Effect of Levosimendan on Low Cardiac Output Syndrome in Patients With Low Ejection Fraction Undergoing Coronary Artery Bypass Grafting With Cardiopulmonary Bypass: The LICORN Randomized Clinical Trial
Bernard Cholley, Thibaut Caruba, Sandrine Grosjean, Julien Amour, Alexandre Ouattara, Judith Villacorta, Bertrand Miguet, Patrick Guinet, François Lévy, Pierre Squara, Nora Aït Hamou, Aude Carillion, Julie Boyer, Marie-Fazia Boughenou, Sebastien Rosier, Emmanuel Robin, Mihail Radutoiu, Michel Durand, Catherine Guidon, Olivier Desebbe, Anaïs Charles-Nelson, Philippe Menasché, Bertrand Rozec, Claude Girard, Jean-Luc Fellahi, Romain Pirracchio, Gilles Chatellier, -, Christian Latrémouille, Paul Achouh, Jérôme Jouan, Alain Bel, Jean-Noël Fabiani, Delphine Hourton, Olivier Bouchot, Adrien Bouglé, Astrid Quessard, Marwan Nader, Pascal Leprince, Delphine Hirtz, Alain Coiffic, Nathalie Noël, Cécile Poisvert, Alain Rémy, Cédric Zaouter, Louis Labrousse, Laurent Barandon, Françoise Gaillat, Catherine-Charlotte Joseph, Frédéric Collart, Nicolas Cotron, Laurent Delille, Jean-Christian Roussel, Hubert-François Carton, Laurent Daviet, Erwan Flecher, Minh Tam Hoang, Alain Brusset, Philippe Estagnaisie, Dan Longrois, Alexandre Mebazaa, Olivier Joulin, Sylvaine Robin, Géraldine Dessertaine, Myriam Cassez Brasseur, Olivier Chavanon, Fabien Dechanet, Clément Boisselier, Pierre Joseph, Olivier Bastien, Jean-François Obadia, Pascal Gueret, François Stéphan, Raphaël Porcher, Bernard Cholley, Thibaut Caruba, Sandrine Grosjean, Julien Amour, Alexandre Ouattara, Judith Villacorta, Bertrand Miguet, Patrick Guinet, François Lévy, Pierre Squara, Nora Aït Hamou, Aude Carillion, Julie Boyer, Marie-Fazia Boughenou, Sebastien Rosier, Emmanuel Robin, Mihail Radutoiu, Michel Durand, Catherine Guidon, Olivier Desebbe, Anaïs Charles-Nelson, Philippe Menasché, Bertrand Rozec, Claude Girard, Jean-Luc Fellahi, Romain Pirracchio, Gilles Chatellier, -, Christian Latrémouille, Paul Achouh, Jérôme Jouan, Alain Bel, Jean-Noël Fabiani, Delphine Hourton, Olivier Bouchot, Adrien Bouglé, Astrid Quessard, Marwan Nader, Pascal Leprince, Delphine Hirtz, Alain Coiffic, Nathalie Noël, Cécile Poisvert, Alain Rémy, Cédric Zaouter, Louis Labrousse, Laurent Barandon, Françoise Gaillat, Catherine-Charlotte Joseph, Frédéric Collart, Nicolas Cotron, Laurent Delille, Jean-Christian Roussel, Hubert-François Carton, Laurent Daviet, Erwan Flecher, Minh Tam Hoang, Alain Brusset, Philippe Estagnaisie, Dan Longrois, Alexandre Mebazaa, Olivier Joulin, Sylvaine Robin, Géraldine Dessertaine, Myriam Cassez Brasseur, Olivier Chavanon, Fabien Dechanet, Clément Boisselier, Pierre Joseph, Olivier Bastien, Jean-François Obadia, Pascal Gueret, François Stéphan, Raphaël Porcher
Abstract
Importance: Low cardiac output syndrome after cardiac surgery is associated with high morbidity and mortality in patients with impaired left ventricular function.
Objective: To assess the ability of preoperative levosimendan to prevent postoperative low cardiac output syndrome.
Design, setting, and participants: Randomized, double-blind, placebo-controlled trial conducted in 13 French cardiac surgical centers. Patients with a left ventricular ejection fraction less than or equal to 40% and scheduled for isolated or combined coronary artery bypass grafting with cardiopulmonary bypass were enrolled from June 2013 until May 2015 and followed during 6 months (last follow-up, November 30, 2015).
Interventions: Patients were assigned to a 24-hour infusion of levosimendan 0.1 µg/kg/min (n = 167) or placebo (n = 168) initiated after anesthetic induction.
Main outcomes and measures: Composite end point reflecting low cardiac output syndrome with need for a catecholamine infusion 48 hours after study drug initiation, need for a left ventricular mechanical assist device or failure to wean from it at 96 hours after study drug initiation when the device was inserted preoperatively, or need for renal replacement therapy at any time postoperatively. It was hypothesized that levosimendan would reduce the incidence of this composite end point by 15% in comparison with placebo.
Results: Among 336 randomized patients (mean age, 68 years; 16% women), 333 completed the trial. The primary end point occurred in 87 patients (52%) in the levosimendan group and 101 patients (61%) in the placebo group (absolute risk difference taking into account center effect, -7% [95% CI, -17% to 3%]; P = .15). Predefined subgroup analyses found no interaction with ejection fraction less than 30%, type of surgery, and preoperative use of β-blockers, intra-aortic balloon pump, or catecholamines. The prevalence of hypotension (57% vs 48%), atrial fibrillation (50% vs 40%), and other adverse events did not significantly differ between levosimendan and placebo.
Conclusions and relevance: Among patients with low ejection fraction who were undergoing coronary artery bypass grafting with cardiopulmonary bypass, levosimendan compared with placebo did not result in a significant difference in the composite end point of prolonged catecholamine infusion, use of left ventricular mechanical assist device, or renal replacement therapy. These findings do not support the use of levosimendan for this indication.
Trial registration: EudraCT Number: 2012-000232-25; clinicaltrials.gov Identifier: NCT02184819.
Conflict of interest statement
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Cholley reports receiving an honorarium for an invited lecture for Orion Pharma. Dr Menasché reports serving on the advisory boards of Edwards Lifesciences and Gecko Biomedical. Dr Rozec reports receiving a grant from Baxter and receiving personal fees from Baxter and Xenios. No other disclosures were reported.
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Source: PubMed