Sol ventrikül fonksiyonları bozulmuş, ejeksiyon fraksiyonu %40’ın altında olan, koroner arter by-pass greft operasyonu yapılacak hastalara verilen levosimendan tedavisinin, kardiyoprotektif etkinliğinin postoperatif olarak değerlendirilmesi

Year 2020, Volume: 3 Issue: 4, 460 - 465, 22.10.2020

Merih Özbayburt , Yıldırım Gültekin , Hüseyin Gemalmaz

https://doi.org/10.32322/jhsm.798470

Cited By: 2

Abstract

ÖZ
Amaç: Bu çalışmanın amacı koroner by-pass ameliyatı yapılacak, sol ventrikül fonksiyonu bozulmuş hastalarda preoperatif levosimendan tedavisinin postoperatif kardiyoprotektif etkinliğini göstermektir.
Gereç ve Yöntem: Bu çalışma Kasım 2008- Eylül 2009 tarihleri arasında, Eskişehir Osmangazi Üniversitesi Tıp Fakültesi Kalp ve Damar Cerrahisi Anabilim Dalında prospektif olarak gerçekleştirildi. Çalışmaya yaşları 48-78 arasında, ejeksiyon fraksiyonu (EF) %40’ın altında koroner arter hastalığı (KAH) olan 20 hasta alındı. Hastalar iki gruba ayrıldı. 1. gruba preoperatif levosimendan verildi (deney grubu). 2. grup kontrol grubuydu. Hepsine koroner arter bypass greft (KABG) cerrahisi uygulandı. Yaş, komorbidite, kardiyopulmoner by-pass (KPB) zamanı, kros klemp (KK) zamanı, hasta damar sayısı, anastomoz sayısı, ekstübasyon süresi, yoğun bakımda ve hastanede kalış süreleri kaydedildi. Preoperatif, postoperatif 1.gün ve postoperatif 7. gün nt-proBNP değerleri ve preoperatif ve postoperatif 15. gün ejeksiyon fraksiyon (EF) değerleri ekokardiyografiyle (EKO) ölçüldü. Kontrol grubu ve deney grubunun verileri karşılaştırılarak ilacın kardiyoprotektif etkinliği değerlendirildi.
Bulgular: İki grup arasında komorbidite, KPB zamanı, KK zamanı, yaş, hasta damar sayısı, anastomoz sayısı, ekstübasyon süresi, yoğun bakımda kalış süresi ve hastanede kalış süresi açısından istatistiksel olarak anlamlı farklılık saptanmadı. (P>0,05). Preoperatif ölçülen EF değerlerinde gruplar arasında anlamlı farklılık gözlenmedi (P>0,05). Postoperatif 15. gündeki EF ölçümlerinin ortalama değerleri deney grubunda %39, kontrol grubunda %40 olarak hesaplandı. EF değerlerindeki artış deney grubunda daha fazlaydı. Bu artışın deney grubunda daha anlamlı olduğu tespit edildi (P=0,008).
Gruplar arasında preoperatif ve postoperatif 1. gün bakılan nt-proBNP değerleri arasında anlamlı farklılık vardı (P<0,05). Gruplarda nt-proBNP değerlerinde postoperatif 7. güne kadar anlamlı bir artış gözlendi. (P<0,001). İstatistiksel olarak bu artış her iki grupta da anlamlı olmasına karşın kontrol grubundaki artışın daha fazla olduğu görüldü. Postoperatif 7. gün bakılan nt-proBNP ölçümleri sonrası 2 grup arasında anlamlı farklılık yoktu (P>0,05).
Sonuç: Bu çalışma sonucunda KABG cerrahisinde düşük EF’li hastalarda levosimendaın myokardiyal koruma ve kontraktilite üzerine olumlu etkinliği olduğu saptandı.

Keywords

Levosimendan, koroner by-pass cerrahisi, sol ventrikül disfonksiyonu

The assessment of the cardioprotective effectiveness of levosimendan on patients with impaired left ventricle functions and less than %40 of ejection fraction who will receive coronary artery bypass graft operation

Abstract

The purpose of this study is to demonstrate the postoperative cardioprotective efficacy of preoperative levosimendan treatment in patients with impaired left ventricular function undergoing coronary by-pass surgery.
Materyal and Method: This study was performed prospectively between November 2008 and September 2009 in Eskişehir Osmangazi Univercity Department of Cardiovascular Surgery. Twenty patients with coronary artery disease (CAD) between the ages of 48-78 and ejection fraction (EF) below 40% were included in the study. levosimendan was given to the first group preoperatively(experimental group). Group 2 was the control group. Coronary artery bypass graft (CABG) surgery was performed in all of them. One group received additional levosimendan infusion, preoperatively. Age, comorbidity, cardiopulmonary by-pass (CPB) time, cross clamp (CC) time, patient vessel number, anastomosis number, extubation times, intensive care stay and hospital stay were recorded. Preoperative, postoperative 1st day and postoperative 7th day nt-proBNP values and preoperative and postoperative 15th day ejection fraction (EF) values with echocardiography (ECHO) were measured. The cardioprotective efficacy of the drug was evaluated by comparing the data of the control group and the experimental group.
Results: No statistically significant difference was found between the two groups in terms of CPB time, CC time, age, comorbidity, number of sick vessels, number of anastomosis, extubation time, length of stay in intensive care and hospital stay. (P> 0.05). There was no significant difference between the groups in preoperative EF values (P> 0.05). The mean values of EF measurements on the postoperative 15th day were calculated as 39% in the experimental group and 40% in the control group. The increase in EF values was greater in the experimental group. This increase was found to be more significant in the experimental group (P = 0.008). There was a significant difference between the groups in preoperative and postoperative 1st day n-tproBNP values (P <0.05). A significant increase was observed in nt-proBNP values in the groups until the 7th postoperative day. (P <0.001). Although this increase was statistically significant in both groups, it was observed that the increase in the control group was higher. After the nt-proBNP measurements on the postoperative 7th day, there was no significant difference between the two groups (P> 0.05).
Conclusion: As a result of this study, it was determined that levosimendan has a positive effect on myocardial protection and contractility in patients with low EF in CABG surgery.
Keywords: Levosimendan; coroner by-pass surgery; left ventricle dyusfunction.

