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Acute and Advanced Heart Failure Blog

Professor Gerhard Pölzl is Chief of the Heart Failure and Heart Transplant Program at the Medical University Innsbruck. His research is focused on clinical studies in advanced and chronic heart failure and on translational studies in cardiomyopathies.

He has been Principal Investigator of the LevoRep clinical trial that tested the efficacy and safety of pulsed infusions of levosimendan in outpatients with advanced heart failure. He is now P.I. of the clinical trial LEODOR, on repetitive use of levosimendan in advanced heart failure.

This blog is focused on the therapeutic options for Acute and Advanced Heart Failure: new data, new studies, new opinions, new trends.


Latest posts

8 May 2018

May 2018 post

Levosimendan in Cardiac Surgery: The Evidence Adds Up

 

If we had a way to reduce the risk of life-threatening complications after cardiac surgery would we use it?  Of course we would. It is for reason that this month’s blog post highlights the recent work of Dr. Qiang and colleagues [1]. In the most up-to-date and comprehensive research of its kind these researchers identified and analyzed data from 25 randomized controlled trials (RCTs) that compared perioperative use of levosimendan with control (placebo, conventional inotropes or intra-aortic balloon pump) in 3247 adult cardiac surgery patients and reported an impressive array of benefits. The main results are that

 

1. Levosimendan reduced mortality after cardiac surgery (OR 0.63; P=0.001). This survival benefit was not confined to patients with markedly reduced left ventricular ejection fraction (LVRF): it extended to patients with LVEF up to 50%. So even patients with only moderate depression of LVEF gained from levosimendan treatment.

 

2. Levosimendan use also significantly reduced: the incidence of postoperative acute kidney injury (OR 0.55; P<0.0001), the use of renal replacement therapy use (OR 0.56; P=0.002), the duration of ICU stay (weighted mean difference [WMD] -0.49 day; P=0.0002), and the duration of mechanical ventilation (WMD -2.30 h; P=0.002).

 

Data of this sort make a strong case for the peri-operative use of levosimendan in adult cardiac surgery but they can’t answer every question. In particular, the outcomes of some recent randomized trials [2,3,4] points to the need for further work to define the optimal dose-range: Qiang and colleagues [1] suggest that adult cardiac surgery may be a situation where initial bolus dosing and a relatively high infusion rate may be needed to secure the full clinical benefit of levosimendan unique inodilator actions. If that proves indeed to be the case then the well-documented safety profile of levosimendan will by another feature favoring its use.

 

References:

1. Qiang H et al. J Cardiovasc Pharmacol 2018 Publish Ahead of Print Apr 3. PMID: 29672418, DOI: 10.1097/FJC.0000000000000584
2. Landoni G et al. N Engl J Med. 2017;376(21):2021-2031
3. Mahta RH et al. N Engl J Med. 2017;376(21):2032-2042
4. Cholley B et al. JAMA. 2017;318(6):548-556

5 April 2018

April 2018 post

What does the Advanced Heart Failure patient want?

In the preamble to their recent paper “Development and testing of a goals of care intervention in advanced heart failure” [Appl Nurs Res. 2017;38:99-106] Professor Cynthia M Dougherty and colleagues outline an array of options for the treatment of advanced heart failure (HF) that create – quite reasonably – the impression that we are in a golden age of therapeutic possibilities for this difficult condition: recurrent parenteral infusions, implanted ventricular assist devices and cardioverter defibrillators, cardiac transplantation, and the total artificial heart.

 

But is a life dominated by this panoply of interventions in every case what our patients want? Maybe; maybe not: and very likely not the same answer every time. We have a responsibility to identify their goals.

 

Dougherty and colleagues’ article is a contribution to the expanding science of “goals of care (GoC)”. I am not going to do them the discourtesy of trying to summarize a complex and supple piece of research in this short blog beyond revealing that giving patients’ the skills and confidence to initiate and maintain constructive conversations about what they want from their treatment emerges as a vital aspect of excellence in medical care for advanced heart failure.

 

In the authors’ own words “Holding a GoC conversation between patient and provider is expected to facilitate concordance between care received and the patient’s values and goals, assist in shared decision making about possible new HF therapies, improve patient-provider communication, and potentially improve quality of life.” We have to note that “is expected”: the outcome we aspire to may not be fully achieved in every case. But to aspire to those outcomes is from every point of view absolutely the right thing to do and I would urge all those involved in the care of patients with advanced heart failure to make a careful study of research on GoC (below are some other recent leads to get you started) and to bring well-founded understanding of patient goals and wishes into the heart of their practice.

 

Leads

• An Intervention to Enhance Goals-of-Care Communication Between Heart Failure Patients and Heart Failure Providers.[J Pain Symptom Manage. 2016]

• Does an intervention designed to improve self-management, social support and awareness of palliative-care address needs of persons with heart failure, family caregivers and clinicians?[J Clin Nurs. 2018]

• Feasibility and acceptability of a nursing intervention with family caregiver on self-care among heart failure patients: a randomized pilot trial.[Pilot Feasibility Stud. 2016]

14 March 2018

March 2018 post

I am pleased to announce that there have been notable advances in the LEODOR trial (Repetitive Levosimendan infusions for patients with advanced chronic heart failure), a randomized, double-blind, placebo-controlled multicenter study sponsored by the University of Innsbruck and supported by a grant of Orion Pharma.

 

The recent achievements include:

- Recruitment of the first patient of a planned 276 cases hospitalized for decompensated heart failure requiring i.v. diuretics, or i.v. vasodilators, or i.v. inotropic therapy, or some combination of these interventions.
- Submission of a formal synopsis of the study protocol to Eur. J. Heart Failure for peer review and publication.

 

On the administration and communication side, LEODOR is now represented on the internet by its own website (http://leodortrial.com/) which proves a wealth of information for everyone with an interest in the conduct and progress of the study and regular updates on recruitment. The “For Patients” page addresses key questions such as:

- What is the purpose of this study?
- Which patients will be chosen to take part?
- What does taking part in this study involve?

While the “For Investigators” page summarizes the aims, design and eligibility criteria for LEODOR and provides additional technical and professional information on subjects including Trial Synopsis, Site Evaluation and Patient Consent through a suite of downloadable PDFs (via http://leodortrial.com/#investigators). The site also offers visitors a photo galley of the 14 principal investigators and a range of opportunities to contact the LEODOR team, which in the fullness of time will include tweets posting significant milestones in the progress of the trial. Go Team LEODOR!