Inhaled levosimendan versus intravenous levosimendan in patients with pulmonary hypertension undergoing mitral valve replacement

Tanveer Singh Kundra, P S Nagaraja, K S Bharathi, Parminder Kaur, N Manjunatha, Tanveer Singh Kundra, P S Nagaraja, K S Bharathi, Parminder Kaur, N Manjunatha

Abstract

Context: Inhaled levosimendan may act as selective pulmonary vasodilator and avoid systemic side effects of intravenous levosimendan, which include decrease in systemic vascular resistance (SVR) and systemic hypotension, but with same beneficial effect on pulmonary artery pressure (PAP) and right ventricular (RV) function.

Aim: The aim of this study was to compare the effect of inhaled levosimendan with intravenous levosimendan in patients with pulmonary hypertension undergoing mitral valve replacement.

Settings and design: The present prospective randomized comparative study was conducted in a tertiary care hospital.

Subjects and methods: Fifty patients were randomized into two groups (n = 25). Group A: Levosimendan infusion was started immediately after coming-off of cardiopulmonary bypass and continued for 24 h at 0.1 mcg/kg/min. Group B: Total dose of levosimendan which would be given through intravenous route over 24 h was calculated and then divided into four equal parts and administered through inhalational route 6th hourly over 24 h. Hemodynamic profile (pulse rate, mean arterial pressure, pulmonary artery systolic pressure [PASP], SVR) and RV function were assessed immediately after shifting, at 1, 8, 24, and 36 h after shifting to recovery.

Statistical analysis used: Intragroup analysis was done using paired student t-test, and unpaired student t-test was used for analysis between two groups.

Results: PASP and RV-fractional area change (RV-FAC) were comparable in the two groups at different time intervals. There was a significant reduction in PASP and significant improvement in RV-FAC with both intravenous and inhalational levosimendan. SVR was significantly decreased with intravenous levosimendan, but no significant decrease in SVR was observed with inhalational levosimendan.

Conclusions: Inhaled levosimendan is a selective pulmonary vasodilator. It causes decrease in PAP and improvement in RV function, without having a significant effect on SVR.

Keywords: Inhalational; intravenous; levosimendan; right ventricular fractional area change; systemic vascular resistance.

