The Effects of Levosimendan During Mitral Valve Surgery
The Effects of Levosimendan During Mitral Valve Surgery
The effects of levosimendan on renal function in patients with low ejection fraction
 undergoing mitral valve surgery will be investigated in a prospective, double-blinded,
 randomized clinical trial using serum creatinine (sCr)milligram in deciliter (mg/dL) values,
 calculated estimated glomerular filtration(eGFR)(ml/min/1.73 m2) rates and perioperative
 clinical follow-up parameters.
Introduction:

 The coronary and peripheral vasodilatory properties of levosimendan has recently been
 investigated in patients with heart failure. It is considered as a promising alternative to
 conventional inotropic agents for patients with low LVEF. However, the effects of
 levosimendan on renal functions in patients undergoing open heart surgeries with CPB are not
 well studied in randomized clinical trials.

 The primary goal of our study was to investigate the effects of levosimendan on 1- renal
 function by evaluation of serum creatinine (mg/dL) values and calculated estimated glomerular
 filtration(eGFR)(ml/min/1.73 m2) rates.

 Our secondary goal was to determine clinical outcomes including;

 1-need for renal replacement therapy (RRT) in patients with low ejection fraction undergoing
 mitral valve repair or replacement surgery with cardiopulmonary bypass (CPB).

 Inclusion and exclusion criterions include as listed below. Patients included into the study
 had a diagnosis of mitral valve insufficiency with or without coronary artery disease and a
 left ventricular ejection fraction (LVEF) of ≤ 45 %.

 Exclusion criteria were unstable angina, diabetes mellitus treated with insulin, clinical
 findings of acute or chronic renal failure (serum creatinine (sCr)> 1.5 mg/dL), severe
 hepatic disease (alanine aminotransferase or aspartate aminotransferase > 100 U litre/L),
 severe chronic obstructive pulmonary disease (forced expired volume in 1 s < 50 % of
 predicted or < 2.0 litre), a history of prior coronary artery bypass graft (CABG) surgery or
 myocardial infarction (MI) within the previous month, emergent operations, patients on
 inotropic support before operation, aortic valvular disease, and infective endocarditis.

 The study protocol:

 The patients will be randomized into two groups. Randomization into two groups was performed
 using sealed envelopes and the sequentially numbered assignments of the participant which
 will be concealed in an envelope and will be opened after anesthesia induction by a health
 care personnel. The observers will be blinded to the inotropic protocol. Caregivers will not
 be blinded, but they will not participate in data collection or data interpretation.

 In the levosimendan group, a loading it of levosimendan (6 μg/kg) will be administered after
 removal of the aortic cross-clamp, followed by an infusion of levosimendan at a dose of 0.1
 μg/kg/min in addition to standard inotropic therapy (one or more agent including; dobutamine,
 epinephrine or norepinephrine)for 24 hours. In the control group, only standard inotropic
 therapy will be administered.

 The need for renal replacement therapy (RRT)will be provided to all patients under the
 following criterions: 1- when urine output was less than 100 mL within the last 8 hours, 2-
 with no response to 50 mg intravenous dose of furosemide, 3- urine sodium concentration
 should be > 40 milliequivalent/liter (mEq/L) before administration of furosemide, 4- blood
 urea nitrogen (BUN) level > 50 mg/dl 5-additional presence of one or more of the following
 factors such as; a- increase in serum creatinine level > 50% from preoperative value, b-
 presence of metabolic acidosis, c- presence of hypervolemia, d- presence of hyperkalemia
 (potassium ion level > 5 Meq/L).

 The study parameters:

 The demographic data includes; age, weight, height, body mass index and gender. The
 cardiovascular risk factors including; diabetes mellitus, hypertension, hypercholesterolemia,
 obesity, history of smoking as well as history of chronic obstructive pulmonary disease and
 peripheral vascular disease were sought.

 Echocardiographic data were performed to evaluate the ejection fraction and valvular
 functions by the same cardiologist using a Vivid 3 echocardiography device (Healthcare
 General Electronics,Hamburg,Germany) before operation and on first hour, 12 and 24 hour after
 operation.

 Pulmonary hypertension (PH) is defined by a mean pulmonary artery pressure (MPAP) >25 mmHg at
 rest. The diagnosis of PH depends on direct measurement of the mean PAP by right heart
 catheterization. However, we used Doppler echocardiographic study to provide an estimate of
 the pulmonary artery systolic pressure (PASP)and mean PAP is calculated with the formula:
 mean PAP = 0.65 PASP + 0.55 mmHg.

 The risk of operation will be evaluated using the European System for the Cardiac Operation
 Risk Evaluation scale (EuroSCORE).

 Acute kidney injury (AKI) is defined as increase in serum creatinine from baseline by > 50 %
 within 48 hours postoperatively.

 SCr levels will be collected on preoperative and postoperative days 1, 3 and 10 and and eGFR
 will be calculated according to the abbreviated Modification of Diet in Renal Disease (MDRD)
 equation.
Inclusion Criteria:

 -  diagnosis of mitral valve insufficiency with or without coronary artery disease and a
 LVEF of ≤ 45 %.

 Exclusion criteria:

 -  unstable angina,

 -  diabetes mellitus treated with insulin, clinical findings of acute or chronic renal
 failure (sCr > 1.5 mg dL-1),

 -  severe hepatic disease (alanine aminotransferase or aspartate aminotransferase > 100 U
 litre L-1),

 -  severe chronic obstructive pulmonary disease (forced expired volume in 1 s < 50 % of
 predicted or < 2.0 litre),

 -  a history of prior CABG surgery or myocardial infarction (MI) within the previous
 month,

 -  emergent operations,

 -  patients on inotropic support before operation,

 -  aortic valvular disease, and

 -  infective endocarditis.