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      Preoperative optimization with levosimendan in heart failure patient undergoing thoracic surgery

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          • The use of levosimendan for perioperative optimization of patients undergoing cardiac surgery has been reported in several studies, however it has not been thouroughly evaluated in cardiac failure patients undergoing non cardiac surgery.

          • Preoperative levosimendan administration is safe and effective in cardiac failure patient undergoing thoracic surgery.

          • Prophylactic preoperative levosimendan treatment in heart failure patients merits further study.



          We present the case of a patient with dilatative cardiomyopathy waiting for heart transplantation with pleural effusion to be subjected to pleural biopsy, treated with preoperative infusion of levosimendan to improve heart performances.

          Presentation of case

          A 56-year-old man (BMI 22,49) with dilatative cardiomyopathy (EF 18%) presented right pleural effusion. The levosimendan treatment protocol consisted of 24 h continuous infusion (0,1 ug/kg/min), without bolus. The patient was under continuous hemodynamic monitoring prior, during and after levosimendan administration. The surgery for pleural biopsy was performed with uniportal Video Assisted Thoracoscopic approach (VATS).


          A significant increase of Cardiac Index (CI) and Stroke Volume Index (SVI) were observed at 4 h after infusion initiation and was sustained during the next 24 h after the end of infusion. Levosimendan administration was safe.


          In this case the prophylactic preoperative levosimendan administration is safe and effective in cardiac failure patient undergoing thoracic surgery, but prophylactic preoperative levosimendan treatment in these patients merits further study.

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          Most cited references 19

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          Levosimendan: molecular mechanisms and clinical implications: consensus of experts on the mechanisms of action of levosimendan.

          The molecular background of the Ca(2+)-sensitizing effect of levosimendan relates to its specific interaction with the Ca(2+)-sensor troponin C molecule in the cardiac myofilaments. Over the years, significant preclinical and clinical evidence has accumulated and revealed a variety of beneficial pleiotropic effects of levosimendan and of its long-lived metabolite, OR-1896. First of all, activation of ATP-sensitive sarcolemmal K(+) channels of smooth muscle cells appears as a powerful vasodilator mechanism. Additionally, activation of ATP-sensitive K(+) channels in the mitochondria potentially extends the range of cellular actions towards the modulation of mitochondrial ATP production and implicates a pharmacological mechanism for cardioprotection. Finally, it has become evident, that levosimendan possesses an isoform-selective phosphodiesterase-inhibitory effect. Interpretation of the complex mechanism of levosimendan action requires that all potential pharmacological interactions are analyzed carefully in the framework of the currently available evidence. These data indicate that the cardiovascular effects of levosimendan are exerted via more than an isolated drug-receptor interaction, and involve favorable energetic and neurohormonal changes that are unique in comparison to other types of inodilators. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
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            Continuous central venous and pulmonary artery oxygen saturation monitoring in the critically ill.

            To compare the course of continuously measured mixed and central venous O(2) saturations in high-risk patients and to evaluate the impact of various factors that might interfere with reflection spectrophotometry. Prospective, descriptive study in the interdisciplinary ICU of a university hospital. 32 critically ill patients with triple-lumen central vein catheters, including 29 patients requiring pulmonary artery catheterization. The accuracy of fiberoptic measurements was assessed by comparison to reference co-oximeter results at regular intervals. We examined the effect on measurement accuracy of physiological variables including hematocrit, hemoglobin, pH, temperature, and the administration of various solutions via central venous catheter. Continuous parallel measurements of SvO(2) and ScvO(2) were performed in patients with each type of catheters over a total observation time of 1097 h. ScvO(2) values were more accurate and stable than in vitro oximeter measurements ( r=0.96 from 150 samples, mean difference 0.15%, average drift 0.10%/day) and was not significantly affected by synchronous infusion therapy or by changes in hematocrit, hemoglobin, pH, or temperature. ScvO(2) values closely paralleled SvO(2), whether measured in vitro ( r=0.88 from 150 samples) or in vivo ( r=0.81 from 395,128 samples) but averaged about 7+/-4 saturation percentage higher. ScvO(2) changed in parallel in 90% of the 1,498 instances in which SvO(2) changed more than 5% (over an average of 43 min). Continuous fiberoptic measurement of central vein O(2) saturation has potential to be a reliable and convenient tool which could rapidly warn of acute change in the oxygen supply/demand ratio of critically ill patients.
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              Levosimendan pre-treatment improves outcomes in patients undergoing coronary artery bypass graft surgery.

              The calcium sensitizer levosimendan has anti-ischaemic effects mediated via the opening of sarcolemmal and mitochondrial ATP-sensitive potassium channels. These properties suggest potential application in clinical situations where cardioprotection would be beneficial, such as cardiac surgery. We thus decided to investigate whether pharmacological pre-treatment with levosimendan reduces intensive care unit (ICU) length of stay in patients undergoing elective myocardial revascularization under cardiopulmonary bypass. One hundred and six patients undergoing elective coronary artery bypass grafting were randomly assigned in a double-blind manner to receive levosimendan or placebo. Levosimendan (24 microg kg(-1)) or placebo was administered as a slow i.v. bolus over a 10 min period before the initiation of bypass. Tracheal intubation time and the length of ICU stay were significantly reduced in the levosimendan group (P 12 h was significantly higher in the control group (18.0% vs 3.8%; P=0.021). Compared with control patients, levosimendan-treated patients had lower postoperative troponin I concentrations (P<0.0001) and a higher cardiac power index (P<0.0001). Pre-treatment with levosimendan in patients undergoing surgical myocardial revascularization resulted in less myocardial injury, a reduction in tracheal intubation time, less requirement for inotropic support, and a shorter length of ICU stay.

                Author and article information

                Role: Prof
                Int J Surg Case Rep
                Int J Surg Case Rep
                International Journal of Surgery Case Reports
                04 August 2016
                04 August 2016
                : 27
                : 1-4
                [a ]Anesthesia and Intensive Care, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
                [b ]Thoracic Surgery, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
                Author notes
                [* ]Corresponding author at: Anesthesia and Intensive Care, AORN dei Colli Vincenzo Monaldi Hospital, Traversa Galliano 9, 80021 Afragola, Naples, Italy.Anesthesia and Intensive CareAORN dei Colli Vincenzo Monaldi HospitalNaplesItaly
                © 2016 The Authors

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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