Conflict of interest statement

There are no conflicts of interest

References

    1. Chin KM, Kim NH, Rubin LJ. The right ventricle in pulmonary hypertension. Coron Artery Dis. 2005;16:13–8.
    1. Simon MA, Pinsky MR. Right ventricular dysfunction and failure in chronic pressure overload. Cardiol Res Pract. 2011;2011:568095.
    1. Voelkel NF, Quaife RA, Leinwand LA, Barst RJ, McGoon MD, Meldrum DR, et al. Right ventricular function and failure: Report of a National Heart, Lung, and Blood Institute Working Group on cellular and molecular mechanisms of right heart failure. Circulation. 2006;114:1883–91.
    1. Reichert CL, Visser CA, van den Brink RB, Koolen JJ, van Wezel HB, Moulijn AC, et al. Prognostic value of biventricular function in hypotensive patients after cardiac surgery as assessed by transesophageal echocardiography. J Cardiothorac Vasc Anesth. 1992;6:429–32.
    1. Dávila-Román VG, Waggoner AD, Hopkins WE, Barzilai B. Right ventricular dysfunction in low output syndrome after cardiac operations: Assessment by transesophageal echocardiography. Ann Thorac Surg. 1995;60:1081–6.
    1. Denault AY, Pearl RG, Michler RE, Rao V, Tsui SS, Seitelberger R, et al. Tezosentan and right ventricular failure in patients with pulmonary hypertension undergoing cardiac surgery: The TACTICS trial. J Cardiothorac Vasc Anesth. 2013;27:1212–7.
    1. Goldman AP, Delius RE, Deanfield JE, Macrae DJ. Nitric oxide is superior to prostacyclin for pulmonary hypertension after cardiac operations. Ann Thorac Surg. 1995;60:300–5.
    1. Radermacher P, Santak B, Wüst HJ, Tarnow J, Falke KJ. Prostacyclin for the treatment of pulmonary hypertension in the adult respiratory distress syndrome: Effects on pulmonary capillary pressure and ventilation-perfusion distributions. Anesthesiology. 1990;72:238–44.
    1. Mishra A, Kumar B, Dutta V, Arya VK, Mishra AK. Comparative effect of levosimendan and milrinone in cardiac surgery patients with pulmonary hypertension and left ventricular dysfunction. J Cardiothorac Vasc Anesth. 2016;30:639–46.
    1. Tavares M, Andrade AC, Mebazaa A. Levosimendan use in several scenarios of acute heart failure. Arq Bras Cardiol. 2008;90:211–5.
    1. Mavrogeni S, Giamouzis G, Papadopoulou E, Limas K, Dritsas A, Manginas A, et al. Effects of levosimendan on systolic function, ergospirometry and cardiac arrhythmia in patients with decompensated advanced heart failure. A six-month follow-up study. Eur J Heart Fail. 2005;S1:94–5.
    1. Alvarez J, Bouzada M, Fernández AL, Caruezo V, Taboada M, Rodríguez J, et al. Hemodynamic effects of levosimendan compared with dobutamine in patients with low cardiac output after cardiac surgery. Rev Esp Cardiol. 2006;59:338–45.
    1. Sanfilippo F, Knight JB, Scolletta S, Santonocito C, Pastore F, Lorini FL, et al. Levosimendan for patients with severely reduced left ventricular systolic function and/or low cardiac output syndrome undergoing cardiac surgery: A systematic review and meta-analysis. Crit Care. 2017;21:252.
    1. Yilmaz MB, Yontar C, Erdem A, Karadas F, Yalta K, Turgut OO, et al. Comparative effects of levosimendan and dobutamine on right ventricular function in patients with biventricular heart failure. Heart Vessels. 2009;24:16–21.
    1. Russ MA, Prondzinsky R, Carter JM, Schlitt A, Ebelt H, Schmidt H, et al. Right ventricular function in myocardial infarction complicated by cardiogenic shock: Improvement with levosimendan. Crit Care Med. 2009;37:3017–23.
    1. Martyniuk TV, Arkhipova OA, Kobal' EA, Danilov NM, Chazova IE. Possibilities of using levosimendan in patients with idiopathic pulmonary hypertension. Ter Arkh. 2012;84:83–8.
    1. Cicekcioglu F, Parlar AI, Ersoy O, Yay K, Hijazi A, Katircioglu SF, et al. Levosimendan and severe pulmonary hypertension during open heart surgery. Gen Thorac Cardiovasc Surg. 2008;56:563–5.
    1. Morais RJ. Levosimendan in severe right ventricular failure following mitral valve replacement. J Cardiothorac Vasc Anesth. 2006;20:82–4.
    1. Amor M, Selas S, Fernandez A, Garea M, Alvarez J. Haemodinamic effects of levosimendan in patients with pulmonary hypertension after cardiac surgical procedures under extracorporeal circulation: 12AP4-6. Eur J Anaesthesiol. 2008;25:174.
    1. Boost KA, Hoegl S, Dolfen A, Czerwonka H, Scheiermann P, Zwissler B, et al. Inhaled levosimendan reduces mortality and release of proinflammatory mediators in a rat model of experimental ventilator-induced lung injury. Crit Care Med. 2008;36:1873–9.
    1. Chaffin JS, Daggett WM. Mitral valve replacement: A nine-year follow-up of risks and survivals. Ann Thorac Surg. 1979;27:312–9.
    1. Ward C, Hancock BW. Extreme pulmonary hypertension caused by mitral valve disease. Natural history and results of surgery. Br Heart J. 1975;37:74–8.
    1. Morelli A, Teboul JL, Maggiore SM, Vieillard-Baron A, Rocco M, Conti G, et al. Effects of levosimendan on right ventricular afterload in patients with acute respiratory distress syndrome: A pilot study. Crit Care Med. 2006;34:2287–93.
    1. Tewari P, Agarwal S, Majumdar G. Levosimendan after mitral valve replacement supports right ventricular function better in mitral stenosis patients with moderate to severe pulmonary hypertension. J Cardiothorac Vasc Anesth. 2017;31:S17–8.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera