. Hemodynamic monitoring included heart rate, invasive blood pressure, cardiac index (CI), pulmonary capillary wedge pressure (PCWP), pulse oximetry, and arterial blood gases with serum lactates at as T0 (baseline), T1 (15 min after obtuse marginal and/or PDA anastomoses), T2 (at end of surgery), T3 (6 h after surgery in Intensive Care Unit [ICU]), T4 (12 h after surgery), and T5 (24 h after surgery in ICU). Vasopressor was added to maintain mean arterial pressure >60 mmHg. Chi-square/Fisher's exact/Mid P exact test and Student's t-tests were applied for categorical and continuous data.
CI was greater and PCWP reduced significantly in Group L during intraoperative and early postoperative period. Serum lactate concentration was lower in patients pretreated with levosimendan. Incidence of postoperative atrial fibrillation (POAF) (36.6 vs. 6.6%; P = 0.01), low cardiac output syndrome (LCOS) (30% vs. 6%; P = 0.02), and acute kidney injury (23.3% vs. 6.7%; P = 0.04) was less in Group L. Three patients (10%) in control group required conversion to cardiopulmonary bypass (CPB) as compared to none in the study group. There was no difference regarding ICU or hospital stay and mortality in both groups.
Preoperative levosimendan helps in successful conduct of OPCAB and reduces the incidence of LCOS, POAF, conversion to CPB, and requirement of intra-aortic balloon pump.
非体外循环冠状动脉搭桥手术（OPCAB）常并发血流动力学不稳定，尤其是既往有左心室（LV）功能障碍的患者，选择合适的血管活性药物对这些患者的围手术期管理至关重要。
研究左西孟旦预防性输注对接受OPCAB手术的LV功能障碍患者的血流动力学影响及近期预后，以及该策略是否有助于OPCAB手术的成功实施。
经机构伦理委员会批准，将60例择期行OPCAB手术的患者随机分为两组（每组n = 30）。纳入LV射血分数<30%的患者。研究组在手术前一晚开始静脉输注左西孟旦（剂量为0.1μg/kg/min），持续24小时，包括术中阶段。血流动力学监测指标包括心率、有创血压、心脏指数（CI）、肺毛细血管楔压（PCWP）、脉搏血氧饱和度，以及在T0（基线）、T1（钝缘支和/或PDA吻合术后15分钟）、T2（手术结束时）、T3（重症监护病房[ICU]术后6小时）、T4（术后12小时）和T5（ICU术后24小时）时测定动脉血气及血清乳酸。添加血管升压药以维持平均动脉压>60mmHg。分类数据和连续数据分别采用卡方检验/费舍尔精确检验/中点精确检验和学生t检验。
L组在术中和术后早期CI更高，PCWP显著降低。左西孟旦预处理患者的血清乳酸浓度更低。L组术后房颤（POAF）发生率（36.6%对6.6%；P = 0.01）、低心排综合征（LCOS）发生率（30%对6%；P = 0.02）和急性肾损伤发生率（23.3%对6.7%；P = 0.04）更低。对照组有3例患者（10%）需要转为体外循环（CPB），而研究组无此情况。两组在ICU住院时间、住院时间和死亡率方面无差异。
术前使用左西孟旦有助于OPCAB手术的成功实施，并降低LCOS、POAF、转为CPB的发生率及主动脉内球囊反搏的需求。
