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Preconditioning with levosimendan reduces postoperative low cardiac output in moderate-severe systolic dysfunction patients who will undergo elective coronary artery bypass graft surgery: a cost-effective strategy.

ABSTRACT: BACKGROUND:Patients with moderate-severe systolic dysfunction undergoing coronary artery bypass graft have a higher incidence of postoperative low cardiac output. Preconditioning with levosimendan may be a useful strategy to prevent this complication. In this context, design cost-effective strategies like preconditioning with levosimendan may become necessary. METHODS:In a sequential assignment of patients with Left Ventricle Ejection Fraction less than 40%, two strategies were compared in terms of cost-effectiveness: standard care (n?=?41) versus preconditioning with Levosimendan (n?=?13). The adverse effects studied included: postoperative new-onset atrial fibrillation, low cardiac output, renal failure and prolonged mechanical ventilation. The costs were evaluated using deterministic and probabilistic sensitivity analysis, and Monte Carlo simulations were performed. RESULTS:Preconditioning with levosimendan in moderate to severe systolic dysfunction (Left Ventricle Ejection Fraction

SUBMITTER: Jimenez-Rivera JJ

PROVIDER: S-EPMC7245898 | biostudies-literature | 2020 May

REPOSITORIES: biostudies-literature

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Preconditioning with levosimendan reduces postoperative low cardiac output in moderate-severe systolic dysfunction patients who will undergo elective coronary artery bypass graft surgery: a cost-effective strategy.

Jiménez-Rivera Juan José JJ Álvarez-Castillo Andrea A Ferrer-Rodríguez Jorge J Iribarren-Sarrías José Luis JL García-González Martín Jesús MJ Jorge-Pérez Pablo P Lacalzada-Almeida Juan J Pérez-Hernández Rosalía R Montoto-López Javier J Martínez-Sanz Rafael R

Journal of cardiothoracic surgery 20200524 1

<h4>Background</h4>Patients with moderate-severe systolic dysfunction undergoing coronary artery bypass graft have a higher incidence of postoperative low cardiac output. Preconditioning with levosimendan may be a useful strategy to prevent this complication. In this context, design cost-effective strategies like preconditioning with levosimendan may become necessary.<h4>Methods</h4>In a sequential assignment of patients with Left Ventricle Ejection Fraction less than 40%, two strategies were co ...[more]

PMID: 32448319

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Project description:Physical inactivity and a sedentary lifestyle are associated with a chronic low-level inflammatory state which has been implicated in the pathogenesis of cardiovascular disease. There is growing interest in exercise programs as part of surgical 'prehabilitation'. We therefore studied preoperative physical activity levels of patients undergoing elective Coronary Artery Bypass Graft (CABG) surgery, and performed an exploratory analysis of the influence of physical activity on postoperative outcome. The Short Questionnaire to Assess Health (SQUASH) was used to assess physical activity among 100 patients, of mean (SD) age 65.4 (7.6) years. Additionally, handgrip strength was measured, and the get-up-and-go test was conducted. Anxiety, depression, and quality of life were assessed, and a computerised cognitive test battery was used to assess cognitive performance preoperatively, and three months after surgery. Preoperatively, 76% of patients met the recommended national guidelines for physical activity. The incidence of pre-existing medical conditions, and other pre-operative patient features were similar in active and inactive patients. Preoperative physical activity was significantly inversely related to the logistic EuroSCORE. The level of physical activity was also significantly inversely related with preoperative C-reactive protein (CRP) and peak postoperative CRP, but physical activity did not appear to be associated with any adverse postoperative outcomes or extended length of hospital stay. The incidence of postoperative neurocognitive disorder (PNCD) at 3 months postoperatively was 26%. Cognitive performance was not related with physical activity levels. In summary, this was the first study to assess activity levels of cardiac surgical patients with the SQUASH questionnaire. The majority of patients were physically active. Although physical activity was associated with lower levels of inflammation in this pilot study, it was not associated with an improved clinical or cognitive postoperative outcome.

Project description:Low cardiac output syndrome after cardiac surgery is associated with high morbidity and mortality in patients with impaired left ventricular function.To assess the ability of preoperative levosimendan to prevent postoperative low cardiac output syndrome.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).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.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.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 ?-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.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.EudraCT Number: 2012-000232-25; clinicaltrials.gov Identifier: NCT02184819.

