Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery.
Randy J. Marcel M.D.
Mehta, R. H., J. D. Leimberger, S. van Diepen, J. Meza, A. Wang, R. Jankowich, R. W. Harrison, D. Hay, S. Fremes, A. Duncan, E. G. Soltesz, J. Luber, S. Park, M. Argenziano, E. Murphy, R. Marcel, D. Kalavrouziotis, D. Nagpal, J. Bozinovski, W. Toller, M. Heringlake, S. G. Goodman, J. H. Levy, R. A. Harrington, K. J. Anstrom and J. H. Alexander (2017). “Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery.” N Engl J Med: 2017 Mar [Epub ahead of print].
Background Levosimendan is an inotropic agent that has been shown in small studies to prevent or treat the low cardiac output syndrome after cardiac surgery. Methods In a multicenter, randomized, placebo-controlled, phase 3 trial, we evaluated the efficacy and safety of levosimendan in patients with a left ventricular ejection fraction of 35% or less who were undergoing cardiac surgery with the use of cardiopulmonary bypass. Patients were randomly assigned to receive either intravenous levosimendan (at a dose of 0.2 mug per kilogram of body weight per minute for 1 hour, followed by a dose of 0.1 mug per kilogram per minute for 23 hours) or placebo, with the infusion started before surgery. The two primary end points were a four-component composite of death through day 30, renal-replacement therapy through day 30, perioperative myocardial infarction through day 5, or use of a mechanical cardiac assist device through day 5; and a two-component composite of death through day 30 or use of a mechanical cardiac assist device through day 5. Results A total of 882 patients underwent randomization, 849 of whom received levosimendan or placebo and were included in the modified intention-to-treat population. The four-component primary end point occurred in 105 of 428 patients (24.5%) assigned to receive levosimendan and in 103 of 421 (24.5%) assigned to receive placebo (adjusted odds ratio, 1.00; 99% confidence interval [CI], 0.66 to 1.54; P=0.98). The two-component primary end point occurred in 56 patients (13.1%) assigned to receive levosimendan and in 48 (11.4%) assigned to receive placebo (adjusted odds ratio, 1.18; 96% CI, 0.76 to 1.82; P=0.45). The rate of adverse events did not differ significantly between the two groups. Conclusions Prophylactic levosimendan did not result in a rate of the short-term composite end point of death, renal-replacement therapy, perioperative myocardial infarction, or use of a mechanical cardiac assist device that was lower than the rate with placebo among patients with a reduced left ventricular ejection fraction who were undergoing cardiac surgery with the use of cardiopulmonary bypass.