Schiefenhövel Fridtjof, Berger Christian, Penkova Liubov, Grubitzsch Herko, Haller Bernhard, Meyer Alexander, Heringlake Matthias, Sander Michael, Erb Joachim M, Balzer Felix, Treskatsch Sascha
Department of Anaesthesiology and Intensive Care (AINS), Medical Center Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany.
Institute for Artificial Intelligence and Informatics in Medicine (AIIM), Chair of Medical Informatics, Medical Center Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany.
Front Cardiovasc Med. 2023 Jul 26;10:1213696. doi: 10.3389/fcvm.2023.1213696. eCollection 2023.
Though a subgroup analysis has shown improved survival for patients suffering severely reduced ventricular function undergoing coronary artery bypass grafting, RCTs were not able to demonstrate overall beneficial effects of perioperative Levosimendan in cardiac surgery. This might be due to Levosimendan's pharmacokinetics reaching a steady-state concentration only 4-8 h after administration. Thus, this study now analysed the influence of timing of Levosimendan administration on perioperative outcome in cardiac surgery patients preoperatively presenting with severely reduced ventricular function and therefore considered at high-risk for intra- or postoperative low cardiac output syndrome. We hypothesized that prolonged preoperative Levosimendan administration ("preconditioning") would reduce mortality.
All adult patients undergoing cardiac surgery between 2006 and 2018 perioperatively receiving Levosimendan were included in this retrospective, observational cohort study ( = 498). Patients were stratified into 3 groups: Levosimendan started on the day prior to surgery ("preop"), Levosimendan started on the day of surgery ("intraop") or post ICU admission ("postop"). After propensity score matching (PSM) was performed, outcomes defined according to proposed standard definitions for perioperative outcome research were compared between groups.
After PSM, there were no significant differences in patients' characteristics, comorbidities and type/priority of surgery between groups. Compared to intraop or postop Levosimendan treatment, preop treated patients had significantly lower in-hospital-mortality (preop vs. intraop. vs. postop = 16,7% vs. 33,3% vs. 42,3%), duration of mechanical ventilation and rate of continuous renal replacement therapy.
Prolonged preoperative treatment with Levosimendan of cardiac surgery patients preoperatively presenting with severely reduced left ventricular function might be beneficial in terms of postoperative outcome. Our results are in line with recent experts' recommendations concerning the prolonged perioperative use of Levosimendan. We strongly recommend that future randomized trials include this "preconditioning" treatment as an experimental arm.
尽管亚组分析显示，接受冠状动脉搭桥术的心室功能严重降低的患者生存率有所提高，但随机对照试验未能证明围手术期使用左西孟旦对心脏手术有总体有益效果。这可能是由于左西孟旦的药代动力学在给药后仅4 - 8小时达到稳态浓度。因此，本研究分析了左西孟旦给药时间对术前心室功能严重降低、因此被认为有术中或术后低心排血量综合征高风险的心脏手术患者围手术期结局的影响。我们假设术前延长左西孟旦给药时间（“预处理”）会降低死亡率。
本回顾性观察队列研究纳入了2006年至2018年围手术期接受左西孟旦的所有成年心脏手术患者（n = 498）。患者分为3组：术前一天开始使用左西孟旦（“术前”）、手术当天开始使用左西孟旦（“术中”）或重症监护病房入院后开始使用（“术后”）。在进行倾向评分匹配（PSM）后，比较各组之间根据围手术期结局研究的拟议标准定义确定的结局。
PSM后，各组患者的特征、合并症以及手术类型/优先级无显著差异。与术中或术后使用左西孟旦治疗相比，术前治疗的患者住院死亡率显著更低（术前 vs. 术中 vs. 术后 = 16.7% vs. 33.3% vs. 42.3%），机械通气时间和持续肾脏替代治疗率也更低。
术前左心室功能严重降低的心脏手术患者术前延长使用左西孟旦可能对术后结局有益。我们的结果与近期关于围手术期延长使用左西孟旦的专家建议一致。我们强烈建议未来的随机试验将这种“预处理”治疗作为一个试验组纳入。
