[The calcium sensitizer levosimendan gives superior results to dobutamine in postoperative low cardiac output syndrome]. / Superioridad del sensibilizante al calcio levosimendán comparado con dobutamina en el síndrome de bajo gasto cardiaco postoperatorio.

INTRODUCTION AND OBJECTIVES: The use of levosimendan to treat postoperative low cardiac output syndrome (LCOS) has been studied in only small patient series and in randomized trials focusing on hemodynamic variables. The objective of the present study was to assess the effectiveness of levosimendan, compared with dobutamine, as a treatment for postoperative LCOS. METHODS: Patients with LCOS were randomly assigned to receive either levosimendan (loading dose, 10 microg/kg, followed by 0.1 microg/kg per min for 24 h) or dobutamine (starting dose, 5 microg/kg per min). Hemodynamic and clinical parameters (including postoperative mortality and major complications), the need for the coadministration of another drug (such as an inotrope or a vasopressor) or for balloon counterpulsation, and length of stay in intensive care were all monitored. RESULTS: The study included 137 patients: 69 received levosimendan, while 68 were treated with dobutamine. Although both agents improved hemodynamic parameters, the effect of levosimendan was greater and occurred earlier than that of dobutamine. In addition, levosimendan use resulted in lower postoperative mortality (8.7% vs. 25%; P< .05), a lower incidence of major postoperative complications, and less need for an additional inotropic drug (8.7% vs. 36.8%; P< .05), a vasopressor (11.6% vs. 30.9%; P< .05), or balloon counterpulsation (2.9% vs. 14.7%; P<0.05). The length of stay in intensive care was also less (66 vs. 158 h; P< .05). CONCLUSIONS: In this randomized study, levosimendan proved more effective than dobutamine. Postoperative morbidity and mortality were lower, fewer patients required either an additional inotropic drug, a vasopressor or intra-aortic balloon counterpulsation, and the length of stay in intensive care was shorter.

Methylene blue reduces mortality and morbidity in vasoplegic patients after cardiac surgery.

BACKGROUND: The discovery of nitric oxide as mediator in cardiac postoperative vasoplegia encourages the use of inhibitory drugs such as methylene blue. This drug has been used with favorable results in isolated cases. The purpose of this article is to analyze the incidence of the postoperative vasoplegic syndrome, to consider its prognosis, and to evaluate the effect of intravenous methylene blue on mortality. METHODS: Cardiac surgery patients were consecutively included. Vasoplegic syndrome was defined by the presence of the following five criteria: (1) hypotension, (2) low filling pressures, (3) high or normal cardiac index, (4) low peripheral resistance, and (5) vasopressor requirements. Those with vasoplegia were randomized to receive 1.5 mg/Kg of methylene blue or a placebo. A p value less than 0.05 was considered significant. RESULTS: Six hundred thirty eight cardiac surgery patients were consecutively included in this study. Fifty-six of these patients fulfilled vasoplegia criteria (8.8%) resulting in higher mortality (10.7% or 6 of 56 patients vs 3.6% or 21 of 582 patients; p value = 0.02). Those treated with methylene blue showed morbidity and mortality reductions (0% versus 21.4% or 6 of 28 patients; p value = 0.01). The duration of the vasoplegic syndrome was shorter in those patients treated with the drug, lasting less than 6 hours in all patients. Patients in the control group showed a slower recovery, lasting more than 48 hours in 8 patients (p value = 0.0007). CONCLUSIONS: Vasoplegic postoperative syndrome was seen in 8.8% of all patients. Outcome in patients with vasoplegia was worse with increased morbidity and mortality. The use of methylene blue reduced the high mortality in this population.