13 1 Academia Anesthesiologica International ¦ Volume 5 ¦ Issue 1 ¦ January-June 2020 131 A Comparative Study of Hemodynamic Effects of Levosimendan and Milrinone in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting Chand Kishan Vyas 1 , Ramesh Kumar 2 , Neelu Sharma 3 , Indu Verma 1 , Anjum Saiyed 1 1 Professor, Department of Anesthesia, SMS Medical College, Jaipur, Rajasthan, India, 2 Post Graduate Student, Department of Anesthesia, SMS Medical College, Jaipur, Rajasthan, India, 3 Assistant Professor, Department of Anesthesia, SMS Medical College, Jaipur, Rajasthan, India. Background: Off-Pump CABG or “beating heart” surgery possess a challenge to the anesthesiologist. Main goals are provision of safe anesthesia with maximum myocardial protection and maintenance of hemodynamics with various manipulation of heart during in order to visualize and graft the coronary arteries. Anesthetic regimen and ionotropic support influences postoperative myocardial function and outcome in coronary bypass surgery patients. Objective: To compare and assess haemodynamic effects of Levosimendan and Milrinone in patient undergoing off pump coronary artery bypass grafting with compromised cardiac function (NYHA III,IV) and pre-operative, left ventricular ejection fraction (LVEF) < 45%. Subjects and Methods: Patients were randomly allocated to 2 groups (64 patients in each group). Levosimendan Group (Group A) received infusion of Inj. Levosimendan 0.1µg/kg/min after loading dose of 12μg/kg over 10 mins. While Milrinone Group (Group B) received infusion of inj. Milrinone 0.5µg/kg/min after loading dose of 50 μg/kg over 10 mins. HR, MAP, CVP, CI, SVRI, lactate levels were monitored at baseline, after induction, after sternotomy, at 30mins ,thereafter 6, 12, and 24 hours using Flo-Trac sensor (Edwards Life sciences). Results: Heart Rate, CI was significantly higher in Levosimendan group while MAP, SVRI and lactate levels were lower in Levosimendan group as compared to Milrinone group. Need of other inotropic support is more in Milrinone group. Conclusion: Levosimendan maintained the haemodynamic parameters better as compared to Milrinone in off pump CABG patients with low preoperative ejection fraction and also better end organ perfusion represented by lower lactate levels. Keywords: Off-pump CABG, Levosimendan, Milrinone, Hemodynamics. Corresponding Author: Dr. Neelu Sharma, Assistant Professor, Department of Anesthesia, SMS Medical College, Jaipur, Rajasthan, India. Received: February 2020 Accepted: February 2020 Introduction Off- Pump coronary artery bypass graft surgery (OPCAB) is considered a safe alternative to conventional coronary artery bypass grafting with cardio-pulmonary bypass (CPB) for myocardial revascularization because it may be associated with decreased postoperative morbidity and reduced total costs. Avoiding CPB eliminates aortic cannulation and cross- clamping and expected to reduce systemic inflammatory response, coagulation disorders and multiple organ dysfunction. [1] However, the haemodynamic instability associated with positioning and stabilizing the heart as well as the interruption of the coronary artery flow is an important factor limiting the performance of OPCAB. [2] A combination of surgical manoeuvers help in preventing conduction and hemodynamic deterioration which might occur during the graft positioning on beating heart. These include trendelenburg position, fluid administration and use of vasopressors and inotropes if necessory. [3] Inotropic agents enhance myocardial contractility at a cost of increase in myocardial oxygen consumption, [4] which may further alter the already compromised myocardial oxygen balance in patients with preexisting ventricular dysfunction. Levosimendan is one of a new class of inodilators which enhances myocardial contractility by sensitizing troponin C to calcium within cardiomyocytes. [5] Levosimendan also has a vasodilating effect on systemic, coronary and pulmonary vasculature through activation of adenosine triphosphate sensitive potassium channels and phosphodiesterase inhibition. [6,7] Milrinone is an inodilator which acts by inhibiting PDE III enzymes and acts independently of β receptors. It lessens myocardial ischaemia and cell damage. [8] Recently, a number of clinical studies have been carried out to evaluate the effects of Milrinone on cardiac function in patients with low ventricular ejection fraction undergoing CABG. However, it has been inconclusive because of the inconsistent results. In addition, some studies found that Milrinone increased the incidence of postoperative atrial arrhythmias and did not show any long-term beneficial effects on survival. While Levosimendan has also shown promise in elective therapy of cardiac surgical patients with high perioperative risk or compromised left ventricular function. ISSN (0): 2456-7388; ISSN (P): 2617-5479