A comparison of dobutamine and levosimendan on hepatic blood flow in patients with a low cardiac output state after cardiac surgery: a randomised controlled study.

Liver dysfunction due to a low cardiac output state after cardiac surgery is associated with a poor prognosis, but whether one inotrope is superior to another in improving hepatic perfusion remains uncertain. This study compared the systemic and hepatic haemodynamic effects of levosimendan to dobutamine in patients with a low cardiac output state (cardiac index < 2.2 l/min/m2) after on-pump cardiac surgery. A total of 25 patients were randomised to receive either an intravenous bolus of levosimendan (12 µg/kg) over 15 minutes, followed by an infusion of 0.2 µg/kg/min for 24 hours, or an infusion of dobutamine 7.5 µg/kg/min for 24 hours and completed the study. The systemic and hepatic haemodynamics at 24 and 48 hours were all better after levosimendan than dobutamine (dobutamine group: cardiac index (l/min/m2)=2.51 [standard deviation ±0.29], 2.40±0.23; portal vein flow (ml/min): 614.0±124.7, 585.9±144.8; pulsatility index: 2.02±0,28, 2.98±0.27 versus the levosimendan group: cardiac index: 3.02± 0.27, 2.98± 0.30; portal vein flow: 723.0± 143.5, 702.9±117.8; pulsatility index: 1.71±0.26, 1.73±0.27). The improvement in portal vein blood flow at 48 hours was significantly better after levosimendan than dobutamine (41% vs. 11% increment from baseline, P<0.05). In addition, there was a significant reduction in hepatic artery resistance after levosimendan but not dobutamine (resistance index reduction 6.5% vs. 0%, P<0.05). In summary, levosimendan can be considered as a selective liver vasodilator and can improve hepatic blood flow through both the hepatic artery and portal venous system, whereas dobutamine can only improve the portal venous blood flow without vasodilating the hepatic artery.

Uso del levosimendán en el paciente quirúrgico crítico / Levosimendan use in critical surgical patient

El levosimendán es el único sensibilizante del calcio utilizado actualmente en la clínica. Su indicación fundamental es la descompensación de la insuficiencia cardiaca, y aunque su eficacia está demostrada en el paciente médico, su uso en el paciente quirúrgico ha sido mucho más restringido, a pesar de lo que ha ido apareciendo en publicaciones en situaciones de evidente riesgo para los enfermos, como son el shock séptico y el shock cardiogénico, y se han descrito algunos efectos, que en nuestra opinión merecen más atención como el efecto cardioprotector y antiaturdimiento miocárdico. A lo largo de esta revisión, pretendemos analizar las nuevas aportaciones aparecidas sobre este fármaco complejo sin duda, pero en nuestra opinión muy útil en algunas situaciones (AU)

Levosimendan is the only calcium sensitiser currently used at clinical level. Its primary indication is decompensated heart failure, and although its effectiveness has been demonstrated in the medical patient, use in the surgical patient has been more restricted. Nevertheless, new publications have appeared in high risk situations, such as septic shock and cardiogenic shock. Other drug effects has been reported, which we believe deserve more attention, as the cardioprotective effect and the anti-myocardial stunning effect. Throughout this review, we intend to analyse the new contributions of this undoubtedly complex drug but, in our opinion, very useful in some situations (AU)