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González Bardanca, Ó. Pato López, M. Díaz Allegue, L. Ramos López" "autores" => array:4 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "González Bardanca" "email" => array:1 [ 0 => "sonia.gonzalez.bardanca@sergas.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ó." "apellidos" => "Pato López" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Díaz Allegue" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Ramos López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Grupo de Trasplante Pulmonar, Servicio de Anestesiología y Reanimación Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Grupo de Trasplante Cardiaco y Cirugía Cardiovascular, Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Utilidad terapéutica de levosimendán en el postoperatorio de trasplante pulmonar: experiencia inicial en la disfunción del ventrículo derecho" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Levosimendan, an inodilator with antioxidant, antiapoptotic, and anti-inflammatory action, is indicated in the treatment of exacerbated chronic heart failure, acute myocardial infarction, cardiogenic shock, and postoperative myocardial stunning. Levosimendan increases cardiac contractility by increasing the affinity of troponin C for calcium. It also induces vasodilation by opening dependent adenosine triphosphate potassium channels, thus favouring cardioprotection.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The results of studies such as LION-HEART, in which intermittent cycles of low-dose levosimendan (0.2 μg/kg/min for 6 h each cycle, 6 cycles every 2 weeks) managed to stabilize cardiac function deterioration, reduce the rate of hospital admissions, and had a tolerability similar to placebo, support the indication for levosimendan in patients with congestive heart failure and decreased left ventricular ejection fraction. In the field of cardiac surgery, however, despite reports that levosimendan optimises haemodynamic stability during preconditioning and in the immediate postoperative period, its safety and efficacy in terms of survival continue to be a source of controversy. This has led recent publications to question whether the existing evidence is sufficiently robust to recommend its use routinely.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Clinical practice guidelines published in this journal are in favour, with a strong grade of recommendation and a moderate level of evidence, of including preconditioning with levosimendan in strategies to reduce the risk of heart failure in patients with reduced left ventricular ejection fraction in the absence of severe pulmonary hypertension (PH) (defined according to the recent definition of PH in the Sixth World Symposium on PH in 2018). At this event, pulmonary vascular resistance (PVR) was reintroduced as a proxy of RV function and as a prognostic factor: a) precapillary PH: mPAP > 20 mmHg, PCP ≤ 15 mmHg, RVP ≥ 3 UW; b) Isolated postcapillary PH: mPAP > 20 mmHg, PCP > 15 mmHg, RVP < 3 UW; and c) combined precapillary and postcapillary PH: PAP > 20 mmHg, PCP > 15 mmHg, RVP ≥ 3 UW, in both cardiac and non-cardiac surgery.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Lung transplantation (LT) is a therapeutic option for certain patients with advanced disease and poor functional reserve. Moments of high cardiovascular demand, especially involving the right ventricle (RV), occur intraoperatively as a result of the hypoxaemia induced by one lung ventilation and the increase in RV afterload caused by clamping the pulmonary artery. It is quite a challenge for the anaesthesiologist to optimize right ventricular function by adjusting preload, contractility and afterload. To achieve this, advanced haemodynamic monitoring using the Swan Ganz catheter and transesophageal echocardiography is very useful, although a wide range of therapeutic strategies must also be available. For example, inhaled nitric oxide and/or prostaglandins reduce RVP, and this in turn reduced RV afterload and improves RV contractility. The inodilators of choice are dobutamine and phosphodiesterase, which have a positive inotropic effect and are more useful in reducing PVR than systemic drugs, although they frequently need to be combined with vasopressors such as norepinephrine to maintain sufficient blood pressure to ensure cerebral and tissue perfusion.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> After reperfusion of the graft (s), releasing the pulmonary artery clamp will lower PVR, and restoring two-lung ventilation will improve ventilation and oxygenation. However, the problems associated with right ventricular dysfunction often continue into the postoperative period as a result of complications such as primary graft failure or vascular anastomotic stenosis. This is particularly common in patients with previous PH and chronic RV dysfunction (dilated ventricles). Therefore, many surgeons perform this procedure under circulatory support (conventional or extracorporeal membrane oxygenation [ECMO]), particularly in patients with PH, and in some cases circulatory support continues into the postoperative period.