Using Of Levosimendan In A Redo Cardiac Pediatric Operation

Abstract

Levosimendan (LS), a new inodilator used in the treatment of decompensate heart failure, has been reported to be effective in patients with high perioperative risks, with abnormal left ventricular function, and who face difficulties in weaning off cardiopulmonary bypass. Cause of its many beneficial effects, the use of LS in cardiac surgery arises. However, experiences about the use of LS in pediatric patients are limited. We administered LS in a case of 3 years old child who developed heart failure during cardiopulmonary bypass removal period. A 3 years old, 11 kg female child was admitted in our center who had a total revision of tetralogy of Fallot four months ago. Any postoperative complaints or symptoms were not present since we find out a large progressive aneurysm in the echocardiographic evaluation of the otogen pericardial patch which was prepared with gluteraldehide. Induction of anesthesia was done with 2 mg/kg ketamin and 0.5 mg/kg atracurium, 20μg/kg atropin was administered also. After endotracheal entubation, invasive blood pressure of the left radial artery and central venous pressure monitoring of the right internal jugular vein was successfully. After the excision of the pericardial patch, the repair of the right ventricular outflow was done with e-PTFE graft. At the end of cardiopulmonary bypass (CPB) surgery deep hypotension occurred. In spite of dopamine (15 μg/kg/min), dobutamine (15μg/kg/min) and adrenalin (1mg/h) infusions, myocardium failed to maintain normotension. Diuresis was suboptimal in our patient also. Upon these LS infusion was started with the loading dose of 12 μg/kg over 10 minutes. Later, 0.2 μg/kg/min maintenance dosage was applied. In an hour we observed 200 cc diuresis and the vital signs were taken under control. LV infusion was completed after 24 hours postoperatively in our intensive care unit. Six hours later we started to reduce the analogous inotropic support (dopamine 10μg/kg/min, dobutamine 10μg/kg/min, adrenalin 0.5mg/h) since the hemodynamic parameters were satisfactory. Twelve hours later another reduction was applied. Since the well tolerance of the myocardium, we were able to stop the other inotropic drug infusions after 48 hours and the patient was discharged from the hospital 10 days after the surgery. Our clinical experiences with LS has shown that it reduces conventional inotropic agents dosages and could be a satisfactory agent in myocardial depression therapy which occurred in CPB surgery intraoperatively also in pediatric patients. However the need for serial randomized controlled studies in pediatric patient about the use of LS is indisputable.