Keywords

Levosimendan, coroner by-pass surgery, left ventricle dyusfunction.

References

• Trachiotis MD, Weintraub MD, Johnston MD, Jones MD, et al. Coranary artery bypass grafting in patients with advanced left ventriculer dysfunction. Ann Thorac Surg 1998; 66: 1632-9.
• Kirklin JK. Prospects for understanding and eliminating the deleterious effects of cardiopulmonary bypass. Ann Thorac Surg 1991; 51: 529–31.
• Temporelli PL, Scapellato F, Corra U, et al. Perioperative and Postoperative Predictors Of Outcome in Patient in low Ejection Fraction Early After Coronary Artery By Pass Grefting. EAPC 2008; 15: 441-7.
• Allman K.C. Shaw LJ, Hachamovitch. Myocardial viability testing and impact of revascularization on prognosis in patients with coronary arter disease and left ventrikular dysfonction: A meta analysis. J Am Coll Card. 2002; 39: 1151-8.
• Anderson JL, Marshal HW, Bray BE. A randomized trial of intracoronary streptokinase in the treatment of acute myocardial infarction. N. Engl. J. Med. 1983 308: 1312-8.
• Bonow RO. The hibernating myocardium: Implications for management of congestive heart failure. AJC 1995; 75: 17-25.
• Packer M, Leier CV. Survival in congestive heart failure during treatment with drugs with positive inotropic actions. Circulation 1987; 75: 55-63.
• Haikala H, Linden IB. Mechanisms of action of calcium-sensitizing drugs. JBF 1998; 60: 10-9.
• Sorsa T, Heikkinen S, Abbot MB, Abusamhadneh E, Laakso T, Tilgman C. Binding of levosimendan, a calcium sensitizer, to cardiac troponin C. JBC 2001; 276: 9337-43.
• Kaheinen P, Polleselo P, Levijoki J, Haikala H. Levosimendan increases diastolic coronary flow in isolated guinea-pig heart by opening ATP-sensitive potassium channels. JCP 2001; 37: 367-74.
• Korkmaz H, Yilmaz M. “The effects of levosimendan use on high-sensitivity C-reactive protein in patients with decompensated heart failure”, AMS 2019; 4: 174-9.
• Kivikko M, Antila S, Eha J, Lehtonen L, Pantikainen PJ. Pharmacokinetics of levosimendan and its metabolites during and after a 24-hour continuous infusion in patients with severe heart failure. JCPT 2002; 40: 465-71.
• Carr JA, Haithcokk BE, Paone G. Long term out come after coronary artery by pass garfting in patients with severe left ventrikular dysfonction: Ann Thorac Surg 2002; 74: 1531-6.
• Allman K.C. Shaw LJ, Hachamovitch D. Myocardial viability testing and impact of revascularization on prognosis in patients with coronary arter disease and left ventrikular dysfonction: A meta analysis. J Am Coll Card. 2002; 39: 1151-8.
• Lu YF, Qi HW, Tang CZ, Wu MY, Wang Y, Zhao FY. Change of N-terminal pro-brain natriuretic peptide and big endothelin in patients undergoing coronary artery bypass grafting. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue 2007; 19: 667-70.
• Parissis J.T, Adamopoulos S, Farmakis D, at al. G. Effect of serial levosimendan infusions on left ventricular performance and plasma biomarkers of myocardial injury and neurohormonal and immune activation in patients with advanced heart failure. Heart 2006; 92: 1768-72.
• Kyrzopoulos S, Adamapoulos S, Parissis J.T, at al. Levosimendan reduces plasma B-type natriuretic peptide and interleukin 6 and improves central hemodynamics in severe heart failure patients. International JC 2004; 99: 409-13.
• Çelik T, İyisoy A, Yüksel UÇ, Kardeşoğlu E. The prolonged lowering effect of levosimendan on brain natriuretic peptide levels in patients with decompansated heart failure: Clinical implications. İJC 2008; 128: 97-9.
• Cheshire C, Bhagra CJ, Bhagra SK. “A review of the management of patients with advanced heart failure in the intensive care unit”. Ann Transl Med 2020; 8: 828-42.
• J. Skorpil, Brat R, Docekal B, Motyk O. Myocardial revascularisation in patients with severe left ventricular dysfunction. Early and midterm results. Biomed Papers 2004; 148: 55-8.
• Santillo E, Migale M, Massini C, Incalzi RA. Levosimendan for Perioperative Cardioprotection: Myth or Reality? CCR 2018; 14: 142-52.