Clin Res Cardiol (2022). https://doi.org/10.1007/s00392-022-02087-y

Prophylactic use of inotropic agents for prevention of low cardiac output syndrome and mortality in adults undergoing cardiac surgery

D. Gayatri1, J. Tongers2, L. Efremov3, R. Mikolajczyk3, D. G. Sedding2, J. Schumann1, für die Studiengruppe: COCHRANE

1Universitätsklinik für Anästhesiologie und operative Intensivmedizin, Universitätsmedizin Halle, Halle (Saale); 2Klinik und Poliklinik für Innere Medizin III, Universitätsklinikum Halle (Saale), Halle (Saale); 3Institut für Epidemiologie, Biometrie und Informatik, Universitätsmedizin Halle, Halle (Saale);

Reduced heart function is a potentially fatal complication after heart surgery. A possible approach to prevent this complication may be the prophylactic treatment with drugs that stimulate the contraction of the heart (inotropic agents). However, national and international guidelines for the prophylaxis of low cardiac output syndrome (LCOS) by pharmacological intervention consistently report limited evidence. This Cochrane review aims to evaluate the efficacy and safety of all inotropic agents that are used to prophylactically minimise the incidence of LCOS in adults undergoing cardiac surgery. We followed Cochrane standard methodological procedures and a pre-defined protocol (DOI: 10.1002/14651858.CD013781). Trials were systematically identified by searching electronic databases of CENTRAL, MEDLINE, Embase and CPCI-S Web of Science as defined by protocol. We included randomised controlled trials enrolling adults (≥18 years), who underwent cardiac surgery and were prophylactically treated with one or multiple inotropic agent(s) in comparison to any type of control (i.e. standard cardiac care, placebo, other inotropic agents) and no language restrictions were applied. We used the five GRADE considerations to assess the quality of evidence from the studies that contributed data to the meta-analyses for the pre-specified outcomes. Two review authors independently extracted data and assessed risk of bias according to the pre-defined protocol. On request, we obtained a reply and additional information from solely one of the study authors of the included studies. We identified 29 included studies with a total of 3,307 patients. The mean age of patients varied between 52.5 and 76 years and the proportion of male patients ranged from 40% to 93.8%. Included studies were categorised into 7 comparisons: amrinone versus placebo, dopamine versus placebo, milrinone versus placebo, levosimendan versus dobutamine, levosimendan versus milrinone, levosimendan versus standard cardiac care and levosimendan versus placebo. Our meta-analyses showed that levosimendan may reduce the risk of all-cause mortality (RR 0.65, 95% CI 0.43 to 0.97) and LCOS (RR 0.43, 95% CI 0.25 to 0.74) compared to placebo but not compared to standard cardiac care, dobutamine or milrinone. Moreover, the beneficial effects of levosimendan were predominantly observed in length of intensive care unit (mean difference -1.00, 95%CI -1.63 to -0.37) and preoperative drug administration (RR 0.30, 95% CI 0.14 to 0.67) compared to placebo. We also found low- to very low-quality evidence for the majority of outcomes. This was mainly due to the small number of included patients (high imprecision of results). Prophylactic treatment with levosimendan may reduce the incidence of LCOS and associated mortality in adult patients undergoing cardiac surgery. However, conclusions on the efficacy and safety of other inotropic agents may not be drawn due to limited study data. Future studies of levosimendan should be designed to derive potential benefit in specific patient groups (with/without left ventricular dysfunction) and surgery types, as well as the optimal administration protocol.

https://dgk.org/kongress_programme/ht2022/aP764.html