| Objective:To study the clinical effects of levosimendan in pediatrics with reduced cardiac output caused by acute heart failure after congenital heart surgery,and explore a method that can increase cardiac output and reduce cardiac preload/afterload in such pediatrics,summarizing the experience of levosimendan in the treatment of acute heart failure after congenital heart surgery.Method:This study used a non-randomized controlled research method.A total of 32 pediatrics with acute heart failure after congenital heart surgery were collected from March 2018 to March 2021 at the Department of Cardiac Surgery of Children’s Hospital Capital Institue of Paediatrics and the Department of Cardiac Surgery of Hebei Children’s Hospital.According to whether levosimendan was added to traditional vasoactive drugs,pediatrics were divided into the study group（traditional vasoactive drugs+levosimendan,19 cases）and the control group（traditional vasoactive drugs,13 cases）.Collect information such as gender,age,body mass,risk adjustment in congenital heart surgery-1 method（RACHS-1）score,cardiopulmonary bypass time,aortic cross clamp time,tracheal intubation time and cardiac intensive care unit（CICU）time,record and analyze the differences in the changes of the following indicators between the two groups of pediatrics:（1）Hemodynamic indicators:at the immediate（T0）,4h（T1）,8h（T2）,12h（T3）,24h（T4）,48h（T5）,72h（T6）:heart rate（HR）,systolic blood pressure（SBP）,diastolic blood pressure（DBP）,cardiac output index（C1）,systemic vascular resistance index（SVRI）,cardiac cycle efficiency（CCE）,stroke volume index（SVI）,pulse pressure variation（PPV）,the rate of the arterial pressure increase during systole（dp/dt）,vasoactive-inotropic score（VIS）;（2）Echocardiographic indicators:collect echocardiography measurement indicators:left ventricular ejection fraction（LVEF）,tricuspid annular plane systolic excursion（TAPSE）,inferior vena cava width at time before medication（D0）,1 day after medication（D1）,3 days（D3）,5 days（D5）,7 days（D7）.（3）Heart failure marker:heart failure marker N terminal pro B type natriuretic peptide（NT-proBNP）detected at D0-D3;（4）Side effects:Hypotension and ventricular tachycardia related to levosimendan.Results:32 pediatrics were included in this study.Due to the many time points,a complete subgroup analysis of various indicators was performed:（1）Hemodynamic indicators:25 pediatrics with complete hemodynamic data were selected for analysis.There were 16 cases in the study group and 9 cases in the control group.Comparison of general clinical data of the two groups of pediatrics:gender,age,body mass,RACHS-1 score,cardiopulmonary bypass time,aortic cross clamp time,the differences were not statistically significant;and the differences of all the baseline hemodynamic data between the two groups were not statistically significant.Other indicators of the two groups of pediatrics were comparable;Comparison of clinical results data:tracheal intubation time and CICU time,the difference was not statistically significant.① HR:At T3,the HR of pediatrics in the study group was lower than it in the control group（148±19beats/min vs 164±17beats/min,P=0.043）;the HR decreased gradually,the HR decreased earlier in the study group,the HR of pediatrics in the study group at T3 was lower than T0,while the HR of pediatrics in the control group at T5 was lower than T0,the difference was statistically significant,P<0.05.② SBP:At T1,the pediatrics in the study group had the higher SBP than those in the control group（94±16mmHg vs 78±10mmHg,P=0.015）.The SBP of the two groups of pediatrics showed a trend of increasing,decreasing and then increasing;at T1,the SBP of pediatrics in the study group began to be higher than T0,while the SBP of pediatrics in the control group began to be higher than T0 at T4,the difference was statistically significant,P<0.05.③ DBP:At T1,the pediatrics in the study group had the higher DBP than those in the control group（54±7mmHg vs 47±7mmHg,P=0.041）.the DBP of the two groups of pediatrics showed a trend of increasing,decreasing and then increasing;the DBP of pediatrics in the study group began to be higher than T0 at T1,while the DBP of pediatrics in the control group started to be higher than T0 at T2,the difference was statistically significant,P<0.05.④ CI:In the early treatment period（T0-T2）,the C1 of pediatrics in the study group was higher than that of traditional vasoactive drugs,and the difference of the CI at each time point was statistically significant（F=5.827,P=0.024）;the CI of pediatrics in the study group was higher than T0 at T1,while the CI of pediatrics in the control group started to be higher than T0 at T2,the difference was statistically significant,P<0.05.⑤ SVRI:There was no significant difference in the SVRI between pediatrics in the study group and control group.The SVRI in the two groups of pediatrics gradually decreased;at T1,the SVRI of pediatrics in the study group was lower than T0,while the control group pediatrics’ SVRI began to be lower than T0 at T5,the difference was statistically significant,P<0.05.