title: A Randomized Blinded Study of the Left Ventricular Myocardial Performance Index Comparing Epinephrine to Levosimendan following Cardiopulmonary Bypass.
abstract: BACKGROUND
  The objective was to evaluate the effect of epinephrine and levosimendan on the left ventricle myocardial performance index in patients undergoing on-pump coronary artery by-pass grafting (CABG).
  
  
  METHODS
  In a double-blind, randomized clinical trial, 81 patients (age: 45-65 years) of both genders were randomly divided to receive either epinephrine at a dosage of 0.06 mcg.kg(1).min(-1) (epinephrine group, 39 patients) or levosimendan at 0.2 mcg.kg(1).min(-1) (levosimendan group, 42 patients) during the rewarming of cardiopulmonary by-pass (CPB). Hemodynamic data were collected 30 minutes after tracheal intubation, before chest open (pre-CPB) and 10 minutes after termination of protamine (post-CPB). As the primary outcome, we evaluated the left ventricle myocardial performance index by the Doppler echocardiography. The myocardial performance index is the sum of the isovolumetric contraction time and the isovolumetric relaxation time, divided by the ejection time. Secondary outcomes were systolic and diastolic evaluations of the left ventricle and postoperative troponin I and MB-CK levels.
  
  
  RESULTS
  Of the 81 patients allocated to the research, we excluded 2 patients in the epinephrine group and 6 patients in the levosimendan group because they didn't wean from CPB in the first attempt. There was no statistical difference between the groups in terms of patient characteristics, risk factors, or CPB time. The epinephrine group had a lower left ventricle myocardial performance index (p = 0.0013), higher cardiac index (p = 0.03), lower systemic vascular resistance index (p = 0.01), and higher heart rate (p = 0.04) than the levosimendan group at the post-CPB period. There were no differences between the groups in diastolic dysfunction. The epinephrine group showed higher incidence of weaning from CPB in the first attempt (95% vs 85%, p = 0.0001) when compared to the levosimendan group and the norepinephrine requirement was higher in the levosimenandan group than epinephrine group (16% vs. 47%; p = 0.005) in post-CPB period. Twenty-four hours after surgery, the plasma levels of troponin I (epinephrine group: 4.5 ± 5.7 vs. levosimendan group: 2.5 ± 3.2 g/dl; p = 0.09) and MB-CK (epinephrine group: 50.7 ± 31 vs. levosimendan group: 37 ± 17.6 g/dl; p = 0.08) were not significantly different between the two groups.
  
  
  CONCLUSIONS
  When compared to levosimendan, patients treated with epinephrine had a lower left ventricle myocardial performance index in the immediate post-CPB period, encouraging an efficient weaning from CPB in patients undergoing on-pump CABG.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT01616069.
authors.affiliation: Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
authors.forename: Marcello Fonseca
authors.initials: MF
authors.lastname: Salgado Filho
authors.affiliation: Faculty of Medical Sciences of Juiz de Fora, Juiz de Fora, Brazil.
authors.forename: Marselha
authors.initials: M
authors.lastname: Barral
authors.affiliation: Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
authors.forename: Louis
authors.initials: L
authors.lastname: Barrucand
authors.affiliation: Fluminense Federal University, Niteroi, Brazil.
authors.forename: Ismar Lima
authors.initials: IL
authors.lastname: Cavalcanti
authors.affiliation: Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
authors.forename: Nubia
authors.initials: N
authors.lastname: Verçosa
mesh_terms: D000368:Aged; D002316:Cardiotonic Agents / Q000494:pharmacology; D001026:Coronary Artery Bypass / Q000379:methods*; D004311:Double-Blind Method; D015150:Echocardiography, Doppler; D004837:Epinephrine / Q000627:therapeutic use*; D005260:Female; D006352:Heart Ventricles / Q000187:drug effects; D006439:Hemodynamics / Q000187:drug effects; D006801:Humans; D006835:Hydrazones / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D011724:Pyridazines / Q000627:therapeutic use*; D000077464:Simendan; D013318:Stroke Volume / Q000187:drug effects; D019210:Troponin I / Q000097:blood; D016277:Ventricular Function, Left / Q000187:drug effects*
chemical_list: D002316:Cardiotonic Agents; D006835:Hydrazones; D011724:Pyridazines; D019210:Troponin I; D000077464:Simendan; D004837:Epinephrine