Alberto Marabotti

Fabio Guarracino

Giovanni Landoni

PATERNOSTER G

Pietro Bertini

English

Archivio della Ricerca - Università della Basilicata

https://doi.org/10.1177/03913988221145502The International Journal of Artificial Organs 1 –2© The Author(s) 2023Article reuse guidelines: sagepub.com/journals-permissionsDOI: 10.1177/03913988221145502journals.sagepub.com/home/jaoIJAO The International  Journal of Artificial  OrgansDear Editor,We read with great interest the work “Levosimendan’s effect on veno-arterial extracorporeal membrane oxygena-tion weaning”1 by Hau et al., recently published in IJAO. They demonstrated an absent improvement in veno-arte-rial (VA) ECMO weaning and a longer ECMO duration in the group of patients treated with levosimendan. This data is countercurrent compared to our recently published meta-analysis: we analyzed 10 observational retrospective studies, including 987 patients. We demonstrated more successful weaning from VA-ECMO in the levosimendan group,2 data in line with the previous meta-analysis.3,4 We also performed again a random effect meta-analysis add-ing Hau et al.’s data and including information from another recent study by Chen et al.,5 and our results were not significantly altered (Figures 1 and 2).We agreed with the explanation Hau et al. gave: levosi-mendan was more easily administered in patients with a severely impaired left ventricular function, delaying the start Levosimendan’s ability on veno-arterial extracorporeal membrane oxygenation weaning: Evidence says yes!Alberto Marabotti1,2, Pietro Bertini3 , Gianluca Paternoster4, Giovanni Landoni5,6  and Fabio Guarracino3Date received: 1 November 2022; accepted: 29 November 20221 Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy2 Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy3 Cardiothoracic and Vascular Anaesthesia and Intensive care, Department of Anaesthesia and Critical Care Medicine, Pisa, Italy4 Division of Cardiac Resuscitation, Cardiovascular Anesthesia and Intensive Care, San Carlo Hospital, Potenza, Italy5 Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy6Vita-Salute San Raffaele University, Milan, ItalyCorresponding author:Pietro Bertini, Cardiothoracic and Vascular Anesthesia and Intensive Care, Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana – Via Roma 67, Pisa 56124, Italy.Email: pietro.bertini@gmail.com1145502 JAO0010.1177/03913988221145502The International Journal of Artificial OrgansMarabotti et al.letter2023Letter to the editorFigure 1. Mortality in VA ECMO patients treated with Levosimendan versus controls: levosimendan administration was associated with a reduced risk of mortality in overall ECMO recipients (191/517 [36.9%] in the levosimendan group versus 307/588 [54.8%] in the control group, RD = −0.14; 95% CI [−0.23 to −0.05].2 The International Journal of Artificial Organs 00(0)of the weaning from ECMO, which was not taken into con-sideration until reaching at least 20% of left ventricular ejec-tion fraction. We believe that their explanation is extendible to other observational studies.6,7 In observational studies, levosimendan is used in patients with poorer left ventricular function, not in a standardized way. This evidence may explain the longer ECMO duration in the levosimendan group. Even in our meta-analysis, including only observa-tional studies, we demonstrated a non-significantly increased ECMO duration in the levosimendan group. Putting this data altogether, we may speculate that observational studies may underpower levosimendan efficacy in ECMO weaning. Observational studies with small samples may therefore lose statistical significance, which becomes apparent when increasing the number of patients is considered, as in meta-analysis. Thus, Hau et al. may not achieve an advantage in weaning from ECMO due to a small study sample, even though they demonstrated a 10% higher ECMO weaning success rate in the levosimendan group. In light of this, the two ongoing randomized trials, LEVOECMO (NCT04728 932) and Weanlevo (NCT04158674), will be able to provide more certain answers. We expect that in randomized trials, the advantageous effect on weaning will be even more pro-nounced, confirming levosimendan’s beneficial effects in VA ECMO patients.Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.FundingThe author(s) received no financial support for the research, authorship, and/or publication of this article.ORCID iDsPietro Bertini  https://orcid.org/0000-0002-3878-044XGiovanni Landoni  https://orcid.org/0000-0002-8594-5980References 1. Hau M, Fong K-M and Au S-Y. Levosimendan’s effect on venoarterial extracorporeal membrane oxygenation wean-ing. Int J Artif Organs 2022; 45: 571–579. 2. Bertini P, Paternoster G, Landoni G, et al. Beneficial effects of levosimendan to wean patients from VA-ECMO: a sys-tematic review and meta-analysis. Minerva Cardiol Angiol. Epub ahead of print 10 June 2022. DOI: 10.23736/s2724-5683.22.06054-9 3. Yang B, Zhao T, Guo B, et al. Short-term effects of levo-simendan use for venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis. Perfusion. Epub ahead of print 23 October 2021. DOI: 10.1177/02676591211051860 4. Kaddoura R, Omar AS, Ibrahim MIM, et al. The effective-ness of levosimendan on veno-arterial extracorporeal mem-brane oxygenation management and outcome: A systematic review and meta-analysis. J Cardiothorac Vasc Anesth 2021; 35: 2483–2495. 5. Chen Y-W, Lee W-C, Wu P-J, et al. Early levosimendan administration improved weaning success rate in extracor-poreal membrane oxygenation in patients with Cardiogenic Shock. Front Cardiovasc Med 2022; 9: 912321. 6. Alonso-Fernandez-Gatta M, Merchan-Gomez S, Gonzalez-Cebrian M, et al. Levosimendan in veno-arterial extracor-poreal membrane oxygenator supported patients: impact on the success of weaning and survival. Artif Organs 2021; 45: 717–725. 7. Guilherme E, Jacquet-Lagrèze M, Pozzi M, et al. Correction to: can levosimendan reduce ECMO weaning failure in car-diogenic shock?: a cohort study with propensity score anal-ysis. Crit Care 2020; 24(1): 487.Figure 2. Weaning success in VA ECMO patients treated with Levosimendan versus controls: levosimendan administration was associated with a higher weaning success in overall ECMO recipients (424/532 [79.7%] in the levosimendan group versus 426/733 [58.1%] in the control group, RD = 0.23; 95% CI [0.11 to 0.35].

LEVOSIMENDAN'S ABILITY ON VENO-ARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATION WEANING: EVIDENCE SAYS YES!

https://iris.unibas.it/bitstream/11563/190060/1/Levosimendan.pdf

LEVOSIMENDAN'S ABILITY ON VENO-ARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATION WEANING: EVIDENCE SAYS YES!

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