PREVENTION OF HEART FAILURE PATIENTS WITH DECREASED EJECTION FRACTION IN NON-CARDIAC SURGERY: LEVOSIMENDAN OR ANESTHETIC CARDIOPROTECTION?.

Background: Chronic heart failure (CHF) significantly worsens the prognosis of surgical treatment in noncardiac surgery, doubling mortality in compared with patients with coronary artery disease. Modern anesthesiology has at least two methods that potentially can improve the results in noncardiac surgery: anesthetic cardioprotection and the prevention of CHF decompensation with levosimendan.

The aim: to study the efficacy of anesthetic cardioprotection andpreoperative preparation with levosimendan for the prevention of CHF decompensation in patients with reduced left ventricular ejectionfraction in noncardiac surgery.

Endpoints: the primary endpoint of the trial is the need and the maximum dose of inotropic drugs in the perioperative period; secondary point: the length of stay in the ICU, composite outcome, the dynamics of SI, FI, the content ofNT-proBNP and TnT Materials and methods: A randomized study was performed in three groups of patients during reconstructive operations on infrarenal part of aorta: control (traditional methodfor prevention of decompensation of CHF were used) - 31 patients; the group with the anesthetic cardioprotectivei - 31 patients; the group with a preoperative preparing with levosimendan - 30 patients.

Results: The incidence of heart failure (estimated by need to use inotropic drugs - IS) was 83% of control group patients and 75% of the patients of the group "VIMA" (p = 0,65). The number ofpatients needing the use of dobutamine in LS-group was significantly below, 50% (p = 0,02 relative to control group and p = 0,08 compared to the group VIMA). IS in the control group was 8 [6, 9] μg xkg⁻¹ - xmin⁻¹ ; group VIMA 8 [3; 9] mg xkg ⁻¹ xmin⁻¹ , whereas in the LS group only 2 [0; 7] mg ⁻¹ xkg⁻¹ xmin⁻¹ . Differences between groups credible, given the Bonferroni correction (p = 0,0015). In our study, was not identified significant differences in 30-day mortality: in the control group it was 3,4%; in the group VIMA of 3,1%; in the group of LS - 0% (p > 0,017); however, a composite outcome (number of adverse events (heart attack+stroke+mortality) were slightly better in the LS group - 17%, against 34% in the control group (p = 0,043).

Conclusion: Preoperative preparation with levosimendan in patients with reduced fraction left ventricle ejection when performing reconstructive operations on the descending aorta reduces the incidence of episodes of decompensation of heart failure compared with the control group to 39,8% (p < 0,05). The use of this technique improves the composite outcome of operations on the infrarenal aorta. The study has not shown the influence of anesthetic cardioprotection in terms of hospitalization and composite outcome of surgical treatment.