Effect of Levosimendan and Milrinone Combination in Chronic Kidney Disease Patients Who Underwent Cardiac Surgery

Abstract

Background: The effect of levosimendan use in chronic kidney disease (CKD) patients who underwent cardiac surgery has been investigated in a small number of subjects. Our purpose of this study was to investigate the hemodynamic effects of perioperative levosimendan in combination with milrinone administration in CKD patients underwent cardiac surgery and with poor left ventricle. Methods: 164 CKD patients (the mean age = 56 yrs) with poor left ventricle and a high pulmonary artery hypertension were included in this study. Mean creatinine clearance was lower than 30-59 mL/min/1,73 m² (moderate to severe renal impairment). Levosimendan and milrinone were administered to 84 patients (study group; SG). The remaining 80 patients treated with placebo (placebo group; PG). We compared cardiac output (CO), cardiac index (CI), systemic vascular resistance (SVRI), pulmonary vascular resistance (PVR), myocardial enzymes, and tumor necrosis factor alpha (TNF-alpha) immediately after surgery and at 2 h, 6 h, 12 h, and 24 h after operation. Results: No significant difference in operative mortality between groups was observed (6.3% vs. 7.7%, P=0.76). The SG showed lower rates of postoperative low-cardiac output syndrome (LCOS) (29.3% vs. 41.6%, P=0.001), and arrhytmia (26.8% vs. 44.6%) (P=0.01). CO and CI values were significantly higher in SG after the end of 6 h. PVR values were significantly low in SG (P=0.034). The amount of inotropic requirement was low in SG (P= 0.002). The laboratory analyses showed that c-TnI and TNF-alpha levels were low in SG (P= 0.0001). Compared to preoperative period, higher mean LVEF was found in both groups in the postoperative period, but the mean increase in LVEF in SG was higher than in the PG (11.70±2.39 vs. 6.2±1.30) (P<0.001). Conclusion: The use of levosimendan plus milrinone significantly improved hemodynamics in CKD patients with poor left ventricle who underwent cardiac surgery. Duration of ICU and hospitalization were decreased significantly with inodilators treatment. Therefore, we suggest the use of levosimendan and milrinone combination in per- and postoperative period in cardiac surgery patients with CKD and poor left ventricle.