Effect of Levosimendan on the Prognosis of Cardiac Surgery in Patients with Cardiac Insufficiency

Effect of Levosimendan on the Prognosis of Cardiac Surgery in Patients with Cardiac Insufficiency | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Effect of Levosimendan on the Prognosis of Cardiac Surgery in Patients with Cardiac Insufficiency Heya Na, Xianen Fa, Yuyang Zhou, Xiangyang Li, Rui Zhu, Lei Liu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-92126/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: To retrospectively analyze the effect of levosimendan on the survival and prognosis of cardiac surgery patients with LVEF < 40%. Methods: the clinical data of 224 patients with preoperative LVEF < 40% were retrospectively analyzed. According to different treatment schemes, the patients were divided into levosimendan group (n = 60) and no-levosimendan group (n = 164,). The control group was treated with routine treatment, and the observation group was treated with levosimendan on the basis of routine treatment. Then a multivariate logistic regression model with a propensity score analysis was used to limit biases and finally the data of 40 patients in each group were selected for analysis. Results: Hemodynamic data showed that the cardiac index, LVEF and PAOP of patients in levosimendan group were significantly improved. The concentration of serum lactic acid in the levosimendan group was lower than that in the control group (P < 0.05). At the same time, postoperative ICU and hospital stay were significantly reduced in levosimendan group (P < 0.05.), Logistics regression analysis showed that levosimendan was the only protective factor for Low cardiac output syndrome (LCOS) (HR=4.33; 95% confidence interval: 1.27- 14.78; P = 0.019). Conclusion: levosimendan can better improve hemodynamics and reduce postoperative ICU time and hospital stay. The use of it tended to decrease the incidence of LCOS significantly. Cardiothoracic Surgery levosimendan cardiac operative propensity score matching Figures Figure 1 Figure 2 Introduction Over the last few decades, mortality associated with heart surgery has declined significantly, despite the increased complexity of the procedure. Although the average perioperative mortality rate is currently 1–2%, the incidence of major cardiovascular complications remains high 1 . Low cardiac output syndrome (LCOS) is the most common and serious complication associated with increased morbidity, short-and long-term mortality, and increased utilization of health-care resources. In addition, the mortality rate of LCOS patients after heart surgery can exceed 20%. The management of LCOS varies with its causes and manifestations. Recognition and treatment of precipitating factors are of prominent. 2 Levosimendan, as a calcium-sensitizing activity, is associated with positive inotropic action and increased myocardial contractility. However, compared with other inotropes, it did not increase intracellular calcium or cyclic adenosine. Thus, the absence of an associated increase in myocardial oxygen consumption also appears to be particularly beneficial for patients undergoing cardiac surgery with limited cardiac reserve. 3 This agent has been used in clinical practice since 2000, especially for the care of patients with heart failure 4 . However, the evidence for its use in surgery is scant. Therefore, we intend to retrospectively analyze the specific efficacy of levosimendan in patients with a left ventricular ejection fraction (LVEF) less than 40% after cardiac surgery. Material And Methods This study was conducted with approval from the Ethics Committee of The Second Affiliated Hospital of Zhengzhou University (approval number 2018-019). As the nature of observational and retrospective study, informed consent was waived. Selection of the study sample This retrospective cohort study was conducted in the Cardiac surgery department of the Second Affiliated Hospital of Zhengzhou University from January 2017 to June 2020. We target the recruitment of patients aged over 18, scheduled for isolated CABG, isolated valve, or combined CABG/valve surgery with cardiopulmonary bypass, who have a LVEF less than 40%, regardless of the method of assessment. All patients were consecutively evaluated. Exclusion criteria were: age < 18 years, preoperative renal failure (creatinine clearance < 30 ml/min), liver failure (prothrombine time < 50%, in the absence of vitamin K antagonist) Pregnancy, emergency surgery, defined as surgery within the 24 h of the operative indication. During the study period, give the attending physician full discretion to administer any other medication, including levosimendan and other vasoactive drugs, as appropriate. Levosimendan was administered without a bolus, by continuous infusion at 0.2ug/kg/min for 24 h. Data collection Data were collected on: age; gender; body mass index > 24 kg/m 2 ; hypertension; diabetes mellitus; cardiopulmonary bypass time; aortic cross-clamping and serum lactic acid levels. Echocardiography was performed by the same team with three ultrasound operators at baseline, intraoperative and postoperative of each patient. The LVEF was measured using biplane Simpson’s method from the two-dimensional echocardiography. All patients underwent continuous monitoring of heart rate and measurement of hemodynamic parameters including pulmonary artery occlusion pressure (PAOP) and cardiac index. Time 0 was defined as the initial hemodynamic measurement, time 1 was recorded on arrival back in the cardiovascular ICU following surgery. Times 2 to 3 were 12 h and 24 h after arrival in the cardiovascular ICU following surgery, respectively. Patients underwent 90 days of postsurgical follow-up, with survival status during this period being recorded. Clinical definitions and study endpoints LCOS incidence was the primary outcome of this trial. LCOS was defined as the presence of low cardiac index ( 16 mmHg) and a SO 2 < 60%. Secondary outcomes for this trial included (a) durations of ICU and hospital stay; (b) serum lactic acid levels at 0, 12, and 48 h post-surgery; (c) invasive hemodynamic parameters at 0, 12, and 48 h post-surgery. Statistical analysis Results were expressed as frequencies and percentages for categorical variables, and as means and standard deviations for continuous variables. Prior to propensity score matching, continuous variables were compared using Student’s t test or the Mann Whitney test, as appropriate. Qualitative variables were compared using Pearson s Chi-square or Fisher s exact test, as appropriate. Mortality at 90 days after cardiac surgery was estimated using the Kaplan Meier method and compared using the log-rank tests. A two-sided p < 0.05 was the significance threshold. The propensity score was defined as the probability of exposure to levosimendan. In order to limit over adjustment due to the use of this score 5 , we selected only the covariates most likely to introduce a confounding bias 6 . The propensity score was estimated using a logistic regression adjusted for age, sex, body mass index > 24 kg/m 2 , presence of high blood pressure and diabetes. Matching was then performed between one patient exposed to levosimendan and up to one unexposed patients 7 , with a propensity score caliper of 0.05. After propensity score matching, Baseline demographic, clinical and echocardiographic data were estimated again to compare baseline characteristics and to therefore assess the accuracy of the matching procedure. Associations between baseline factors and LCOS incidence were assessed using univariate analysis and multivariate logistic regression modeling. Hazard ratios (HR) and their 95% confidence intervals were calculated. A two-tailed p value < 0.05 was considered significant. All the statistical analyses were performed at the Second Affiliated Hospital of Zhengzhou University (Henan Province, China) with the use of SPSS software, version 25.0. Results Study population Over the study period, 271 patients in high-risk with an ejection