Liu Yuliang, Zhang Lichen, Yao Yong, Li Yihui, Qin Weidong, Li Yuan, Xue Wanlin, Li Pengyong, Chen Yuguo, Chen Xiaomei, Guo Haipeng
Department of Critical Care Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, 107 Wenhua Xi Road, Jinan, 250012, Shandong, China.
The Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.
Clin Res Cardiol. 2024 Apr;113(4):509-521. doi: 10.1007/s00392-023-02208-1. Epub 2023 May 22.
For patients with severe cardiopulmonary failure, such as cardiogenic shock, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is primarily utilized to preserve their life by providing continuous extracorporeal respiration and circulation. However, because of the complexity of patients' underlying diseases and serious complications, successful weaning from ECMO is often difficult. At present, there have been limited studies on ECMO weaning strategies, so the principal purpose of this meta-analysis is to examine how levosimendan contributes to the weaning of extracorporeal membrane oxygenation.
The Cochrane Library, Embase, Web of Science, and PubMed were browsed for all potentially related research about clinical benefits of levosimendan in weaning patients receiving VA-ECMO and included 15 of them. The main outcome is success of weaning from extracorporeal membrane oxygenation, with the secondary outcomes of 1-month mortality (28 or 30 days), ECMO duration, hospital or intensive care unit (ICU) length of stay, and use of vasoactive drugs.
1772 patients altogether from 15 publications were incorporated in our meta-analysis. We used fixed and random-effect models to combine odds ratio (OR) and 95% confidence interval (CI) for dichotomous outcomes and standardized mean difference (SMD) for continuous outcomes. The weaning success rate in the levosimendan group was considerably higher in contrast to the comparison (OR = 2.78, 95% CI 1.80-4.30; P < 0.00001; I = 65%), and subgroup analysis showed that there was less heterogeneity in patients after cardiac surgery (OR = 2.06, 95% CI, 1.35-3.12; P = 0.0007; I = 17%). In addition, the effect of levosimendan on improving weaning success rate was statistically significant only at 0.2 mcg/kg/min (OR = 2.45, 95% CI, 1.11-5.40; P = 0.03; I = 38%). At the same time, the 28-day or 30-day proportion of deaths in the sample receiving levosimendan also decreased (OR = 0.47, 95% CI, 0.28-0.79; P = 0.004; I = 73%), and the difference was statistically significant. In terms of secondary outcomes, we found that individuals undergoing levosimendan treatment had a longer duration of VA-ECMO support.
In patients receiving VA-ECMO, levosimendan treatment considerably raised the weaning success rate and helped lower mortality. Since most of the evidence comes from retrospective studies, more randomized multicenter trials are required to verify the conclusion.
对于严重心肺功能衰竭患者，如心源性休克，静脉-动脉体外膜肺氧合（VA-ECMO）主要用于通过提供持续的体外呼吸和循环来维持其生命。然而，由于患者基础疾病的复杂性和严重并发症，成功撤离ECMO往往很困难。目前，关于ECMO撤离策略的研究有限，因此本荟萃分析的主要目的是研究左西孟旦如何有助于体外膜肺氧合的撤离。
检索Cochrane图书馆、Embase、Web of Science和PubMed，查找所有关于左西孟旦在接受VA-ECMO的患者撤离过程中临床益处的潜在相关研究，并纳入其中15项。主要结局是体外膜肺氧合撤离成功，次要结局包括1个月死亡率（28天或30天）、ECMO持续时间、住院或重症监护病房（ICU）住院时间以及血管活性药物的使用。
我们的荟萃分析共纳入了15篇出版物中的1772例患者。我们使用固定效应模型和随机效应模型，对二分结局合并比值比（OR）和95%置信区间（CI），对连续结局合并标准化均数差（SMD）。与对照组相比，左西孟旦组的撤离成功率显著更高（OR = 2.78，95% CI 1.80 - 4.30；P < 0.00001；I² = 65%），亚组分析表明心脏手术后患者的异质性较小（OR = 2.06，95% CI 1.35 - 3.12；P = 0.0007；I² = 17%）。此外，左西孟旦仅在0.2 mcg/kg/min时对提高撤离成功率的作用具有统计学意义（OR = 2.45，95% CI 1.11 - 5.40；P = 0.03；I² = 38%）。同时，接受左西孟旦治疗的样本中28天或30天的死亡比例也有所下降（OR = 0.47，95% CI 0.28 - 0.79；P = 0.004；I² = 73%），差异具有统计学意义。在次要结局方面，我们发现接受左西孟旦治疗的个体VA-ECMO支持时间更长。
在接受VA-ECMO的患者中，左西孟旦治疗显著提高了撤离成功率并有助于降低死亡率。由于大多数证据来自回顾性研究，需要更多的随机多中心试验来验证该结论。
