Use of Levosimendan in Postoperative Setting After Surgical Repair of Congenital Heart Disease in Children

Abstract

Low cardiac output is one of the most common complications after cardiac surgery. Levosimendan, a new inotrope agent, has been demonstrated in adult patient to be an effective treatment for this purpose when classical therapy is not effective. The aim of this study was to evaluate the effect of Levosimendan on cardiac output parameters in cardiac children with low cardiac output syndrome (LCOS.). We carried out a retrospective analysis on 62 children hospitalized in our pediatric intensive care unit (PICU) after cardiac surgery, which demonstrated LCOS not responding to classical catecholamine therapy and who received levosimendan as rescue therapy. LCOS parameters like diuresis, central venous oxygen saturation (SvO), venous-to-arterial CO difference (∆avCO), and plasmatic lactate were compared before therapy and at 3, 6, 12, and 24 h after the beginning of the levosimendan infusion. We also analyzed the effect on the Vasoactive-inotropic score (VIS), adverse events, and mortality. After the beginning of levosimendan infusion, diuresis (1.1 vs. 3.5 ml/kg/h, p = 0.001) and SvO (59.5 vs. 63.3%, p = 0.026) increased significantly during the 24 h of infusion, and at the same time, plasmatic lactate (2.3 vs. 1.3 mmol/l, p < 0.001) decreased. ∆avCO (10.8 vs. 9.4 mmHg, p = 0.21) and the VIS (44.5 vs. 22.5, p = 0.143) also decreased, but not significantly. No side effects were noted. The mortality in this patient group was 16%. Levosimendan is an effective treatment in children presenting LCOS after congenital heart surgery. Our study confirms the improvement of cardiac output already shown in other pediatric studies, with no undesirable side effects.

Levosimendan for Pediatric Anomalous Left Coronary Artery From the Pulmonary Artery Undergoing Repair: A Single-Center Experience

“…Anesthesiologists in our center have adopted the mindset that levosimendan should be administered at the discretion of the clinician as early as possible, and generally be started at the induction of anesthesia to decrease the incidence of postoperative LCOS and to prevent any unwanted consequences. The retrospective but single-group analysis conducted by Amiet et al ( 15 ) involving 62 pediatric patients in the ICU after cardiac surgery demonstrated that using levosimendan as a rescue treatment once LCOS occurred could increase central venous oxygen saturation and reduce lactate 24 h later. They reported that in their clinical routine, they even infused the drug 24 h before various complicated surgeries in newborns.…”

“…They reported that in their clinical routine, they even infused the drug 24 h before various complicated surgeries in newborns. On other occasions, levosimendan was only regarded as a Supplementary agent during CPB weaning ( 16 – 18 ) or even as a rescue when difficulty arose ( 15 ). The LEVO-CTS ( 10 ) trial even claimed that levosimendan administration started just before surgery was actually not effective enough to reduce or avoid cardiac damage.…”

“…In Ricci's cohort, renal function was replaced by urine output and peritoneal dialysis use, and a neutral outcome after levosimendan administration was demonstrated ( 16 ). However, a retrospective series conducted by Amiet et al found that levosimendan could increase diuresis from 1.1 to 3.5 mL/kg/h by improving cardiac output ( 15 ). In our clinical practice, all 10 cases of peritoneal dialysis were applied to correct a series of consequences such as oliguria or anuria, which was secondary to the postoperative cardiac function of critically ill patients.…”

A Comparative Study of Hemodynamic Effects of Levosimendan and Milrinone in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

“…[28] Amiet et al also studied Levosimendan in pediatric patients and observed lower lactate levels. [33] Study by Matthias et al (55) also showed better metabolic effects of milrinone in comparison to adrenaline in term of lower lactate level in plasma. [34] Tatlis et al also suggested that Milrinone has a beneficiary effect on aerobic tissue metabolism after extracorporeal circulation reflected on serum lactate, possibly due to a combination of positive inotropic and peripheral vasodilatory effect of the drug.…”

A Tale of 2 Inodilators: Much Ado About Nothing?

“…1 This is an important area of research, as lowcardiac-output syndrome (LCOS) after congenital heart surgery occurs in up to 25% of pediatric patients and is a major contributor to postoperative morbidity and mortality. 2 Milrinone, a phosphodiesterase-3 inhibitor, long has been used as an inodilator to prevent or attenuate the development of LCOS after cardiac surgery.…”