| Background:Levosimendan has been shown to effectively improve hemodynamics of patients with cardiac surgery,especially those complicated with preoperative cardiac insufficiency or contractile dysfunction.However,a prospective,randomized controlled trial(RCT)demonstrated that levosimendan treatment increased the risk of bleeding,including postoperative drainage bleeding,late cardiac tamponade and the number of reoperations for bleeding in patients undergoing cardiac surgery,which might be attributed to its anti-platelet effect as proved in in-vitro experiments.As a result,the safety of perioperative levosimendan administration has been questioned,probably limiting its wide administration in patients with compromised cardiac function undergoing cardiac surgery.So far,there is no relevant evidence-based research on the relation between perioperative levosimendan administration and the risk of bleeding.Purpose:We performed a meta-analysis by reviewing relevant literature to evaluate whether or not perioperative levosimendan administration is related to increased bleeding risk in patients with cardiac surgery.Methods:The PubMed,the Ovid,the EMBASE and the Cochrane Library were searched for relevant RCTs before July 1st,2018.The outcome variables include the incidence of reoperation due to massive hemorrhage,chest tube blood drainage,as well as blood transfusion and blood component transfusion.Results:A total of 1130 patients in 8 RCTs(560 in levosimendan group and 570 in control group)were included according to our inclusion criteria.Analysis showed that perioperative levosimendan administration neither increased the rate of reoperation due to excessive bleeding(P=0.98,OR=1.01,95%CI:0.52?1.97),nor increased the amount of postoperative chest tube drainage(P=0.22,SMD=0.32,95%CI:-0.19?0.83)when compared with control group.Besides,levosimendan didn't influence the rate of red blood cells transfusion(P=0.83,OR=0.97,95%CI:0.72-1.30),the rate of platelets transfusion(P=0.98,OR=1.01,95%CI:0.41-2.50)or the amount of fresh frozen plasma transfusion(P=0.13,SMD=-0.21,95%CI:-0.49?0.06).Sensitivity analysis was adopted to further evaluate the above outcome variables.Analysis of reoperation rate due to bleeding was stable and reliable,while analysis of red blood cell transfusion rate was relatively reliable.Analysis of fresh frozen plasma transfusion amount after heterogeneity control(I2=56%changed to I2=0%)showed no statistical difference(P=0.74,SMD=-0.04,95%CI:-0.31-0.22).Due to limited number of included studies,sources of heterogeneity for the chest tube drainage amount and the platelets transfusion rates could not be explored.Thus the random-effects model was used in their analysis to make sure that the results remain conservative and robust.Conclusion:Perioperative levosimendan administration didn't increase the incidence of reoperation due to bleeding,the rates of red blood cell and platelet transfusion,as well as the amounts of postoperative chest drainage and fresh frozen plasma transfusion after cardiac surgery.Thus,levosimendan might be a safe choice for patients in the perioperative period.Besides,more studies are needed to further confirm the results due to the limitations.Aims:To discuss the clinical characteristics,diagnosis,treatments and follow-up of a TA patient with dilated cardiomyopathy-like changes and cardiac failure without coronary and valve involvement.We aim to make a further understanding of TA and early identify TA in the context of cardiac failure and,which can help to reduce the missed diagnosis in clinical practice.We look forward to enrich clinical experience of diagnosis and treatments in TA combined with cardiac failure.Methods:This paper retrospectively analyzed the medical records of a TA patient.At the same time,relevant literature was retrieved online through Pubmed.Combined with the characteristics of this case,to summarize the diagnostic main points,characteristics of heart involved,pathophysiological mechanism of myocardial involvement,common concomitant disease,treatments and prognosis.Results:The The young male patient developed acute onset of cough,expectoration,dyspnea and some other non-specific symptoms.Ultrasonic cardiogram revealed cardiomyopathy,diffuse hypofunction in left ventricular free wall,a decreased LVEF of 30%and dilated left atrium and left ventricle.He was diagnosed with cardiac failure and tuberculosis in other hospital by clinical manifestations,laboratory findings and correlated imaging methods.After conventional treatments for cardiac failure and tuberculosis,the patient's dyspneic symptom had no improvement and got even worse.Thus,he was transferred to our hospital.Physical examination showed a difference of 30mmHg(1mmHg=0.133kPa)in systolic blood pressure between the two arms.Further examination revealed systolic vascular bruits audible on auscultation over the proximal portion of the right common carotid artery and left upper abdomen.The right brachial and radial artery pulses were weaker compared to the left.Imageological examination revealed diffused thickness with stenosis in the proximal and middle portion of right common carotid artery and in the proximal left renal artery.By communicating with the patient,a progressive weakness with movement in the right upper limb in the past half a year was discovered.According to 1990 criteria for the classification of Takayasu arteritis,he was finally diagnosed with TA.After admited to hospital,ultrasonic cardiogram revealed cardiomyopathy,diffuse hypofunction in ventricular wall,a decreased LVEF of 33%and dilated left atrium and left ventricle.Hematological examination showed obviously increased CRP and ESR.Since pathogenesis like chronic hypertension,coronary artery disease(no obvious abnormality in coronary artery CTA),valvular heart disease and drug abuse was excluded,the cardiomyopathy was most likely due to the rapid progression of TA activity.Thus,the patient was treated with glucocorticoid on the basis of strong anti-tuberculosis and conventional anti heart failure drugs.After treatment,CRP and ESR soon returned to normal.The heart failure symptoms were improved as well.Several times of follow-up showed that the symptoms and quality of life were improved gradually.Heart function and size got better as well.By reviewing relevant studies,we found that involvement of heart in TA was probably due to inflammation of the heart,like the progress in the artery wall,manifested as myocarditis caused by infiltration of inflammatory cells and inflammatory response mediated by cytotoxic factors.Besides,cardiomyopathy without obvious inflammatory cell infiltration was probably due to increased expression of HLA-DR in small vessels and deposition of immune complexes(IgG,IgM,C3,C1q)in endothelium of myocardial small vessels.In our patient,markers of myocardial injury had no obvious increase during the pathogenetic process.Besides,the heart structure and function gradually returned to normal after treatment.As a result,the patient had no obvious 'myocardial necrosis'.Considering that coronary artery CTA and markers of myocardial injury were largely normal and that ECG showed subendocardial myocardial ischemia,we thought that the cardiomyopathy of this patient was probably due to myocardial small vessel injury caused by TA.Immune complexes deposited and mediated inflammatory injury in these vessels,resulted in subendocardial myocardial ischemia and'myocardial hibernation'.After proper immunosuppressive therapy,cardiac structure and function gradually returned to the normal state.Conclusion:Takayasu arteritis(TA),a rare systemic granulomatous vasculitis,predominantly affects the aorta and its major division branches with the pathogenesis still remaining unknown.To avoid missed diagnosis,the possibility of TA should be taken into consideration for young patients with cardiac failure and stenotic lesions of aorta and its major division branches.Detailed and comprehensive physical examinations contribute to the diagnosis of TA,especially significant difference in systolic blood pressure between arms and bruit audible on auscultation over large arteries.Tuberculosis infection may be associated with TA.Autoimmune-mediated inflammatory responses may play an important role in cardiomyopathy.For TA complicated with cardiac failure,in addition to conventional cardiac failure treatment,active intervention in inflammatory activities of TA provides benefits to therapeutic effect.On the basis of strong anti-tuberculosis,glucocorticoid therapy is helpful to promote the cardiac recovery of both the structure and function. |
PDF Full Text Request