Levosimendan for patients with severely reduced left ventricular systolic function and/or low cardiac output syndrome undergoing cardiac surgery: a systematic review and meta-analysis.

BACKGROUND: Previous studies have shown beneficial effects of levosimendan in high-risk patients undergoing cardiac surgery. Two large randomized controlled trials (RCTs), however, showed no advantages of levosimendan. METHODS: We performed a systematic review and meta-analysis (MEDLINE and Embase from inception until March 30, 2017), investigating whether levosimendan offers advantages compared with placebo in high-risk cardiac surgery patients, as defined by preoperative left ventricular ejection fraction (LVEF) ≤ 35% and/or low cardiac output syndrome (LCOS). The primary outcomes were mortality at longest follow-up and need for postoperative renal replacement therapy (RRT). Secondary postoperative outcomes investigated included myocardial injury, supraventricular arrhythmias, development of LCOS, acute kidney injury (AKI), duration of mechanical ventilation, intensive care unit and hospital lengths of stay, and incidence of hypotension during drug infusion. RESULTS: Six RCTs were included in the meta-analysis, five of which investigated only patients with LVEF ≤ 35% and one of which included predominantly patients with LCOS. Mortality was similar overall (OR 0.64 [0.37, 1.11], p = 0.11) but lower in the subgroup with LVEF < 35% (OR 0.51 [0.32, 0.82], p = 0.005). Need for RRT was reduced by levosimendan both overall (OR 0.63 [0.42, 0.94], p = 0.02) and in patients with LVEF < 35% (OR 0.55 [0.31, 0.97], p = 0.04). Among secondary outcomes, we found lower postoperative LCOS in patients with LVEF < 35% receiving levosimendan (OR 0.49 [0.27, 0.89], p = 0.02), lower overall AKI (OR 0.62 [0.42, 0.92], p = 0.02), and a trend toward lower mechanical support, both overall (p = 0.07) and in patients with LVEF < 35% (p = 0.05). CONCLUSIONS: Levosimendan reduces mortality in patients with preoperative severely reduced LVEF but does not affect overall mortality. Levosimendan reduces the need for RRT after high-risk cardiac surgery.

Mitral Regurgitation Grading in the Operating Room: A Systematic Review and Meta-analysis Comparing Preoperative and Intraoperative Assessments During Cardiac Surgery.

OBJECTIVE: To assess differences in mitral regurgitation (MR) grade between the preoperative and the intraoperative evaluations. DESIGN: Systematic review and meta-analysis of 6 observational studies found from MEDLINE and EMBASE. SETTING: Cardiac surgery. PARTICIPANTS: One hundred thirty-seven patients. INTERVENTION: Comparison between the preoperative MR assessment and the intraoperative evaluation conducted under general anesthesia (GA), with or without "hemodynamic matching" (HM) (artificial increase of afterload). MEASUREMENTS AND MAIN RESULTS: The primary outcome was the difference between the preoperative and intraoperative MR grade under "GA-only" or "after-HM." Secondary analyses addressed differences according to effective regurgitant orifice area (EROA), regurgitant volume (RVol), color-jet area, and vena contracta width. Risk of MR underestimation was found under "GA-only" (SMD: 0.55; 95% confidence interval [CI], 0.31-0.79, p < 0.00001), but not "after-HM" (SMD: -0.16; 95% CI, -0.46 to 0.13, p = 0.27). Under "GA-only", EROA had a trend toward underestimation (p = 0.07), RVol was reliable (p = 0.17), while reliance on color-jet area and vena contracta width incur risk of underestimation (both p = 0.003). After HM, EROA accurately reflected preoperative MR (p = 0.68) while RVol had a trend toward overestimation (p = 0.05). The overall reported incidence of misdiagnoses was slightly more common under "GA-only" (mean 48%, 39% underestimation, 9% overestimation; range: 32%-57%) than "after-HM" (mean 41%, 12% underestimation, 29% overestimation; range: 33%-50%). Only the minority of misdiagnoses were clinically relevant: underestimation was around 10% (both approaches), but 18% had clinically significant overestimation "after-HM" as compared with 3% under GA-only. CONCLUSIONS: Intraoperative assessment under "GA-only" significantly underestimated MR. A more accurate intraoperative evaluation can be obtained with afterload manipulation, although HM strategy carries high risk of clinically significant overestimation.

[Pharmacoepidemiological study of the use of psychotropics in hospitalized patients]. / Estudio farmacoepidemiológico de la utilización de psicofármacos en pacientes internados.

OBJECTIVE: To assess consumption and the exposition of patients admitted to the Universitary Hospital of the Interamerican Open University (UAI), between October and December of 2007-2009. METHODS: Descriptive observational study. The information was obtained of the Pharmacia Sector. We analyze the dispensations (Units); the exposition was evaluated using the defined daily dose per 100 beds/day. We analyzed how many of the psychotropics used were considerated essentials drugs for the WHO. We assessed the adverse drug reactions registered. RESULTS: The psychopharmacological drugs represented the 43%, 41%, and the 44% (period 2007-2009) of the drugs used for the Central Nervous System. The benzodiazepines represented more of the 50% of the psychopharmacological drugs used. The exposure was respectively of 57%, 66%, and 40% (for all the patients admitted to the hospital on period 2007-2009). The essential medicines used fluctuate between 41% and 48%. From 32 adverse reactions connected with the Central Nervous System, 20 (62.5%) were attributed to psychotropics. CONCLUSIONS: 1. We established the quantity of the psychotropics dispensations, as well as the level of the exposure. 2. The psychotropic utilization of the essentials medicines list of the WHO was above 40%.