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The pathophysiology of this procedure, together with the published evidence on the use of levosimendan in patients with right heart failure associated with PAH and weaning from ECMO,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> encouraged us to start administering levosimendan in the early postoperative period of lung transplantation (first 72 postoperative hours) and in patients with one or more of these indications. In the past 5 years (2016–2020), 9 patients have received levosimendan in the immediate postoperative period of LT: 4 undergoing double LT, 4 left LT, 1 right LT. Of these, 6 (66%) had pre-transplant echocardiographic signs of RV involvement, defined as overload septal motion/pressure/or ventricular dilation (RV baseline end-diastolic diameter > 0.6 × LV end-diastolic diameter), and 8 (88%) also presented PH, defined as mean pulmonary arterial pressure >25 mmHg. In most patients, the drug was started in the resuscitation unit (n = 8, 88%) as a treatment for exacerbated or <span class="elsevierStyleItalic">de novo</span> RV dysfunction – defined as tricuspid annular plane systolic excursion (TAPSE) ≤16 mm and/or fractional area changes in RV < 32% – refractory to milrinone, norepinephrine, and inhaled nitric oxide started in the operating room, while only I patient (11%) started it intraoperatively in the context of intraoperative biventricular dysfunction. Interestingly, this patient already had ischaemia-induced moderate left ventricular systolic dysfunction, although he had been successfully revascularized before transplantation.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We analysed the possible therapeutic benefits in patients who completed the levosimendan cycle (n = 8, since 1 patient died due to bleeding complications in the immediate postoperative period). On echocardiography, all (n = 8, 100%) showed progressive recovery of right ventricular function until good cardiac output was finally maintained: CI > 2–2.5 l/min/m<span class="elsevierStyleSup">2</span>, with mixed venous saturation >70%. This allowed us to gradually withdraw inotropics in all these patients. In 6 patients (75%), we were able to withdraw mechanical ventilation within 72 h, while the remaining 2 (25%) required prolonged mechanical ventilation due to <span class="elsevierStyleItalic">St. maltophilia</span> and <span class="elsevierStyleItalic">Pseudomonas</span> spp pneumonia. All patients were discharged from the resuscitation unit and are alive at the time of writing; and all but 1 have been discharged home.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In summary, our findings suggest that levosimendan can be beneficial in the management of right ventricular dysfunction in the perioperative period of LT patients, but out results need to be investigated further in clinical trials.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González Bardanca S, Pato López Ó, Díaz Allegue M, Ramos López L. Utilidad terapéutica de levosimendán en el postoperatorio de trasplante pulmonar: experiencia inicial en la disfunción del ventrículo derecho. Rev Esp Anestesiol Reanim. 2021;68:548–550.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Levosimendan following cardiac surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.M. Conte" 1 => "D.S. Florisson" 2 => "J.A. de Bono" 3 => "R.A. Davies" 4 => "A.E. Newcomb" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.hlc.2018.02.018" "Revista" => array:6 [ "tituloSerie" => "Heart Lung Circ." 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Vol. 68. Issue 9.
Pages 548-550 (November 2021)
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Vol. 68. Issue 9.
Pages 548-550 (November 2021)
Letter to the Director
Therapeutic utility of levosimendan during the postoperative period of lung transplantation: initial experience in right ventricular dysfunction
Utilidad terapéutica de levosimendán en el postoperatorio de trasplante pulmonar: experiencia inicial en la disfunción del ventrículo derecho
a Grupo de Trasplante Pulmonar, Servicio de Anestesiología y Reanimación Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
b Grupo de Trasplante Cardiaco y Cirugía Cardiovascular, Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
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From Monday to Friday from 9 a.m. to 6 p.m. (GMT + 1) except for the months of July and August which will be from 9 a.m. to 3 p.m.
Calls from Spain
932 415 960
Calls from outside Spain
+34 932 415 960
E-mail