Long presentation on mechanism of action of levosimendan 07.11.2014
Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il...
Transcript of Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il...
![Page 1: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/1.jpg)
Il Levosimendan in Cardiochirurgia
Fabio Guarracino
U.O.C. Anestesia e T.I. CardiotoracicaAzienda Ospedaliero Universitaria Pisana
Pisa, Italy
![Page 2: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/2.jpg)
Heart Failure and Cardiac Surgery
Regional and global ischaemia/reperfusion
of myocardium lead to variable degree of
stunning and depressed contractility.
Inotropic support can be frequently required.
![Page 3: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/3.jpg)
• Systolic dysfunction
•Diastolic d
ysfun
ction
![Page 4: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/4.jpg)
“PISA experience”: 121 pts
• 97 AHF in cardiac surgery
• 1 bi-VAD
• 2 myocardities
• 15 CHF decompensation
• 6 Myocardial depression in sepsis
![Page 5: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/5.jpg)
“PISA experience” in cardiochirurgia
Pazienti con funzione ventricolare moderatamente depressa
Pazienti con funzione ventricolare severamente depressa
![Page 6: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/6.jpg)
PVA
![Page 7: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/7.jpg)
Cardiac performance
VENTRICULAR ELASTANCE
Ees= ESP x (ESV-V0)
ARTERIAL ELASTANCE
Ea= ESP / SV
Circulation 1981; 65: 99-108
![Page 8: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/8.jpg)
Accoppiamento ventricolo- arterioso
Circ Res 1989; 65: 483-93.
Efficienza ottimale: Ea/Ees 0,5-1
Nei cuori scompensati: Ea/Ees >1
Ea/Ees
descrive i rapporti tra sistema vascolare e cuore
![Page 9: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/9.jpg)
Parametri valutati
ECG: FC
Cat. arterioso: PAM
Swan Ganz: PVC, PAP, PCWP, CO, RVS, RVP
TEE: VTSsx, VTDsx
PTSVsx = PAM
PTDVsx = PCWP
SV = VTD - VTS
EF = SV / VTD
Parametri derivati
![Page 10: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/10.jpg)
Pisa experience: pts with moderate LV dysfunction
• 12 pts
• FE 35%
![Page 11: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/11.jpg)
Timing
condizioni basali
20 min. dopo bolo di Levo 12 µg/Kg
![Page 12: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/12.jpg)
EF>30%
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0
1
2
3
4
5
6
7
RVS EF % CO
3,8±1,0 4,4±1,1p<0,01
42±1,0 48±0,1p<0,02
2068±740 1632±595p<0,01
![Page 13: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/13.jpg)
0
2
4
6
8
10
12
14
0
5
10
15
20
25
0
0,5
1
1,5
2
2,5
Ees Ea Ea/Ees
7,19±3,4 8,68±4,7p<0,01
7,9±2,6 5,9±2,6p<0,07
1,1±0,5 0,8±0,5p<0,02
![Page 14: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/14.jpg)
Pisa experience: patients with LV dysfunction
• 10 pts
• FE 24%
• 6 CABG
• 2 CABG + AVS
• 2 AVS + MVS
![Page 15: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/15.jpg)
Metodi
Bolo Levo
condizioni basali
20 min. dopo bolo di Levo 12 µg/Kg
Infusione continua Levo 0.1 µg/Kg/min x 24 h
![Page 16: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/16.jpg)
Ea
Ees pre Ees post
Ees
Ea pre Ea post
patie
nts
Ea/Ees
Ea/Ees pre Ea/Ees post
patie
nts
3,3±,1 4,8±1,6p<0,01
5,4±1,3 4,2±1,1p<0,01
2,05±1,0 1,1±0,56p<0,01
![Page 17: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/17.jpg)
PCWP
1 2pre post
pa
tie
nts
20±3 18±1p<0,01
Cardiac Index
1 2
pre post
patie
nts
2,05±0,6 2,5±0,5p<0,01
EF%
0
1
2
3
4
1 2
pre post
0,27±0,1 0,38±0,1p<0,01
![Page 18: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/18.jpg)
Farmaci associati nel gruppo a bassa FE
• Dobutamina
• Noradrenalina
LEVO mai come ultima spiaggia
![Page 19: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/19.jpg)
Levosimendan: uso in TI cardiochirurgica
• 97 pazienti
• età media 78 anni
• NYHA III-IV
![Page 20: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/20.jpg)
Risultati nelle 24 ore
1,5
2
2,5
3
3,5
4
4,5
5
basale
post-L
EVO 6 h 12 h
18 h
24 h
CI
![Page 21: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/21.jpg)
5
10
15
20
25
basale
post-L
EVO 6 h 12 h
18 h
24 h
WP
Risultati nelle 24 ore
![Page 22: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/22.jpg)
405060708090
100110120
basale
post-L
EVO 6 h 12 h
18 h
24 h
MAP
Risultati nelle 24 ore
![Page 23: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/23.jpg)
30
40
50
60
70
80
90
100
basale
post-L
EVO 6 h 12 h
18 h
24 h
SVO2
Risultati nelle 24 ore
![Page 24: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/24.jpg)
100
300
500
700
900
1100
1300
1500
basale 12 h 24 h
BNP
Risultati nelle 24 ore
![Page 25: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/25.jpg)
Levosimendan in cardiochirurgia
• COME
• QUANDO
• PERCHE’
![Page 26: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/26.jpg)
Levosimendan: come lo uso?
• Levo 0.1- mcg kg-1 min-1
• Infusione continua x 24 ore
Eventuale 2nd dose > 5 gg.
![Page 27: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/27.jpg)
Necessità di risposta rapida (min.)
• Levo 12 mcg kg-1 bolo in 10 min.
• Levo 0.1 mcg kg-1 min-1 x 24 ore
________________________
• Levo 0.2 mcg kg-1 min-1 x 24 ore
![Page 28: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/28.jpg)
Quando lo uso
PREOP
• EF < 30%• BNP ↑• PHP with RVF• Risky IABP
INTRAOP
• AHF
• Difficult weaning CPB
• AS with low EF
POSTOP
• Low CO sdr.
• 2nd dose
• Septic myoc. depression
![Page 29: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/29.jpg)
Perché lo uso?
• Inotropic effect
• Antistunning effect
• No MVO2 increase
• Early B blocker therapy
• ACE inh.
• Pre-postconditioning?
![Page 30: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/30.jpg)
Levosimendan in the cardiac surgical patient
increases cardiac output
seems to preserve diastole
reduces RV afterload
improves heart-arterial coupling (Ea/Ees)
![Page 31: Il Levosimendan in Cardiochirurgia Fabio Guarracino levosimendan in cardiochirurgia.pdf · Il Levosimendan in Cardiochirurgia Fabio Guarracino U.O.C. Anestesia e T.I. Cardiotoracica](https://reader033.fdocuments.us/reader033/viewer/2022051510/6002629b6760ec011115d401/html5/thumbnails/31.jpg)
Atti delAtti delCorso di Aggiornamento Corso di Aggiornamento
Insufficienza cardiaca Insufficienza cardiaca nel paziente nel paziente cardiochirurgicocardiochirurgico: : dalla fisiopatologia dalla fisiopatologia alle nuove opzioni alle nuove opzioni terapeuticheterapeutiche
CLICCARE PER TORNARE ALL’INDICE DELLE RELAZIONI