Improved results in the treatment of patients with ischemic cardiomyopathy and extremely reduced LV-function (EF ≤20%) using a standardized perioperative protocol with the use of levosimendan

Objectives: Patients with extremely reduced left ventricular function face a very high perioperative risk that may overwhelm the benefits of surgery. This study evaluated the risk reduction achieved by introducing a standardized protocol with preoperative start of levosimendan therapy and IABP.

Methods: All consecutive patients with an EF below 20% that were operated for coronary artery disease and/or mitral insufficiency between 01'2010 and 06'2012 were included in this retrospective study. Since 06'2011 in those patients (Lev, n = 23) levosimendan infusion was began shortly after arriving in the operating theatre and a IABP was installed percutaneously before start of surgery. Levosimendan was continued for 24 hours. Hemodynamic management included conventional catecholamine and phosphodiesterase inhibitor use.

Operative results were compared to those of a group of 22 patients operated from 01'010 to 06'2011, that were managed perioperatively without the use of levosimendan (Conv). Beside mortality, need for inotropic support, markers of ischemia, pre- and post-op EF, time on ventilator and in the intensive care unit were evaluated and short term survival and NYHA stage assessed by telephone interview.

Results: Both groups did not differ concerning pre-operative EF (Lev 14.09 ± 4.6%; Conv 18.1 ± 7.5%), logistic Euroscore (Lev 35.0 ± 18.9%; Conv 30.9 ± 16.2%), demographic and clinical parameters. Applying the standardized protocol in hospital mortality significantly decreased (Lev vs. Conv 13% vs. 45%). Study patients significantly needed less time on ventilator (71.95 ± 71h vs. 162.95 ± 217.5h) and in the intensive care unit (7.62 ± 3.7 d vs. 12.42 ± 10 d) and showed better renal function. Intra-operatively during perfusion less variance in flow, reduced need for vasopressors and less increase of lactate were seen. Postoperatively LVEF in the Lev group significantly improved (Lev: 14.1 ± 6.7%, Conv: 5.6 ± 9.6%). During follow-up 3 patients died (1 lung-cancer, 2 cardiac) and 22 reported good exercise tolerance (NYHA I/II), whereas 3 patients remained in NYHA class III.

Conclusions: With this concept even patients with extremely reduced ventricular function can be managed with acceptable perioperative mortality and low risk of complications. Applying this protocol patients in this high risk group can be treated with excellent short term benefit.