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Cardiac surgery

Levosimendan for Hemodynamic Support after Cardiac Surgery

27 Jul, 17 | by lfountain

Left ventricular dysfunction following cardiac surgery remains a significant perioperative challenge, one often treated with inotropic support, however practice patterns vary widely and there are few outcome data to support a standardized practice. Levosimendan represents a newer class of “inodilators”, calcium sensitizers, thought to improve cardiac output without increasing myocardial oxygen consumption. In the Levosimendan to Reduce Mortality in High Risk Cardiac Surgery Patients (CHEETAH) randomized trial, 506 patients with a preoperative ejection fraction < 25%, a preoperative need for  intraaortic balloon pump (IABP) support, or post-operative need for support with IABP or high-dose inotropes within 24 hours of cardiopulmonary bypass were randomized 1:1 to receive either levosimendan infusion or placebo plus standard medical therapy in a double-blinded fashion. The primary outcome of the study was 30-day mortality. No difference in the primary outcome was found between the levosimendan group (12.9% mortality) and the placebo group (12.8% mortality) (ARR 0.1%, CI -5.7-5.9, P 0.97), leading to early interruption of the trial for futility. There were also no significant differences in secondary outcomes or adverse events. Notably the mean levosimendan dose was 0.066 +/- 0.031 mcg/kg/min, lower than all previous trials which used at least 0.1 mcg/kg/min.

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Statin does not protect against acute kidney injury following cardiac surgery

29 Mar, 16 | by flee

Although statins affect mechanisms that lead to postoperative acute kidney injury (AKI), observational studies have failed to demonstrate a consistent effect of statin therapy on the risk of AKI after cardiac surgery. The Statin AKI Cardiac Surgery randomized control trial sought to determine if high-dose, short-term atorvastatin reduced the risk of AKI following cardiac surgery.  This double-blind, placebo-controlled, single center trial, evaluated high-dose perioperative atorvastatin on AKI in 615 patients undergoing elective coronary artery bypass surgery, valvular heart surgery, or ascending aortic surgery.  The intervention arm received atorvastation 80mg the day prior to surgery, 40mg day of surgery, and 40mg daily for the duration of hospitalization. Patients were randomized with stratification for prior statin use, presence of chronic kidney disease (GFR < 60 ml/min/1.73m2), and history or diabetes. The primary outcome of AKI was defined as an increase of 0.3mg/dL in serum creatinine or initiation of renal replacement therapy within 48 hours of surgery.  The study was terminated after a second interim analysis for concern of increased risk of AKI among statin naïve patients and for futility among patients who were previously on a statin.

 

 

Conclusion: High-dose statin therapy does not reduce the risk of AKI following cardiac surgery.

 

Summarized by Lauren E. Thompson and Steven M. Bradley

 

Billings FT 4th, Hendricks PA, Schildcrout JS, Shi Y, Petracek MR, Byrne JG, Brown NJ. High-Dose Perioperative Atorvastatin and Acute Kidney Injury Following Cardiac Surgery: A Randomized Clinical Trial.

JAMA. 2016;315(9):877-888.

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