fraction less than 40% were included in the study. Among these, 47 patients were excluded from the study (12 were < 18 years, 6 had preoperative renal failure, 3 had liver failure, 6 were pregnant, 20 received emergency surgery). A total of 224 patients with severely reduced left ventricular ejection fraction (LVEF < 40%) were eligible for the study. In 2017–2018, in 2018–2019, in 2019–2020 and in 2020–2021, seven out of 35 patients (20%), 20 out of 63 (31.7%), 32 out 75 (42.7%) and 11 out 51 (21.6%) were, respectively, treated with levosimendan. Forty propensity-matched patients were evaluated in the levosimendan group and 40 in the non-levosimendan group (Fig. 1). Characteristics and outcome of the 224 pre‑matched patients Table 1 presents the basic characteristics of the included 224 patients (prior to matching). The average age was 55.29 ± 8 years and the proportion of male was 47.3%. The proportion of body mass index greater than 24 kg/m 2 accounted for 48.7% (Table 1 ). During the study period, 60 patients were treated with levosimendan (26.8%). There was no difference in mean cardiopulmonary bypass time and aortic crossclamp time compared with the control group. All the patients in the levosimendan group and the no-levosimendan group had severely reduced left ventricular ejection fraction with LVEF < 40%, but the difference between the groups was statistically significant (P = 0.02). Characteristics and outcome of the 80 matched patients After propensity score matching, differences in the characteristics of patients between the levosimendan group and the non-levosimendan group were not statistically significant (Table 2). Baseline hemodynamic parameters and serum lactate concentration were comparable in both groups (Fig. 2). Hemodynamic data demonstrate a rapid improvement in cardiac index, LVEF and PAOP in patients receiving levosimendan. Serum lactate concentration was consistently lower in levosimendan group at majority of time intervals. These effects persisted at all time intervals during and after surgery. Significant reduction in ICU and hospital stay occurred in levosimendan group at the postoperative period as compared to no levosimendan group (P < 0.05). Out of 80 patients, 63 patients (78.75%) were not presented in the postoperative phase with low cardiac output syndrome (LCOS). After propensity score matching, exposure to levosimendan was the only remaining factor associated with a significant reduction in the occurrence of LCOS rates (hazard ratio = 4.33; 95% confidence interval: 1.27–14.78; P = 0.019) (Table 3). Discussion This retrospective study suggests that patients with a severely reduced left ventricular ejection fraction due to impaired contractility may probably benefit from levosimendan. This agent acutely improves hemodynamics during postoperative recovery and also reduced the length of ICU stay and the length of hospital stay. As far as we known, levosimendan’s unique properties are attributed to its multiple and complementary mechanisms of action. In addition to its hemodynamic actions on coronary and pulmonary vessels, another hypothesis for the beneficial effects of levosimendan may be its positive effects on systemic vasodilation 3 . This is relevant to the reduction on serum lactic acid. Bravo et al conducted a study in the critically ill infants with congenital heart defects suffering from LCOS and found that many poor perfusion physiological variables and biomarkers indicators showed a different profile after levosimendan infusion, such as a significant decrease in serum lactate levels. Finally, levosimendan served a beneficial function on cerebral and systemic perfusion in this restricted patients 8 . In addition, the patients with severe, low-output heart failure were also able to benefit from levosimendan 9 10 . In our view, extending the study population to non-cardiac surgery patients is relevant for physicians in the field because low cardiac output syndrome may occur in many cases. To our knowledge, two other randomized controlled trials (RCTs) have not shown beneficial effects of the use of levosimendan compared with placebo in patients with preoperative severely depressed LVEF 11 12 . And Wang et al. also suggested that levosimendan had no significance for the improvement of the incidence of postoperative LCOS 13 . The beneficial effects of levosimendan are still debated in clinical practice. Nonetheless, researchers in the first study reported a beneficial effect in a subgroup of patients with a more severe reduction of LVEF 12 . Another analysis also shows that the beneficial effect of levosimendan can only be observed in patients with LVEF < 50% 14 . Van et al., divided the patients into different cardiac surgery methods 15 . Desai et al studied patients undergoing off-pump coronary artery bypass surgery 16 . In terms of the incidence of LCOS, no significant results were observed in either study, which is consistent with our observation. A large mate analysis also suggested that levosimendan could benefit the patients with lower LVEF (< 35%) in terms of the incidence of postoperative LCOS 17 .Levosimendan can reduce the incidence of LCOS after heart surgery, which can only be observed in patients with a more severe reduction of LVEF 18 . All of our patients had significant hemodynamic disorders with an ejection fraction less than 40%. In addition, Orriach et al. found that levosimendan can improve the renal function of postoperative LCOS patients 19 . This suggests that levosimendan can not only reduce the incidence of LCOS, but also benefit the patients who have already experienced LCOS, expanding the scope of application of levosimendan to a certain extent. Limitations Our study has several limitations. The retrospective nature of the analysis is clearly a weakness. In addition, our study may suffer from a lack of power because of the low number of patients and events evaluated. The main limitation of our study is that administration of levosimendan was not randomized. However, to limit biases due to the absence of randomization, we used a multivariate logistic regression model with a propensity score analysis. Conclusion This study suggests that levosimendan can better improve hemodynamics and reduce postoperative ICU time and hospital stay. And the use of levosimendan tended to decrease the incidence of LCOS significantly. Abbreviations LCOS: low cardiac output syndrome; LVEF: left ventricular ejection fraction; ICU: intensive care unit. Declarations Ethical Approval and Consent to participate This study was conducted with approval from the Ethics Committee of The Second Affiliated Hospital of Zhengzhou University (approval number 2018-019). The need for informed consent was waived because of the observational and retrospective nature of the study. Consent for publication Not applicable. Availability of supporting data The data used and/or analyzed in the present study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study is funded by National Science and Technology Planning Project of China, 2011BAI11B21 and Innovative talents of health science and technology in Henan Province of China, 201003040. Authors' contributions HN and XF had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. HN, XF and YZ conceptualized and designed the study. HN, XL, RZ and BL were involved in acquisition of data. HN, XL, RZ, LL and BL analyzed and interpreted the data.HN and BL drafted the manuscript. XF, YZ and LL critically revised the manuscript for important intellectual content. HN and XL carried out the statistical analysis. XF and YZ were involved in funding, administrative, technical or material support. XF, YZ, XL, RZ, LL and BL supervised the study. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Lomivorotov VV, Efremov SM, Kirov MY, et al. Low-Cardiac-Output Syndrome After Cardiac Surgery. 2016:S1053077016301513. Follath F, Cleland J, Just H, et al. Efficacy and safety of intravenous levosimendan compared with dobutamine in severe low-output heart failure (the LIDO study): a randomised double-blind trial. 