The use of levosimendan is discussed in some interesting papers published recently. Unfortunately, data on pediatric and neonatal populations remain weak. Moreover, even if pharmacokinetic studies exist, the exact dose scheme and timing for administration were not clearly established in this population. Do you administer a loading dose? Do you consider the administration of levosimendan at the end of cardiopulmonary bypass, just before surgery, the night before ? Does levosimendan decrease the total amount of vasoactive agents administered? Does levosimendan improve outcomes, ICU length of stay, morbidity, and mortality? I think that it would be interesting to start levosimendan infusion at least 12 hours before surgery. Would be interested to receive informations about your experience.
We started the levosimendan treatment in pretransplant patients with congestive heart failure to "prevent" assist device intervention. In the last two years we applied it as rescue medication ,when the inotropic drugs (epi, milrinon, norepi, vazopressin or their high dose requirement) failed in weaning the patient from CPB or in the early postoperative period. I feel that it yielded better results (we had not compared it so far to a non intervention group). We did not give loading dose, we started with the middle dose.
According to my adult experiences, it is advisable to start the levosimendan 24 hours before surgery. The effect will be there for five days. The option to commence it during bypass is also feasible. The weaning from inotropic support seems to be smoother and easier. I have experienced less rebound reaction during the decrease of the vasoactive drugs.
Thank you Andrea for you answer. It is also my experience in adult. But I have never used it in congenital heart surgery.
Levosimendan is excellent as an inotropic support overall in patient with dilated cardiomyopathy and in the postoperative of complex congenital heart surgery, my experience is that when you have a patient with poor ventricular function and low cardiac outflow and with conventional inotropics you dont have better results you should start levosimendan because it increases myocardial contractility, improved haemodinamics and diltated periferical and coronary vessels. You can start with a loading dose aprox of 6 mcg/kg one hour followed by infusion for 24-48 hrs at 0.1-0.2 mcg/kg/min. The half life of levosimendan is aprox 8 days and your patient will improve significativally with less medications
Levosimendan is not used as regular medication in Brasil. But, some groups here had the opportunity of using it with a good result in postoperative patients, when inotrope drugs failed in weaning them from cpb. It looks like a very good option, but we have very little experience with it.
I have used levosimendan as an inotropic support for many years in patients with severe left ventricular dysfunction. It has strong effect on cardiac performance, and during this time period need for IABP has dramatically decreased in our clinic. But, the most important point is the timing of administration. If you delay, it will not work. You should read cardiac performance carefully during the operation, if cardiac performance gives bad signals (pulmonary hypertension, hypotension, tachycardia and etc) of low cardiac output, you should start levosimendan as soon as possible. Correct timing is the key point.
Use of Levosimendan in a pediatric patient with dilated cardiomyopathy is very usefull !!!. We use Levosimendan instead of a continous inotropic support in all pts with DCM and CHD in the pediatric group (from newborn to adulthood).
At our department (pediatric cardiology), we reserve the use of levosimendan in congenital heart surgery for children with myocardial dysfunction/ reduced ventricular function. As the majority of CHD patients are scheduled for surgery electively and tend to have normal ventricular function, we do not see the need to administer levosimendan routinely. However, in selected cases - neonates included - we used levosimendan, starting just before surgery and continuing infusion for 24 hours. To my knowledge, our anaesthesiologists did not administer a loading dose.
We use levosimendan in high risk adults with congenital heart disease, with ventricular dysfunction undergoing long and complicated reoperation of their congenital heart disease. It usually concerns patients with multiple valve surgery together with residual shunt lesion, PH, some cases of Ebstein anomaly and others. We start levosimendan usually just before surgery. The results are very good.
I do have experience in using levosimindan in pediatric patients with cardiomyopathy and I believe it is a useful drug.
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We use levosimendan in pediatric patients undergoing congenital heart surgery intraoperatively and postoperatively. We use it mainly for patients with (right) miocardial disfunction / risk of myocardial ischemia-cardioprotection. We avoid loading dose to prevent hypothension, administering it at 0,2 mcg/kg/min during 24 hours than can be repeated weekly in selected cases of postoperative bad evolution.
We use levosimendan especially in adults who require ionotropic support and were on beta blocker therapy for heart failure where beta adrenergic agonist infusions are less effective.
We have had increasing positive experience with levosimendan in selected cases of postoperative ventricular dysfunction (right or left) and low cardiac output after congenital heart surgery in the context of an overall regimen of minimization of oxygen demands, preload and afterload optimization, rhythm control (with LV or biventricular pacing if necessary), and multi-agent inotropic support. We have also used levosimendan to support ventricular function in cases of acute myocarditis and cardiomyopathy. We are convinced that its use provides significant incremental hemodynamic benefit which may prove sufficient to avert instituting mechanical circulatory support in neonates, infants, and small children.