Cardiovascular Journal of Africa: Vol 32 No 6 (NOVEMBER/DECEMBER 2021)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 6, November/December 2021 340 AFRICA 14 728 pg/ml. Despite intensive treatment, the patient’s symptoms worsened and a decision was made to administer a levosimendan infusion at a dose of 12.5 mg/24 hours. After the infusion, the patient’s condition improved. The glomerular filtration rate (GFR) increased from 33 to 47 ml/ min. In addition, the LVEF improved from 15 to 20% and NT-proBNP was 5 658 pg/ml. The patient was discharged in a stable state with NYHA class improved to II. A similar scenario occurred one month later (June 2019). The patient presented in NYHA class IV, with a LVEF of 10% and NT-proBNP value of 11 960 pg/ml. Similar to the previous hospitalisations, the patient showed a poor response to the intense diuretic and inotropic treatment. Levosimendan (12.5 mg/24-hour infusion) was administered, followed by a milrinone infusion of 84 mg/24 hours for five days. The LVEF improved to 15% and the NT-proBNP value decreased to 5 213 pq/ml. Also, the patent’s NYHA class improved to III. In this particular case, the exacerbations of HF symptoms responded poorly to standard therapy and only after the levosimendan infusion did the clinical condition improve. Case report 2 A 40-year-old woman presented to the clinic (November 2018) with acute HF (severe dyspnoea at rest: NYHA class IV). She had a co-morbidity of breast cancer and a history of chemotherapy with doxorubicin, among others. During her control echo six weeks earlier, LVEF was within the normal range, but three weeks prior to hospitalisation, a worsening of her LVEF had been observed. Consequently, treatment with beta-blockers, angiotensin converting enzyme inhibitors, mineralocorticoid receptor antagonists and furosemide were started on an out-patient basis. The patient’s state was gradually worsening, with increasing dyspnoea, decreasing exercise tolerance, and fatigue, which eventually required hospitalisation. Additional tests revealed general hypokinesis with a LVEF of 15% and elevated BNP level (757 pg/ml). Due to a poor response to intravenous diuretic, on the fifth day, a levosimendan (12.5 mg/24-hour) infusion was administered. The response and tolerance for treatment was satisfying. A follow-up echo showed a significant improvement in LVEF to 35%. Subsequently, during the course of the hospitalisation, the LVEF decreased. Afterwards, on the 12th day of hospitalisation, another dose of levosimendan 12.5 mg/24 hours was administered. The patient’s LVEF increased again to 35% and the BNP level decreased to 423 pq/ml. After obtaining a stable clinical state (NYHA class II), the patient was discharged. Another decompensation event followed in February 2019. The patient presented with exertional dyspnoea (NYHA class III), nausea and abdominal pain. The LVEF decreased to 15%, whereas BNP level was 2 361 pg/ml. Because of the previous adequate response to levosimendan, it was again employed at the same dose. LVEF improved to 30% and BNP level decreased to 1 062 pg/ml. The patient was discharged home in a stable state in NYHA class II. A similar scenario occurred seven weeks later. The patient was admitted with NYHA class IV, LVEF of 15% and BNP of 4 352 pg/ml. Due to only a mild improvement after an intensive diuretic treatment with the accompanied dobutamine infusion (7–15 mcg/kg/min), a levosimendan infusion (12.5 mg/24 hours) was administered. Not only was the response to the treatment satisfactory but also good tolerance was observed. LVEF increased to 25%, and BNP level decreased to 1 720 pq/ml. The patient was discharged in a stable state with NYHA improved to class III. This case illustrates, most of all, the safety of repetitive use of levosimendan in patients with anthracycline cardiomyopathy. The efficacy of the treatment was also satisfactory. Case report 3 A 65-year-old man presented to the clinic (July 2019) due to decompensation of chronic HF with severe dyspnoea during mild exertion (NYHA class III). His co-morbidities included ischaemic heart disease with a history of NSTEMI (2009) and PCIs (2005, 2007), hypertension, a transient ischaemic attack (2018), an ICD implantation (2006) and upgrade to a CRT-D (2013). Echocardiography on admission showed LVEF at 20% and a laboratory test revealed elevated BNP (2 767 pg/ml) and creatinine (172 μmol/l) levels, and also decreased GFR (37 ml/ min). The patient required intensive diuretic treatment. Due to a poor response, dobutamine (7–15 mcg/kg/min) and noradrenaline were employed, which resulted in a slight clinical and haemodynamic improvement. Levosimendan was administered at a dose of 12.5 mg/24 hours, and the patient’s state further improved. GFR increased to 52 ml/min and the creatinine level decreased to 127 μmol/l. The BNP level dropped to 2 535 pg/ml and LVEF increased to 30%. The patient was discharged home in a stable state in NYHA class II. Another exacerbation of HF symptoms followed in October 2019. The patient presented with paroxysmal dyspnoea and nausea (NYHA class III). His LVEF was again at 20%. The GFR dropped to 31 ml/min and creatinine level increased to 178 μmol/l. The BNP level was 2 863 pg/ml at admission. Again, due to the poor response to the diuretic and catecholamine treatment, levosimendan was administered (12.5 mg/24-hour infusion). The patient’s response was not as good as during the previous hospitalisation. Nevertheless, it was satisfactory. The BNP value decreased to 2 781 pg/ml and LVEF increased to 25%. The GFR increased to 43 ml/ml and creatinine level dropped to 150 μmol/l. Despite only a moderate response of the BNP and LVEF, clinical symptoms were improved to NYHA class II. This case is an example of the fact that even despite the lack of improvement in echocardiographic or biochemical parameters in the form of natriuretic peptides, after application of levosimendan, an improvement in terms of the clinical state can be achieved. Case report 4 A 49-year-old man presented to the clinic (August 2019) with oedema of the lower limbs, ascites, severe dyspnoea at rest (NYHA class IV) and his body weight was increased by 13 kg. His co-morbidities included chronic atrial fibrillation, hypertension, type 2 diabetes, post minimally invasive aortic valve replacement (2018) and ICD implantation (2015). At admission, the LVEF was 20% and BNP level was 1 528 pg/ml. The patient required furosemide and dobutamine infusions, which were continued up to the point when his body mass had dropped by approximately 10 kg. The attempts to discontinue dobutamine and furosemide resulted in worsening dyspnoea