2002;360(9328):196-202. doi: 10.1016/s0140-6736(02)09455-2 Levin R, Degrange M, Del Mazo C, et al. Preoperative levosimendan decreases mortality and the development of low cardiac output in high-risk patients with severe left ventricular dysfunction undergoing coronary artery bypass grafting with cardiopulmonary bypass. 2012;17(3):125-30. Papp Z, Agostoni P, Alvarez J, et al. Levosimendan Efficacy and Safety: 20 Years of SIMDAX in Clinical Use. 2020;76(1):4-22. doi: 10.1097/fjc.0000000000000859 Schuster T, Lowe W, Platt RJJoce. Propensity score model overfitting led to inflated variance of estimated odds ratios. 2016;80:97-106. doi: 10.1016/j.jclinepi.2016.05.017 Brookhart MA, Schneeweiss S, Rothman KJ, et al. Variable selection for propensity score models. 2006;163(12):1149-56. Austin PCJMBR. An Introduction to Propensity Score Methods for Reducing the Effects of Confounding in Observational Studies. 2011;46(3):399-424. Bravo MC, Lopez P, Cabanas F, et al. Acute Effects of Levosimendan on Cerebral and Systemic Perfusion and Oxygenation in Newborns: An Observational Study. 2011;99(3):217-23. Cholley B, Levy B, Fellahi J, et al. Levosimendan in the light of the results of the recent randomized controlled trials: an expert opinion paper. 2019;23(1):385. doi: 10.1186/s13054-019-2674-4 Cosentino N, Niccoli G, Fracassi F, et al. Rationale, Experimental Data, and Emerging Clinical Evidence on Early and Preventive Use of Levosimendan in Patients with Ventricular Dysfunction. 2019 doi: 10.1093/ehjcvp/pvz065 Landoni G, Lomivorotov V, Alvaro G, et al. Levosimendan for Hemodynamic Support after Cardiac Surgery. 2017;376(21):2021-31. doi: 10.1056/NEJMoa1616325 Mehta R, Leimberger J, van Diepen S, et al. Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery. 2017;376(21):2032-42. doi: 10.1056/NEJMoa1616218 Wang A, Cui C, Fan Y, et al. Prophylactic use of levosimendan in pediatric patients undergoing cardiac surgery: a prospective randomized controlled trial. 2019;23(1):428. doi: 10.1186/s13054-019-2704-2 Qiang H, Luo X, Huo J, et al. Perioperative Use of Levosimendan Improves Clinical Outcomes in Patients After Cardiac Surgery: A Systematic Review and Meta-Analysis. 2018;72(1):11-18. Van Diepen S, Mehta RH, Leimberger JD, et al. Levosimendan in patients with reduced left ventricular function undergoing isolated coronary or valve surgery. 2019 Desai P, Sarkar M, Umbarkar SJAoCA. Prophylactic preoperative levosimendan for off-pump coronary artery bypass grafting in patients with left ventricular dysfunction: Single-centered randomized prospective study. 2018;21(2):123-28. Weber C, Esser M, Eghbalzadeh K, et al. Levosimendan Reduces Mortality and Low Cardiac Output Syndrome in Cardiac Surgery. 2020;68(5):401-09. doi: 10.1055/s-0039-3400496 Weber C, Esser M, Eghbalzadeh K, et al. Levosimendan Reduces Mortality and Low Cardiac Output Syndrome in Cardiac Surgery. 2019 Orriach JLG, Arce IN, Rodriguez PH, et al. Preservation of renal function in cardiac surgery patients with low cardiac output syndrome: levosimendan vs beta agonists. 2019;19(1):212. Tables Table 1 Baseline patient characteristics in pre-matched groups Variables Total Levosimendan P value (n=225) No(n=164) Yes(n=60) Male 106(47.3) 76(46.3) 30(50) 0.627 Age (years) 55.29±8.360 52.60±7.877 62.63±4.214 0.000 BMI＞24kg/m² 109(48.7) 75(45.7) 34(56.7) 0.147 Isolated CABG 70(31.3) 52(31.7) 18(30) 0.951 Isolated valve surgery 86(38.4) 62(37.8) 24(40) Combined CABG and valve 68(30.4) 50(30.5) 18(30) Diabetes mellitus 93(41.5) 64(39.0) 29(48.3) 0.211 Hypertension 103(46.0) 75(45.7) 28(46.7) 0.901 CPB(min) 128.37±21.086 129.38±21.318 125.60±20.352 0.235 Aortic crossclamp time(min) 96.83±16.219 97.62±16.129 94.68±16.406 0.231 LVEF(%) 35.49±3.131 35.20±3.216 36.30±2.751 0.012 Results are expressed as mean ± SD or number (%) CABG, Coronary artery bypass grafting; BMI, body mass index;LVEF, left ventricular ejection fraction; CPB, cardiopulmonary bypass Table 2 Patient characteristics in propensity-matched groups Variables Total Levosimendan P value (n=80) No(n=40) Yes(n=40) Male 41(51.25) 20(50) 21(20.5) 0.823 Age (years) 43(53.75) 21(52.5) 22(55) 0.823 BMI＞24kg/m² 60.53±3.978 60.30±4.345 60.75±3.614 0.616 Isolated CABG 22(27.5) 18(28.6) 4(23.5) 0.891 Isolated valve surgery 34(42.5) 26(41.3) 8(47.1) Combined CABG and valve 24(30) 19(30.2) 5(29.4) Diabetes mellitus 34(42.5) 16(40) 18(45) 0.651 Hypertension 30(37.5) 13(32.5) 17(42.5) 0.356 CPB(min) 125.66±19.573 124.35±18.530 126.98±20.715 0.552 Aortic crossclamp time(min) 99.91±14.995 102.30±14.235 97.53±15.528 0.156 Duration of mechanical ventilation(hour) 41.00（36.00-47.75） 45.5(38-52.25) 38(34-45) 0.002 ICU stay(day) 4.5750（4.11-5.61） 5.6(4.77-6.53) 4.13(3.74-4.53) 0.000 Hospital stay(day) 9.4450（8.44-11.86） 11.82(10.55-13.25) 8.49(7.69-9.08) 0.000 LCOS 17(21.25) 13(32.5) 4(10) 0.014 Results are expressed as mean ± SD or number (%) CABG, Coronary artery bypass grafting; BMI, body mass index;LVEF, left ventricular ejection fraction; CPB, cardiopulmonary bypass; LCOS, Low cardiac output syndrome,ICU, Intensive Care Unit Table 3 Baseline factors predictive of LCOS incidence Variables LCOS P value No(n=63) Yes(n=17) Male 34(54) 7(41.2) 0.349 BMI＞24kg/m² 35(55.6) 8(47.1) 0.533 Age (years) 60.41±4.01 60.94±3.94 0.63 Isolated CABG 18(28.6) 4(23.5) 0.891 Isolated valve surgery 26(41.3) 8(47.1) Combined CABG and valve 19(30.2) 5(29.4) Diabetes mellitus 28(44.4) 6(35.3) 0.489 Hypertension 24(38.1) 6(35.3) 0.832 CPB(min) 124.83±19.46 128.76±20.28 0.465 Levosimendan 36(57.14) 4（23.5) 0.014 LVEF 35.42±3.02 36.65±2.74 0.137 HR 65.73±3.05 64.59±3.20 0.179 CI 2.10±0.18 2.09±0.19 0.843 Results are expressed as mean ± SD or number (%) CABG, Coronary artery bypass grafting; BMI, body mass index; LVEF, left ventricular ejection fraction; CPB: cardiopulmonary bypass; LCOS, Low cardiac output syndrome, ICU, Intensive Care Unit; HR, Heart rates; CI, Cardiac index. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-92126","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":3489494,"identity":"bc957149-7b67-49a0-8e77-0ae723ec713b","order_by":0,"name":"Heya Na","email":"","orcid":"","institution":"The Second Affiliated Hospital of Zhengzhou University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Heya","middleName":"","lastName":"Na","suffix":""},{"id":3489495,"identity":"32ba6a0b-12d9-4401-bd06-028042d426fb","order_by":1,"name":"Xianen 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the study sample","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-92126/v1/d18f3a056827b0db20ff6025.jpg"},{"id":3024739,"identity":"0a5948af-062f-452a-a6f9-ee34e6371a06","added_by":"auto","created_at":"2020-10-16 14:05:30","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":201882,"visible":true,"origin":"","legend":"Baseline hemodynamic parameters and serum lactate concentration were comparable in both groups .","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-92126/v1/cdefe02518688c14b2721bd9.jpg"},{"id":13603983,"identity":"e92fd513-dac0-403b-9ba0-fb85bcf76f32","added_by":"auto","created_at":"2021-09-17 05:57:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":443838,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-92126/v1/10a1bbef-acaa-41b0-9a4a-af4ced35b82f.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eEffect of Levosimendan on the Prognosis of Cardiac Surgery in Patients with Cardiac Insufficiency\u003c/p\u003e","fulltext":[{"header":"Introduction","content":" \u003cp\u003eOver the last few decades, mortality associated with heart surgery has declined significantly, despite the increased complexity of the procedure. Although the average perioperative mortality rate is currently 1\u0026ndash;2%, the incidence of major cardiovascular complications remains high\u003csup\u003e1\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLow cardiac output syndrome (LCOS) is the most common and serious complication associated with increased morbidity, short-and long-term mortality, and increased utilization of health-care resources. In addition, the mortality rate of LCOS patients after heart surgery can exceed 20%. The management of LCOS varies with its causes and manifestations. Recognition and treatment of precipitating factors are of prominent.