CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 7, August 2013
260
AFRICA
Effectiveness of prophylactic levosimendan in high-risk
valve surgery patients
OZGUR ERSOY, EMRE BOYSAN, ERTEKIN UTKU UNAL, KEREM YAY, UMIT YENER, FERIT CICEKCIOGLU,
FEHMI KATIRCIOGLU
Abstract
Background:
Levosimendan has anti-ischaemic effects,
improves myocardial contractility and increases systemic,
pulmonary and coronary vasodilatation. These properties
suggest potential advantages in high-risk cardiac valve
surgery patients where cardioprotection would be valuable.
The present study investigated the peri-operative haemo-
dynamic effects of prophylactic levosimendan infusion in
cardiac valve surgery patients with low ejection fraction and/
or severe pulmonary arterial hypertension.
Methods:
Between May 2006 and July 2007, 20 consecutive
patients with severe pulmonary arterial hypertension (systolic
pulmonary artery pressure
≥
60 mmHg) and/or low ejection
fraction (
<
50%) who underwent valve surgery in our clinic
were included in the study and randomised into two groups.
Levosimendan was administered to 10 patients in group I and
not to the 10 patients in the control group. Cardiac output
(CO), cardiac index (CI), systemic vascular resistance (SVR),
pulmonary vascular resistance (PVR) and mean pulmonary
artery pressure (MPAP) were recorded for each patient pre-
operatively and for 24 hours following the operation.
Results:
CO and CI values were higher in the levosimendan
group during the study period (
p
<
0.05). MPAP and PVR
values were significantly lower in the levosimendan group for
the 24-hour period (
p
<
0.05) and SVR values were signifi-
cantly lower after 24 hours in both groups. When clinical
results were considered, no difference in favour of levosi-
mendan was detected regarding the mortality and morbidity
rates between the groups.
Conclusion:
Levosimendan improved the haemodynamics in
cardiac valve surgery patients with low ejection fraction and/
or severe pulmonary arterial hypertension, and facilitated
weaning from cardiopulmonary bypass in such high-risk
patients when started as a prophylactic agent.
Keywords:
cardiac valve, cardiac surgery, pulmonary hyperten-
sion, levosimendan, left ventricular dysfunction
Submitted 22/4/13, accepted 7/6/13
Cardiovasc J Afr
2013;
24
: 260–264
DOI: 10.5830/CVJA-2013-047
Pulmonary arterial hypertension and low ejection fraction
were among the key factors determining prognosis during the
postoperative period in patients with cardiac valve disease who
underwent cardiac surgery.
1,2
Left ventricular dysfunction, which
makes weaning from cardiopulmonary bypass (CPB) difficult
and increases morbidity and mortality rates, may develop in
the patient group that has either or both pulmonary arterial
hypertension and low ejection fraction.
Levosimendan is a recently introduced calcium sensitiser. It
enhances myocardial contractility by sensitisation of troponin
C to calcium, and provides systemic, pulmonary and coronary
arterial and venous vasodilatation due to activation of the
ATP-sensitive potassium channels in smooth muscle fibres.
3
It
has positive inotropic and anti-stunning effects.
4,5
It has been
reported that levosimendan facilitated weaning from CPB in
high-risk patient groups by reducing pulmonary arterial pressure
and increasing both right and left ventricular contractility, which
means improved ejection fraction and cardiac output.
6,7
In the present study, we documented haemodynamic changes
caused by levosimendan infusion, instituted just after the induction
of anaesthesia, as a measure in cardiac valve surgery patients with
low ejection fraction and/or pulmonary arterial hypertension.
Methods
Between May 2006 and July 2007, 20 consecutive patients with
severe pulmonary arterial hypertension (systolic pulmonary
artery pressure
≥
60 mmHg) and low ejection fraction (
<
50%)
who underwent valve surgery in our clinic, were included in the
study and randomised to two groups (levosimendan and control
groups). The conventional definition of pulmonary arterial
hypertension includes mean pulmonary arterial pressure of
>
25 mmHg at rest as assessed by right heart catheterisation. Our
study group of patients was selected as having severe pulmonary
hypertension, which was defined in our clinical practice as
systolic pulmonary artery pressure
≥
60 mmHg.
This study complied with the Declaration of Helsinki and
ethical approval was granted by the local institutional review
board. Informed consent was obtained from all patients.
The anaesthetic and surgical management of all patients was
the same in both groups. Induction and maintenance of general
anaesthesia with endotracheal intubation was standardised in all
the patients (sufentanil, midazolam, pancuronium or atracurium,
and sevoflurane in oxygen with air). Invasive haemodynamic
monitoring, including thermodilution catheterisation, was
established, allowing for haemodynamic measurements at
different time points.
Department of Cardiovascular Surgery, Turkey Yuksek
Ihtisas Hospital, Ankara, Turkey
OZGUR ERSOY, MD
EMRE BOYSAN, MD
ERTEKIN UTKU UNAL, MD,
KEREM YAY, MD
UMIT YENER, MD
FERIT CICEKCIOGLU, MD
Department of Cardiovascular Surgery, Ankara Hospital,
Ankara, Turkey
FEHMI KATIRCIOGLU, MD