⑥ CCE:At T1,the CCE of pediatrics in the study group was higher than those in the control group（-0.107（-0.239,-0.008）vs-0.405（-0.635,-0.330）,P=0.032）.The CCE of the two groups of pediatrics increased gradually over time,at T1,the CCE of pediatrics in the study group was higher than T0,while the CCE of pediatrics in the control group started to be higher than T0 at T6,the difference was statistically significant,P<0.05.⑦ SVI:In the early treatment period（T0-T2）（F=13.469,P=0.001）and within 72 hours of treatment period（F=6.118,P=0.021）,the SVI of pediatrics in the study group was higher than that in the control group,and only slightly lower than the control group at T4;The SVI of pediatrics in the two groups gradually increased with time.The SVI of pediatrics in the study group was higher than T0 at T1,and the SVI of pediatrics in the control group was higher than T0 at T2.The difference was statistically significant,P<0.05.⑧ dp/dt:The dp/dt of pediatrics in the study group at each time point was compared with those in the control group,and the difference was not statistically significant.At T1,the dp/dt of pediatrics in the study group started to be lower than T0 and the difference was statistically significant,P<0.05;there was no statistically significant difference in the dp/dt of pediatrics in the control group compared with T0 at each time point.⑨ PPV:The PPV of pediatrics in the study group was compared with pediatrics in the control group at each time point,and the differences were not statistically significant.At T6,the PPV of pediatrics in the study group was lower than that at T0,the difference was statistically significant,P<0.05;there was no statistically significant difference in PPV of pediatrics in the control group compared with T0 at each time point.⑩ VIS:The VIS of pediatrics in the study group was higher than those in the control group at T2,T3,and T5,and the differences were statistically significant,P<0.05.There was no statistically significant difference in VIS at each time point.（2）Echocardiographic indicators:17 pediatrics with complete echocardiographic data were selected for comparative analysis.There were 10 cases in the study group and 7 cases in the control group.There was no statistical difference in gender,age,body mass,RACHS-1 score,cardiopulmonary bypass time,and aortic cross clamp time between the two groups.The LVEF of pediatrics in the study group was lower than that of pediatrics in the control group at all time points,but the difference was not statistically significant.The LVEF of pediatrics in the two groups increased gradually,and the difference was statistically significant,P<0.05.The TAPSE of pediatrics in the study group was higher than that in the control group at all time points.Repeated measurement analysis showed that there was no statistically significant difference in TAPSE between the two groups at different time points（F=4.351,P=0.054）,but the TAPSE of pediatrics in the study group had a more obvious rising trend than that in the control group.The TAPSE of pediatrics in the study group at D3（6±1mm vs 5±1mm,P=0.017）,D7（7±1mm vs 5±2mm,P=0.011）was higher than the control group.The TAPSE of pediatrics in the study group gradually increased,and at D7 it was higher than D0（7±1mm vs 5±2mm,P=0.003）;at each time point,the TAPSE of pediatrics in the control group was compared with D0,the differences were not statistically significant.The width of the inferior vena cava:at D0（7±2mm vs 5±2mm,P=0.041）and D5（6±1mm vs 5±1mm,P=0.036）time points,the width of the inferior vena cava in the study group was higher than those in the control group;at D7,the width of the inferior vena cava in the study group was lower than D0（6±2mm vs 7±2mm,P=0.006）;in the control group,the width of the inferior vena cava was different at each time point,there was no statistical significance.（3）Heart failure marker indicators:21 pediatrics with complete NT-proBNP data were selected for comparative analysis,14 cases in the study group and 7 cases in the control group.There was no statistical difference in gender,age,body mass,RACHS-1 score between the two groups.But in the study group,the cardiopulmonary bypass time（117（87,182）min vs 61（39,76）min,P=0.003）and the aortic cross clamp time（58（49,105）min vs 35（21,43）min,P<0.001）were longer than the control group.The degree of NT-proBNP decline in the study group at D3 was higher than that in the control group（-8569（-16003,-5421）pg/ml vs-2298（-4844,-845）pg/ml,P=0.001）.（4）Side effects:None of the children included in the trial experienced hypotension and ventricular tachycardia related to levosimendan.Conclusion:It’s safe to use levosimendan in the treatment of acute heart failure after congenital heart surgery,and compared with traditional vasoactive drugs:levosimendan can improve the hemodynamic performance of pediatrics in a short time,improve the CCE,reduce the SVRI,so as to improve the CI and make a faster decline of the NT-proBNP;levosimendan cannot reduce the dose of vasoactive drugs in pediatrics with acute heart failure,nor can it shorten the tracheal intubation time and CICU time;we can’t come to a conclusion that the levosimendan can improve the left ventricular ejection fraction of pediatrics,but we find that the levosimendan can enhance the systolic function of the right ventricle in the early stage of acute heart failure. |
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