\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eLevosimendan, as a calcium-sensitizing activity, is associated with positive inotropic action and increased myocardial contractility. However, compared with other inotropes, it did not increase intracellular calcium or cyclic adenosine. Thus, the absence of an associated increase in myocardial oxygen consumption also appears to be particularly beneficial for patients undergoing cardiac surgery with limited cardiac reserve.\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis agent has been used in clinical practice since 2000, especially for the care of patients with heart failure \u003csup\u003e4\u003c/sup\u003e. However, the evidence for its use in surgery is scant. Therefore, we intend to retrospectively analyze the specific efficacy of levosimendan in patients with a left ventricular ejection fraction (LVEF) less than 40% after cardiac surgery.\u003c/p\u003e "},{"header":"Material And Methods","content":" \u003cp\u003eThis study was conducted with approval from the Ethics Committee of The Second Affiliated Hospital of Zhengzhou University (approval number 2018-019). As the nature of observational and retrospective study, informed consent was waived.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSelection of the study sample\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study was conducted in the Cardiac surgery department of the Second Affiliated Hospital of Zhengzhou University from January 2017 to June 2020.\u003c/p\u003e \u003cp\u003eWe target the recruitment of patients aged over 18, scheduled for isolated CABG, isolated valve, or combined CABG/valve surgery with cardiopulmonary bypass, who have a LVEF less than 40%, regardless of the method of assessment. All patients were consecutively evaluated. Exclusion criteria were: age\u0026thinsp;\u0026lt;\u0026thinsp;18 years, preoperative renal failure (creatinine clearance\u0026thinsp;\u0026lt;\u0026thinsp;30\u0026nbsp;ml/min), liver failure (prothrombine time\u0026thinsp;\u0026lt;\u0026thinsp;50%, in the absence of vitamin K antagonist) Pregnancy, emergency surgery, defined as surgery within the 24\u0026nbsp;h of the operative indication.\u003c/p\u003e \u003cp\u003eDuring the study period, give the attending physician full discretion to administer any other medication, including levosimendan and other vasoactive drugs, as appropriate. Levosimendan was administered without a bolus, by continuous infusion at 0.2ug/kg/min for 24\u0026nbsp;h.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eData were collected on: age; gender; body mass index\u0026thinsp;\u0026gt;\u0026thinsp;24\u0026nbsp;kg/m\u003csup\u003e2\u003c/sup\u003e; hypertension; diabetes mellitus; cardiopulmonary bypass time; aortic cross-clamping and serum lactic acid levels.\u003c/p\u003e \u003cp\u003eEchocardiography was performed by the same team with three ultrasound operators at baseline, intraoperative and postoperative of each patient. The LVEF was measured using biplane Simpson\u0026rsquo;s method from the two-dimensional echocardiography.\u003c/p\u003e \u003cp\u003eAll patients underwent continuous monitoring of heart rate and measurement of hemodynamic parameters including pulmonary artery occlusion pressure (PAOP) and cardiac index.\u003c/p\u003e \u003cp\u003eTime 0 was defined as the initial hemodynamic measurement, time 1 was recorded on arrival back in the cardiovascular ICU following surgery. Times 2 to 3 were 12\u0026nbsp;h and 24\u0026nbsp;h after arrival in the cardiovascular ICU following surgery, respectively.\u003c/p\u003e \u003cp\u003ePatients underwent 90 days of postsurgical follow-up, with survival status during this period being recorded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eClinical definitions and study endpoints\u003c/h2\u003e \u003cp\u003eLCOS incidence was the primary outcome of this trial. LCOS was defined as the presence of low cardiac index (\u0026lt;\u0026thinsp;2.2\u0026nbsp;L/min/m\u003csup\u003e2\u003c/sup\u003e)\u003csup\u003e2\u003c/sup\u003e, elevated PAOP (\u0026gt;\u0026thinsp;16\u0026nbsp;mmHg) and a SO\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;\u0026lt;\u0026thinsp;60%. Secondary outcomes for this trial included (a) durations of ICU and hospital stay; (b) serum lactic acid levels at 0, 12, and 48\u0026nbsp;h post-surgery; (c) invasive hemodynamic parameters at 0, 12, and 48\u0026nbsp;h post-surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eResults were expressed as frequencies and percentages for categorical variables, and as means and standard deviations for continuous variables. Prior to propensity score matching, continuous variables were compared using Student\u0026rsquo;s t test or the Mann Whitney test, as appropriate. Qualitative variables were compared using Pearson s Chi-square or Fisher s exact test, as appropriate. Mortality at 90 days after cardiac surgery was estimated using the Kaplan Meier method and compared using the log-rank tests. A two-sided p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was the significance threshold.\u003c/p\u003e \u003cp\u003eThe propensity score was defined as the probability of exposure to levosimendan. In order to limit over adjustment due to the use of this score \u003csup\u003e5\u003c/sup\u003e, we selected only the covariates most likely to introduce a confounding bias\u003csup\u003e6\u003c/sup\u003e. The propensity score was estimated using a logistic regression adjusted for age, sex, body mass index\u0026thinsp;\u0026gt;\u0026thinsp;24\u0026nbsp;kg/m\u003csup\u003e2\u003c/sup\u003e, presence of high blood pressure and diabetes. Matching was then performed between one patient exposed to levosimendan and up to one unexposed patients\u003csup\u003e7\u003c/sup\u003e, with a propensity score caliper of 0.05.\u003c/p\u003e \u003cp\u003eAfter propensity score matching, Baseline demographic, clinical and echocardiographic data were estimated again to compare baseline characteristics and to therefore assess the accuracy of the matching procedure.\u003c/p\u003e \u003cp\u003eAssociations between baseline factors and LCOS incidence were assessed using univariate analysis and multivariate logistic regression modeling. Hazard ratios (HR) and their 95% confidence intervals were calculated. A two-tailed p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant. All the statistical analyses were performed at the Second Affiliated Hospital of Zhengzhou University (Henan Province, China) with the use of SPSS software, version 25.0.\u003c/p\u003e \u003c/div\u003e "},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eStudy population\u003c/h2\u003e\n\u003cp\u003eOver the study period, 271 patients in high-risk with an ejection fraction less than 40% were included in the study. Among these, 47 patients were excluded from the study (12 were \u0026lt;\u0026thinsp;18 years, 6 had preoperative renal failure, 3 had liver failure, 6 were pregnant, 20 received emergency surgery). A total of 224 patients with severely reduced left ventricular ejection fraction (LVEF\u0026thinsp;\u0026lt;\u0026thinsp;40%) were eligible for the study. In 2017\u0026ndash;2018, in 2018\u0026ndash;2019, in 2019\u0026ndash;2020 and in 2020\u0026ndash;2021, seven out of 35 patients (20%), 20 out of 63 (31.7%), 32 out 75 (42.7%) and 11 out 51 (21.6%) were, respectively, treated with levosimendan. Forty propensity-matched patients were evaluated in the levosimendan group and 40 in the non-levosimendan group (Fig.\u0026nbsp;1).