Peri-operative Levosimendan in Patients Undergoing Cardiac Surgery: An Overview of the Evidence

Abstract

Levosimendan, a calcium sensitiser, has recently emerged as a valuable agent in the peri-operative management of cardiac surgery patients. Levosimendan is a calcium-sensitising ionodilator. By binding to cardiac troponin C and reducing its calcium-binding co-efficient, it enhances myofilament responsiveness to calcium and thus enhances myocardial contractility without increasing oxygen demand. Current evidence suggests that levosimendan enhances cardiac function after cardiopulmonary bypass in patients with both normal and reduced left ventricular function. In addition to being used as post-operative rescue therapy for low cardiac output syndrome, a pre-operative levosimendan infusion in high risk patients with poor cardiac function may reduce inotropic requirements, the need for mechanical support, the duration of intensive care admissions as well as post-operative mortality. Indeed, it is these higher-risk patients who may experience a greater degree of benefit. Larger, multicentre randomised trials in cardiac surgery will help to elucidate the full potential of this agent.

Impact of prophylactic administration of Levosimendan on short-term and long-term outcome in high-risk patients with severely reduced left-ventricular ejection fraction undergoing cardiac surgery – a retrospective analysis

“…LS application had no significant effect on overall 30-days survival which is on one hand contradictory to previous studies showing positive effects of prophylactic LS on short-term survival [11, 12]. On the other hand, recent meta-analysis of the available data revealed conflicting results on whether or not LS reduces mortality [18, 19]. A differentiated analysis of our patient subgroups showed tendencies towards positive effects of LS on 30-days survival in patients undergoing valve/aortic or combination procedures, patients with moderate chronic renal impairment, patients who had no recent myocardial infarction, patients with LVEF <25% and patients with EuroSCORE II risk estimation scores >23.…”

The Role of Levosimendan in Patients with Decreased Left Ventricular Function Undergoing Cardiac Surgery

“…Levosimendan has been used in the treatment of heart failure (HF) over the past decade. Studies have shown clinical improvement in terms of hemodynamic parameters, cardiac function, shorter overall in-hospital stay, while data for long-term mortality is still controversial [ 23 ].…”

“…Evidence shows the benefit of coronary surgery over medical treatment in patients suffering from both decreased left ventricular function and coronary artery disease [ 20 , 28 ]. Patients undergoing cardiac surgery with high-risk profile require peri-operative and post-operative inotropic support and levosimedan seems to be an attractive option in such patients [ 23 ]. Different meta-analyses have suggested mortality benefits in patients undergoing cardiac surgery receiving levosimendan.…”

“…Reports from several clinical studies have compared levosimendan versus milrinone, placebo, dobutamine or intra-aortic balloon pump (IABP)[ 23 ]. Patients with preserved or reduced left ventricular function received levosimendan in pre, intra or post- operative setting (period).…”

“…Levin and colleagues randomised 253 parents with LCOS after surgery, to receive either levosimandan or dobitamine. Patients in levosimendan group showed reduced requirements for inotrops, vasopressors, IABP use, as well as decrease postoperative mortality (7.1 vs. 15.9%) [ 23 , 40 ].…”