Abstract
Several kinds of inotropes have been used in critically ill patients to improve hemodynamics and renal dysfunction after cardiac surgery; however, the treatment strategies for reducing mortality and increasing renal protection in patients who underwent cardiac surgery remain controversial. Therefore, we performed a comprehensive network meta-analysis to overcome the lack of head-to-head comparisons. A systematic database was searched up to 31 December 2020, for randomized controlled trials that compared different inotropes on mortality outcomes and renal protective effects after cardiac surgery. A total of 29 trials were included and a frequentist network meta-analysis was performed. Inconsistency analyses, publication bias, and subgroup analyses were also conducted. Compared with placebo, use of levosimendan significantly decreased the risks of mortality (odds ratio (OR): 0.74; 95% confidence interval (CI): 0.56–0.97) and risk of acute renal injury (OR: 0.61; 95% CI: 0.45–0.82), especially in low systolic function patients. Use of levosimendan also ranked the best treatment based on the P-score (90.1%), followed by placebo (64.5%), milrinone (49.6%), dopamine (49.5%), dobutamine (29.1%), and fenoldopam (17.0%). Taking all the available data into consideration, levosimendan was a safe renal-protective choice for the treatment of patients undergoing cardiac surgery, especially for those with low systolic function.
Highlights
2 million cardiac surgeries are performed annually worldwide [1]
All relevant randomized controlled trials were searched from PubMed, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) up to December 2020, while some unpublished data were searched from ClinicalTrials.gov registers
Eligible studies meeting the following criteria were included: (1) randomized controlled trials reporting on mortality or renalrelated endpoints; (2) enrolled patients aged 18 years or older with acute preoperative circulatory insufficiency requiring treatment with a positive inotrope or by mechanical means (IABP or ECLS); (3) intervention group received any inotropic agents, such as catecholamines, phosphodiesterase-3 inhibitors, or other calcium sensitizer drug, such as levosimendan; (4) comparators were placebo or any inotropic agents other than the agent used in the intervention group; (5) study reports were not limited by language; and (6) the cardiac surgical procedure could be coronary artery bypass grafting (CABG), CABG plus aortic valve surgery, isolated mitral valve surgery, or any combination of these procedures
Summary
In. 45% of patients undergoing cardiac surgery, renal failure, a major complication, occurs and is strongly associated with increased morbidity [2,3,4] and mortality [5,6,7,8]. Besides low cardiac output and cardiogenic shock, post-cardiac surgery can precipitate renal failure, sepsis, vasoplegic shock, and atheroembolic etiologies of shock that can cause AKI. Treatments are different among low cardiac output syndrome (LCOS), sepsis, vasoplegic shock, and atheroembolic etiologies of shock-caused AKI. Inotropic agents are frequently administered in cardiac surgery patients to improve hemodynamic function to avoid hypotension and LCOS [10]. The potentially renoprotective function of inotropes after cardiac surgery have been investigated [11,12]
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