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eCharacteristics and outcome of the 224 pre‑matched patients\u003c/h2\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents the basic characteristics of the included 224 patients (prior to matching). The average age was 55.29\u0026thinsp;\u0026plusmn;\u0026thinsp;8\u0026nbsp;years and the proportion of male was 47.3%. The proportion of body mass index greater than 24\u0026nbsp;kg/m\u003csup\u003e2\u003c/sup\u003e accounted for 48.7% (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). During the study period, 60 patients were treated with levosimendan (26.8%). There was no difference in mean cardiopulmonary bypass time and aortic crossclamp time compared with the control group. All the patients in the levosimendan group and the no-levosimendan group had severely reduced left ventricular ejection fraction with LVEF\u0026thinsp;\u0026lt;\u0026thinsp;40%, but the difference between the groups was statistically significant (P\u0026thinsp;=\u0026thinsp;0.02).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003eCharacteristics and outcome of the 80 matched patients\u003c/h2\u003e\n\u003cp\u003eAfter propensity score matching, differences in the characteristics of patients between the levosimendan group and the non-levosimendan group were not statistically significant (Table\u0026nbsp;2).\u003c/p\u003e\n\u003cp\u003eBaseline hemodynamic parameters and serum lactate concentration were comparable in both groups (Fig.\u0026nbsp;2). Hemodynamic data demonstrate a rapid improvement in cardiac index, LVEF and PAOP in patients receiving levosimendan. Serum lactate concentration was consistently lower in levosimendan group at majority of time intervals. These effects persisted at all time intervals during and after surgery. Significant reduction in ICU and hospital stay occurred in levosimendan group at the postoperative period as compared to no levosimendan group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003cp\u003eOut of 80 patients, 63 patients (78.75%) were not presented in the postoperative phase with low cardiac output syndrome (LCOS). After propensity score matching, exposure to levosimendan was the only remaining factor associated with a significant reduction in the occurrence of LCOS rates (hazard ratio\u0026thinsp;=\u0026thinsp;4.33; 95% confidence interval: 1.27\u0026ndash;14.78; P\u0026thinsp;=\u0026thinsp;0.019) (Table\u0026nbsp;3).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":" \u003cp\u003eThis retrospective study suggests that patients with a severely reduced left ventricular ejection fraction due to impaired contractility may probably benefit from levosimendan.\u003c/p\u003e \u003cp\u003eThis agent acutely improves hemodynamics during postoperative recovery and also reduced the length of ICU stay and the length of hospital stay.\u003c/p\u003e \u003cp\u003eAs far as we known, levosimendan\u0026rsquo;s unique properties are attributed to its multiple and complementary mechanisms of action.\u003c/p\u003e \u003cp\u003eIn addition to its hemodynamic actions on coronary and pulmonary vessels, another hypothesis for the beneficial effects of levosimendan may be its positive effects on systemic vasodilation\u003csup\u003e3\u003c/sup\u003e. This is relevant to the reduction on serum lactic acid. Bravo et al conducted a study in the critically ill infants with congenital heart defects suffering from LCOS and found that many poor perfusion physiological variables and biomarkers indicators showed a different profile after levosimendan infusion, such as a significant decrease in serum lactate levels. Finally, levosimendan served a beneficial function on cerebral and systemic perfusion in this restricted patients\u003csup\u003e8\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn addition, the patients with severe, low-output heart failure were also able to benefit from levosimendan\u003csup\u003e9 10\u003c/sup\u003e. In our view, extending the study population to non-cardiac surgery patients is relevant for physicians in the field because low cardiac output syndrome may occur in many cases.\u003c/p\u003e \u003cp\u003eTo our knowledge, two other randomized controlled trials (RCTs) have not shown beneficial effects of the use of levosimendan compared with placebo in patients with preoperative severely depressed LVEF\u003csup\u003e11 12\u003c/sup\u003e. And Wang et al. also suggested that levosimendan had no significance for the improvement of the incidence of postoperative LCOS\u003csup\u003e13\u003c/sup\u003e. The beneficial effects of levosimendan are still debated in clinical practice. Nonetheless, researchers in the first study reported a beneficial effect in a subgroup of patients with a more severe reduction of LVEF\u003csup\u003e12\u003c/sup\u003e. Another analysis also shows that the beneficial effect of levosimendan can only be observed in patients with LVEF\u0026thinsp;\u0026lt;\u0026thinsp;50%\u003csup\u003e14\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eVan et al., divided the patients into different cardiac surgery methods\u003csup\u003e15\u003c/sup\u003e. Desai et al studied patients undergoing off-pump coronary artery bypass surgery\u003csup\u003e16\u003c/sup\u003e. In terms of the incidence of LCOS, no significant results were observed in either study, which is consistent with our observation. A large mate analysis also suggested that levosimendan could benefit the patients with lower LVEF (\u0026lt;\u0026thinsp;35%) in terms of the incidence of postoperative LCOS \u003csup\u003e17\u003c/sup\u003e.Levosimendan can reduce the incidence of LCOS after heart surgery, which can only be observed in patients with a more severe reduction of LVEF \u003csup\u003e18\u003c/sup\u003e. All of our patients had significant hemodynamic disorders with an ejection fraction less than 40%.\u003c/p\u003e \u003cp\u003eIn addition, Orriach et al. found that levosimendan can improve the renal function of postoperative LCOS patients\u003csup\u003e19\u003c/sup\u003e. This suggests that levosimendan can not only reduce the incidence of LCOS, but also benefit the patients who have already experienced LCOS, expanding the scope of application of levosimendan to a certain extent.\u003c/p\u003e "},{"header":"Limitations","content":" \u003cp\u003eOur study has several limitations. The retrospective nature of the analysis is clearly a weakness. In addition, our study may suffer from a lack of power because of the low number of patients and events evaluated. The main limitation of our study is that administration of levosimendan was not randomized. However, to limit biases due to the absence of randomization, we used a multivariate logistic regression model with a propensity score analysis.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eThis study suggests that levosimendan can better improve hemodynamics and reduce postoperative ICU time and hospital stay. And the use of levosimendan tended to decrease the incidence of LCOS significantly.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eLCOS: low cardiac output syndrome; LVEF: left ventricular ejection fraction; ICU: intensive care unit.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted with approval from the Ethics Committee of The Second Affiliated Hospital of Zhengzhou University (approval number 2018-019). The need for informed consent was waived because of the observational and retrospective nature of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of supporting data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used and/or analyzed in the present study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is funded by National Science and Technology Planning Project of China, 2011BAI11B21 and Innovative talents of health science and technology in Henan Province of China, 201003040.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHN and XF had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. HN, XF and YZ conceptualized and designed the study. HN, XL, RZ and BL were involved in acquisition of data. HN, XL, RZ, LL and BL analyzed and interpreted the data.HN and BL drafted the manuscript. XF, YZ and LL critically revised the manuscript for important intellectual content. HN and XL carried out the statistical analysis. XF and YZ were involved in funding, administrative, technical or material support. XF, YZ, XL, RZ, LL and BL supervised the study. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLomivorotov VV, Efremov SM, Kirov MY, et al. Low-Cardiac-Output Syndrome After Cardiac Surgery. 2016:S1053077016301513.\u003c/li\u003e\n\u003cli\u003eFollath F, Cleland J, Just H, et al. Efficacy and safety of intravenous levosimendan compared with dobutamine in severe low-output heart failure (the LIDO study): a randomised double-blind trial. 2002;360(9328):196-202. doi: 10.1016/s0140-6736(02)09455-2\u003c/li\u003e\n\u003cli\u003eLevin R, Degrange M, Del Mazo C, et al. Preoperative levosimendan decreases mortality and the development of low cardiac output in high-risk patients with severe left ventricular dysfunction undergoing coronary artery bypass grafting with cardiopulmonary bypass. 2012;17(3):125-30.\u003c/li\u003e\n\u003cli\u003ePapp Z, Agostoni P, Alvarez J, et al. Levosimendan Efficacy and Safety: 20 Years of SIMDAX in Clinical Use. 2020;76(1):4-22. doi: 10.1097/fjc.0000000000000859\u003c/li\u003e\n\u003cli\u003eSchuster T, Lowe W, Platt RJJoce. Propensity score model overfitting led to inflated variance of estimated odds ratios. 2016;80:97-106. doi: 10.1016/j.jclinepi.2016.05.017\u003c/li\u003e\n\u003cli\u003eBrookhart MA, Schneeweiss S, Rothman KJ, et al. Variable selection for propensity score models. 2006;163(12):1149-56.\u003c/li\u003e\n\u003cli\u003eAustin PCJMBR. An Introduction to Propensity Score Methods for Reducing the Effects of Confounding in Observational Studies. 2011;46(3):399-424.\u003c/li\u003e\n\u003cli\u003eBravo MC, Lopez P, Cabanas F, et al. Acute Effects of Levosimendan on Cerebral and Systemic Perfusion and Oxygenation in Newborns: An Observational Study. 2011;99(3):217-23.\u003c/li\u003e\n\u003cli\u003eCholley B, Levy B, Fellahi J, et al. Levosimendan in the light of the results of the recent randomized controlled trials: an expert opinion paper. 2019;23(1):385. doi: 10.1186/s13054-019-2674-4\u003c/li\u003e\n\u003cli\u003eCosentino N, Niccoli G, Fracassi F, et al. Rationale, Experimental Data, and Emerging Clinical Evidence on Early and Preventive Use of Levosimendan in Patients with Ventricular Dysfunction. 2019 doi: 10.1093/ehjcvp/pvz065\u003c/li\u003e\n\u003cli\u003eLandoni G, Lomivorotov V, Alvaro G, et al. Levosimendan for Hemodynamic Support after Cardiac Surgery. 2017;376(21):2021-31. doi: 10.1056/NEJMoa1616325\u003c/li\u003e\n\u003cli\u003eMehta R, Leimberger J, van Diepen S, et al. Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery. 2017;376(21):2032-42. doi: 10.1056/NEJMoa1616218\u003c/li\u003e\n\u003cli\u003eWang A, Cui C, Fan Y, et al. Prophylactic use of levosimendan in pediatric patients undergoing cardiac surgery: a prospective randomized controlled trial. 2019;23(1):428. doi: 10.1186/s13054-019-2704-2\u003c/li\u003e\n\u003cli\u003eQiang H, Luo X, Huo J, et al. Perioperative Use of Levosimendan Improves Clinical Outcomes in Patients After Cardiac Surgery: A Systematic Review and Meta-Analysis. 2018;72(1):11-18.\u003c/li\u003e\n\u003cli\u003eVan Diepen S, Mehta RH, Leimberger JD, et al. Levosimendan in patients with reduced left ventricular function undergoing isolated coronary or valve surgery. 2019\u003c/li\u003e\n\u003cli\u003eDesai P, Sarkar M, Umbarkar SJAoCA. Prophylactic preoperative levosimendan for off-pump coronary artery bypass grafting in patients with left ventricular dysfunction: Single-centered randomized prospective study. 2018;21(2):123-28.\u003c/li\u003e\n\u003cli\u003eWeber C, Esser M, Eghbalzadeh K, et al. Levosimendan Reduces Mortality and Low Cardiac Output Syndrome in Cardiac Surgery. 2020;68(5):401-09. doi: 10.1055/s-0039-3400496\u003c/li\u003e\n\u003cli\u003eWeber C, Esser M, Eghbalzadeh K, et al. Levosimendan Reduces Mortality and Low Cardiac Output Syndrome in Cardiac Surgery. 2019\u003c/li\u003e\n\u003cli\u003eOrriach JLG, Arce IN, Rodriguez PH, et al. Preservation of renal function in cardiac surgery patients with low cardiac output syndrome: levosimendan vs beta agonists. 2019;19(1):212.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" width=\"0\"\u003e\u003ccaption\u003eTable 1 \u003cbr /\u003eBaseline patient characteristics in\u0026nbsp;pre-matched groups\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"131\"\u003e\n\u003cp\u003e\u003cstrong\u003eLevosimendan\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e\u003cstrong\u003e(n=225)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"131\"\u003e\n\u003cp\u003e\u003cstrong\u003eNo(n=164)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e\u003cstrong\u003eYes(n=60)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e106(47.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"131\"\u003e\n\u003cp\u003e76(46.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e30(50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e0.627\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eAge (years)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e55.29\u0026plusmn;8.360\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"131\"\u003e\n\u003cp\u003e52.60\u0026plusmn;7.877\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e62.63\u0026plusmn;4.214\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eBMI＞24kg/m\u0026sup2;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e109(48.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"131\"\u003e\n\u003cp\u003e75(45.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e34(56.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e0.147\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eIsolated CABG\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e70(31.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"131\"\u003e\n\u003cp\u003e52(31.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e18(30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e0.951\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eIsolated valve surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e86(38.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"131\"\u003e\n\u003cp\u003e62(37.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e24(40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e \u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eCombined CABG and valve\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e68(30.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"131\"\u003e\n\u003cp\u003e50(30.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e18(30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e \u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eDiabetes mellitus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e93(41.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"131\"\u003e\n\u003cp\u003e64(39.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e29(48.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e0.211\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eHypertension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e103(46.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"131\"\u003e\n\u003cp\u003e75(45.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e28(46.