Project description:Purpose Predictive analytics (PA) is a new trending approach in the field of healthcare that uses machine learning to build a prediction model using supervised learning algorithms. Isolated coronary artery bypass grafting (iCABG), an open-heart surgery, is commonly performed in the treatment of coronary heart disease. Aim The aim of this study was to develop and evaluate a model to predict postoperative length of stay (PLoS) for iCABG patients using supervised machine learning techniques, and to identify the features with the highest contribution to the model. Methods This is a retrospective study that uses historic data of adult patients who underwent isolated CABG (iCABG). After initial data pre-processing, data imputation using the kNN method was applied. The study used five prediction models using Naïve Bayes, Decision Tree, Random Forest, Logistic Regression and k Nearest Neighbor algorithms. Data imbalance was managed using the following widely used methods: oversampling, undersampling, “Both”, and random over-sampling examples (ROSE). The features selection process was conducted using the Boruta method. Two techniques were applied to examine the performance of the models, (70%, 30%) split and cross-validation, respectively. Models were evaluated by comparing their performance using AUC and other metrics. Results In the final dataset, six distinct features and 621 instances were used to develop the models. A total of 20 models were developed using R statistical software. The model generated using Random Forest with “Both” resampling method and cross-validation technique was deemed the best fit (AUC=0.81; F1 score=0.82; and recall=0.82). Attributes found to be highly predictive of PLoS were pulmonary artery systolic, age, height, EuroScore II, intra-aortic balloon pump used, and complications during operation. Conclusion This study demonstrates the significance and effectiveness of building a model that predicts PLoS for iCABG patients using patient specifications and pre-/intra-operative measures.

Project description:Corin is a natriuretic peptide-converting enzyme that cleaves precursor pro-B-type natriuretic peptide to active B-type natriuretic peptide (BNP) (diuretic, natriuretic, and vasodilatory properties). Increased plasma BNP is a known diagnostic and prognostic heart failure (HF) biomarker in ambulatory and surgical patients. Recent studies indicate that plasma corin is decreased significantly in chronic HF patients, yet perioperative plasma corin concentrations have not been assessed in cardiac surgical patients. The objectives of this study were to determine the effect of coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB) on plasma corin concentrations and to assess the association between change in perioperative plasma corin concentration and long-term postoperative HF hospitalization or death. It was hypothesized that plasma corin concentrations decrease significantly from preoperative baseline during postoperative days 1 to 4 and that hospitalization or death from HF during the 5 years after surgery is associated with higher relative difference (preoperative baseline to postoperative nadir) in plasma corin concentrations.Prospective observational pilot study.Two institutions: Brigham and Women's Hospital, Boston, Massachusetts and the Texas Heart Institute, St. Luke's Hospital, Houston, Texas.99 patients of European ancestry who underwent isolated primary CABG surgery with CPB.Nonemergency isolated primary CABG surgery with CPB.Plasma corin concentration was assessed preoperatively and at 4 postoperative time points (postoperative days 1-4). HF hospitalization or HF death events during the 5 years after surgery were identified by review of hospital and death records. Postoperative plasma corin concentrations were significantly lower than preoperative baseline concentrations (p<0.0001). Perioperative corin concentrations were significantly higher in males than in females (p<0.0001). Fifteen patients experienced long-term postoperative HF events. Patients who experienced HF hospitalization or HF death during study follow-up had significantly higher relative difference in plasma corin concentration (preoperative baseline to postoperative nadir) than patients who did not experience HF events during study follow-up (p=0.03).Plasma corin concentrations decrease significantly from preoperative concentrations after CABG surgery. HF hospitalization or HF death during the 5 years after CABG surgery with CPB is associated with larger relative decrease in plasma corin concentration from preoperative baseline. Further investigation is warranted to determine the role of corin in postoperative HF biology.

Dataset Information

Preconditioning with levosimendan reduces postoperative low cardiac output in moderate-severe systolic dysfunction patients who will undergo elective coronary artery bypass graft surgery: a cost-effective strategy.

Publications

Preconditioning with levosimendan reduces postoperative low cardiac output in moderate-severe systolic dysfunction patients who will undergo elective coronary artery bypass graft surgery: a cost-effective strategy.

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