Summary
Background
Right ventricular competence plays a pivotal role in the clinical course of acute pulmonary embolism. A fatal outcome of an event is mainly due to right heart failure. Levosimendan is a calcium sensitizer, which so far has been evaluated in the setting of left heart failure. We describe the effects of levosimendan in the setting of right heart failure due to acute pulmonary embolism.
Methods and results
We evaluated the hemodynamic effects and the clinical course of 7 patients in whom therapy of acute pulmonary embolism was augmented by levosimendan. All patients showed echocardiographic signs of right ventricular distension; 6 of the 7 patients showed hypotension with a systemic systolic blood pressure of <90 mmHg. Under therapy with levosimendan 6 of the 7 cases showed a rapid clinical and hemodynamic recovery, characterized by a significant decrease of systolic pulmonary artery pressure and heart rate within the next 12 and 24 hours. Six patients survived the event. Therapy with levosimendan was not discontinued in any patient. Four patients were treated in addition with fibrinolysis, while 3 patients were treated with heparin alone. In none of these patients was an escalation in therapy required.
Conclusion
This is a first report of a successful use of levosimendan in the setting of acute right heart failure due to acute pulmonary embolism. Randomized prospective trials are necessary to validate these acute results, to check for side effects and prognostic implications in a larger number of patients, before this kind of therapy can be recommended for regular therapy.
Zusammenfassung
Hintergrund
Die Prognose der akuten Lungenembolie wird maßgeblich von der Kompetenz des rechten Ventrikels beeinflusst. Ursache des Todes bei akuter Lungenembolie ist in den allermeisten Fällen ein akutes Rechtsherzversagen. Levosimendan ist ein Calciumsensitizer, welcher bei der Therapie der akuten Linksherzinsuffizienz positive Ergebnisse gezeigt hat. Wir untersuchten die Effekte von Levosimendan bei akuter Rechtsherzinsuffizienz durch Lungenembolie.
Methoden und Ergebnisse
Wir beschreiben die hämodynamischen Auswirkungen und den Krankheitsverlauf von 7 Patienten, bei denen die Therapie der akuten Lungenembolie durch Levosimendan ergänzt wurde. Bei allen Patienten lag eine echokardiographisch nachweisbare Rechtsherzbelastung vor; 6 der 7 Patienten wiesen eine Hypotension mit einem systolischen Blutdruck von <90 mmHg auf. Unter Therapie mit Levosimendan kam es in 6 der 7 Fälle rasch zu einer klinischen Stabilisierung. Es konnte ein Abfall des pulmonalarteriellen Druckes und der Herzfrequenz über 12 und 24 h dokumentiert werden. 6 Patienten überlebten das Ereignis. Bei keinem Patienten musste die Therapie mit Levosimendan vorzeitig beendet werden. Therapie der akuten Lungenembolie war in 4 Fällen eine Fibrinolysetherapie, in 3 Fällen Antikoagulation. Bei keinem Patienten musste nach Therapiebeginn mit Levosimendan eine Therapieeskalation erfolgen. Nach Beendigung der Therapie wurde keine hämodynamische Verschlechterung beobachtet.
Zusammenfassung
Diese ersten Beobachtungen weisen auf positive Effekte einer Therapie der hämodynamisch bedeutsamen akuten Lungenembolie hin. Jedoch sind prospektive, randomisierte Studien erforderlich, um diese Ergebnisse zu untermauern.
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Post, F., Mertens, D., Peetz, D. et al. Levosimendan bei der Therapie der akuten hämodynamisch bedeutsamen Lungenembolie. Intensivmed 43, 636–642 (2006). https://doi.org/10.1007/s00390-006-0709-y
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DOI: https://doi.org/10.1007/s00390-006-0709-y