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e0.901\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eCPB(min)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e128.37\u0026plusmn;21.086\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"131\"\u003e\n\u003cp\u003e129.38\u0026plusmn;21.318\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e125.60\u0026plusmn;20.352\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e0.235\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eAortic crossclamp time(min)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e96.83\u0026plusmn;16.219\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"131\"\u003e\n\u003cp\u003e97.62\u0026plusmn;16.129\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e94.68\u0026plusmn;16.406\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e0.231\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eLVEF(%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e35.49\u0026plusmn;3.131\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"131\"\u003e\n\u003cp\u003e35.20\u0026plusmn;3.216\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"87\"\u003e\n\u003cp\u003e36.30\u0026plusmn;2.751\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003e0.012\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" width=\"577\"\u003e\n\u003cp\u003eResults are expressed as mean \u0026plusmn; SD or number (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" width=\"577\"\u003e\n\u003cp\u003eCABG, Coronary artery bypass grafting; BMI, body mass index;LVEF, left ventricular ejection fraction; CPB, cardiopulmonary bypass\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" width=\"100%\"\u003e\u003ccaption\u003eTable 2 \u003cbr /\u003ePatient characteristics in propensity-matched groups\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"34%\"\u003e\n\u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"20%\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"18%\"\u003e\n\u003cp\u003e\u003cstrong\u003eLevosimendan\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"34%\"\u003e\n\u003cp\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"20%\"\u003e\n\u003cp\u003e\u003cstrong\u003e(n=80)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"18%\"\u003e\n\u003cp\u003e\u003cstrong\u003eNo(n=40)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e\u003cstrong\u003eYes(n=40)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"34%\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"20%\"\u003e\n\u003cp\u003e41(51.25)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"18%\"\u003e\n\u003cp\u003e20(50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e21(20.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e0.823\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"34%\"\u003e\n\u003cp\u003eAge (years)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"20%\"\u003e\n\u003cp\u003e43(53.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"18%\"\u003e\n\u003cp\u003e21(52.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e22(55)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e0.823\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"34%\"\u003e\n\u003cp\u003eBMI＞24kg/m\u0026sup2;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"20%\"\u003e\n\u003cp\u003e60.53\u0026plusmn;3.978\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"18%\"\u003e\n\u003cp\u003e60.30\u0026plusmn;4.345\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e60.75\u0026plusmn;3.614\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e0.616\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"34%\"\u003e\n\u003cp\u003eIsolated CABG\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"20%\"\u003e\n\u003cp\u003e22(27.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"18%\"\u003e\n\u003cp\u003e18(28.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e4(23.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e0.891\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"34%\"\u003e\n\u003cp\u003eIsolated valve surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"20%\"\u003e\n\u003cp\u003e34(42.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"18%\"\u003e\n\u003cp\u003e26(41.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e8(47.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e \u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"34%\"\u003e\n\u003cp\u003eCombined CABG and valve\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"20%\"\u003e\n\u003cp\u003e24(30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"18%\"\u003e\n\u003cp\u003e19(30.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e5(29.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e \u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"34%\"\u003e\n\u003cp\u003eDiabetes mellitus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"20%\"\u003e\n\u003cp\u003e34(42.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"18%\"\u003e\n\u003cp\u003e16(40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e18(45)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e0.651\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"34%\"\u003e\n\u003cp\u003eHypertension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"20%\"\u003e\n\u003cp\u003e30(37.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"18%\"\u003e\n\u003cp\u003e13(32.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e17(42.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e0.356\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"34%\"\u003e\n\u003cp\u003eCPB(min)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"20%\"\u003e\n\u003cp\u003e125.66\u0026plusmn;19.573\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"18%\"\u003e\n\u003cp\u003e124.35\u0026plusmn;18.530\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e126.98\u0026plusmn;20.715\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e0.552\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"34%\"\u003e\n\u003cp\u003eAortic crossclamp time(min)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"20%\"\u003e\n\u003cp\u003e99.91\u0026plusmn;14.995\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"18%\"\u003e\n\u003cp\u003e102.30\u0026plusmn;14.235\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e97.53\u0026plusmn;15.528\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e0.156\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"34%\"\u003e\n\u003cp\u003eDuration of mechanical ventilation(hour)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"20%\"\u003e\n\u003cp\u003e41.00（36.00-47.75）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"18%\"\u003e\n\u003cp\u003e45.5(38-52.25)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e38(34-45)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e0.002\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"34%\"\u003e\n\u003cp\u003eICU stay(day)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"20%\"\u003e\n\u003cp\u003e4.5750（4.11-5.61）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"18%\"\u003e\n\u003cp\u003e5.6(4.77-6.53)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e4.13(3.74-4.53)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"34%\"\u003e\n\u003cp\u003eHospital stay(day)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"20%\"\u003e\n\u003cp\u003e9.4450（8.44-11.86）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"18%\"\u003e\n\u003cp\u003e11.82(10.55-13.25)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e8.49(7.69-9.08)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e0.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"34%\"\u003e\n\u003cp\u003eLCOS\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"20%\"\u003e\n\u003cp\u003e17(21.25)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"18%\"\u003e\n\u003cp\u003e13(32.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e4(10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e0.014\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"100%\"\u003e\n\u003cp\u003eResults are expressed as mean \u0026plusmn; SD or number (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"100%\"\u003e\n\u003cp\u003eCABG, Coronary artery bypass grafting; BMI, body mass index;LVEF, left ventricular ejection fraction; CPB, cardiopulmonary bypass; LCOS, Low cardiac output syndrome,ICU, Intensive Care Unit\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" width=\"100%\"\u003e\u003ccaption\u003eTable 3 \u003cbr /\u003eBaseline factors predictive of LCOS incidence\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 27%;\"\u003e\n\u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16%;\"\u003e\n\u003cp\u003e\u003cstrong\u003eLCOS\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 17%;\"\u003e\n\u003cp\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 10%;\"\u003e\n\u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 27%;\"\u003e\n\u003cp\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16%;\"\u003e\n\u003cp\u003e\u003cstrong\u003eNo(n=63)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 17%;\"\u003e\n\u003cp\u003e\u003cstrong\u003eYes(n=17)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 10%;\"\u003e\n\u003cp\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 27%;\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16%;\"\u003e\n\u003cp\u003e34(54)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 17%;\"\u003e\n\u003cp\u003e7(41.