Use of Levosimendan as a Strategy to Wean off Veno-Arterial ECMO in Cardiogenic Shock; A Systematic Review and Metanalysis

Abstract

Introduction: The COAPT trial demonstrated a clinical benefit in pts meeting fairly strict criteria for entry. Most notable was a criteria that pts had an EROA 0.3, or a regurgitant volume (RV) 45. The Carillon device has been studied in 3 prospective trials with independent core lab echo assessments. Methods: Pts receiving a Carillon device from these trials were pooled for analysis and divided into 2 groups; those with EROA < 0.3 and RV < 45 and those with an EROA 0.3 or RV 45. Pts were then evaluated for clinical outcomes and % improvement in regurgitant volume (RV) from baseline to one year, as well as % improvement in LV end diastolic volume. Results: Baseline data are summarized in Table 1. Pts with more severe baseline MR had a higher proportion of afib and ischemic etiology of cardiomyopathy, in addition to larger LV and left atrial volumes. Echo parameter changes at one year are provided in Table 2. Marked improvements for RV,LVEDV and LVESV were observed in both groups, although there was slightly more improvements in the pts with more baseline MR. EF improved more in pts with lesser degrees of MR, suggesting a benefit to treating earlier in the disease process. Conclusions: Treatment of functional mitral regurgitation (FMR) with the Carillon Device in "COAPT eligible" patients resulted in marked remodeling. Similar outcomes were observed in patients with less severe FMR, suggesting earlier intervention may be beneficial.

The Effectiveness of Levosimendan on Veno-Arterial Extracorporeal Membrane Oxygenation Management and Outcome: A Systematic Review and Meta-Analysis

“…They reported success rate of 82% versus 65% (OR 1.27, CI 95% 1.13-1.4; P <0.01, I 2 =26%) as compared to the control group. [46] While writing the manuscript of this systematic review,…”

Levosimendan for VA‐ECMO weaning: the silver lining

“… 1 Findings were consistent with that of the meta‐analyses of four ( n = 471) and five studies ( n = 557) by Silvestri et al . 4 and Burgos et al ., 5 respectively, who investigated a similar clinical question. Levosimendan improved haemodynamic and echocardiographic parameters as well.…”

“… 2 The awaited study will address the limitations and heterogeneous aspects of the currently available observational studies on this subject matter presented in recent meta‐analyses. 1 , 4 , 5 Examples of limitations include the observational nature of the studies, inconsistency in the VA‐ECMO weaning definition, and the protocols used across the studies; variability in levosimendan dose and time of administration; and the absence of details about inotropes or intra‐aortic balloon pump use. 1 , 3 We published a systematic review and meta‐analysis of seven observational studies ( n = 630) evaluating levosimendan use in VA‐EMCO weaning in critically ill patients.…”

Levosimendan and Venoarterial ECMO—A Promising Application

“…3 Similar positive results from pooled analysis were also reported by Silvestri and colleagues in 2019. 9 In their analysis of four studies (considered in the Kaddoura analysis), patients who received levosimendan were more likely to successfully wean from VA ECMO (odds ratio 1.3, 95% confidence interval 1.1-1.4, P < 0.01). 9 Recently, Burgos et al performed a similar meta-analysis published in 2020, including five of the studies included in the Kaddoura meta-analysis.…”

“…9 In their analysis of four studies (considered in the Kaddoura analysis), patients who received levosimendan were more likely to successfully wean from VA ECMO (odds ratio 1.3, 95% confidence interval 1.1-1.4, P < 0.01). 9 Recently, Burgos et al performed a similar meta-analysis published in 2020, including five of the studies included in the Kaddoura meta-analysis. 10 In their analysis of 557 patients (299 in the levosimendan cohort), levosimendan was significantly associated with successful weaning (relative risk = 1.4, 95% confidence interval 1.1-1.8, P = 0.004) and a decreased risk for mortality (relative risk = 0.62, 95% confidence interval 0.4 -0.9, P=0.007).…”