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 10%;\"\u003e\n\u003cp\u003e0.349\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 27%;\"\u003e\n\u003cp\u003eBMI＞24kg/m\u0026sup2;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16%;\"\u003e\n\u003cp\u003e35(55.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 17%;\"\u003e\n\u003cp\u003e8(47.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 10%;\"\u003e\n\u003cp\u003e0.533\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 27%;\"\u003e\n\u003cp\u003eAge (years)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16%;\"\u003e\n\u003cp\u003e60.41\u0026plusmn;4.01\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 17%;\"\u003e\n\u003cp\u003e60.94\u0026plusmn;3.94\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 10%;\"\u003e\n\u003cp\u003e0.63\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 27%;\"\u003e\n\u003cp\u003eIsolated CABG\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16%;\"\u003e\n\u003cp\u003e18(28.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 17%;\"\u003e\n\u003cp\u003e4(23.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 10%;\"\u003e\n\u003cp\u003e0.891\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 27%;\"\u003e\n\u003cp\u003eIsolated valve surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16%;\"\u003e\n\u003cp\u003e26(41.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 17%;\"\u003e\n\u003cp\u003e8(47.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 10%;\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 27%;\"\u003e\n\u003cp\u003eCombined CABG and valve\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16%;\"\u003e\n\u003cp\u003e19(30.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 17%;\"\u003e\n\u003cp\u003e5(29.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 10%;\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 27%;\"\u003e\n\u003cp\u003eDiabetes mellitus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16%;\"\u003e\n\u003cp\u003e28(44.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 17%;\"\u003e\n\u003cp\u003e6(35.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 10%;\"\u003e\n\u003cp\u003e0.489\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 27%;\"\u003e\n\u003cp\u003eHypertension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16%;\"\u003e\n\u003cp\u003e24(38.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 17%;\"\u003e\n\u003cp\u003e6(35.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 10%;\"\u003e\n\u003cp\u003e0.832\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 27%;\"\u003e\n\u003cp\u003eCPB(min)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16%;\"\u003e\n\u003cp\u003e124.83\u0026plusmn;19.46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 17%;\"\u003e\n\u003cp\u003e128.76\u0026plusmn;20.28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 10%;\"\u003e\n\u003cp\u003e0.465\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 27%;\"\u003e\n\u003cp\u003eLevosimendan\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16%;\"\u003e\n\u003cp\u003e36(57.14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 17%;\"\u003e\n\u003cp\u003e4（23.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 10%;\"\u003e\n\u003cp\u003e0.014\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 27%;\"\u003e\n\u003cp\u003eLVEF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16%;\"\u003e\n\u003cp\u003e35.42\u0026plusmn;3.02\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 17%;\"\u003e\n\u003cp\u003e36.65\u0026plusmn;2.74\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 10%;\"\u003e\n\u003cp\u003e0.137\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 27%;\"\u003e\n\u003cp\u003eHR\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16%;\"\u003e\n\u003cp\u003e65.73\u0026plusmn;3.05\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 17%;\"\u003e\n\u003cp\u003e64.59\u0026plusmn;3.20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 10%;\"\u003e\n\u003cp\u003e0.179\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 27%;\"\u003e\n\u003cp\u003eCI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 16%;\"\u003e\n\u003cp\u003e2.10\u0026plusmn;0.18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 17%;\"\u003e\n\u003cp\u003e2.09\u0026plusmn;0.19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 10%;\"\u003e\n\u003cp\u003e0.843\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 70%;\" colspan=\"4\"\u003e\n\u003cp\u003eResults are expressed as mean \u0026plusmn; SD or number (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 70%;\" colspan=\"4\"\u003e\n\u003cp\u003eCABG, Coronary artery bypass grafting; BMI, body mass index; LVEF, left ventricular ejection fraction; CPB: cardiopulmonary bypass; LCOS, Low cardiac output syndrome, ICU, Intensive Care Unit; HR, Heart rates; CI, Cardiac index.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"levosimendan, cardiac operative, propensity score matching","lastPublishedDoi":"10.21203/rs.3.rs-92126/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-92126/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective: To retrospectively analyze the effect of levosimendan on the survival and prognosis of cardiac surgery patients with LVEF \u0026lt; 40%. \u003c/p\u003e\u003cp\u003eMethods: the clinical data of 224 patients with preoperative LVEF \u0026lt; 40% were retrospectively analyzed. According to different treatment schemes, the patients were divided into levosimendan group (n = 60) and no-levosimendan group (n = 164,). The control group was treated with routine treatment, and the observation group was treated with levosimendan on the basis of routine treatment. Then a multivariate logistic regression model with a propensity score analysis was used to limit biases and finally the data of 40 patients in each group were selected for analysis. \u003c/p\u003e\u003cp\u003eResults: Hemodynamic data showed that the cardiac index, LVEF and PAOP of patients in levosimendan group were significantly improved. The concentration of serum lactic acid in the levosimendan group was lower than that in the control group (P \u0026lt; 0.05). At the same time, postoperative ICU and hospital stay were significantly reduced in levosimendan group (P \u0026lt; 0.05.), Logistics regression analysis showed that levosimendan was the only protective factor for Low cardiac output syndrome (LCOS) (HR=4.33; 95% confidence interval: 1.27- 14.78; P = 0.019). \u003c/p\u003e\u003cp\u003eConclusion: levosimendan can better improve hemodynamics and reduce postoperative ICU time and hospital stay. The use of it tended to decrease the incidence of LCOS significantly.\u003c/p\u003e","manuscriptTitle":"Effect of Levosimendan on the Prognosis of Cardiac Surgery in Patients with Cardiac Insufficiency","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-10-16 14:02:20","doi":"10.21203/rs.3.rs-92126/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"34d49648-4ac8-4d41-b1b9-6a63b4d51786","owner":[],"postedDate":"October 16th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":798442,"name":"Cardiothoracic Surgery"}],"tags":[],"updatedAt":"2021-09-15T16:10:25+00:00","versionOfRecord":[],"versionCreatedAt":"2020-10-16 14:02:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-92126","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-92126","identity":"rs-92126","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}