Perioperative Levosimendan Infusion in Patients With End-Stage Heart Failure Undergoing Left Ventricular Assist Device Implantation

Abstract

Left ventricular assist device (LVAD) therapy has been instrumental in saving lives of patients with end-stage heart failure (HF). Recent generation devices have short-to-mid-term survival rates close to heart transplantation. Unfortunately, up to 1 in 4 patients develop a life-threatening right-sided HF (RHF) early post LVAD implantation, with high morbidity and mortality rate, necessitating prolonged ICU stay, prolonged inotropic support, and implantation of a right-ventricular assist device. Pre-operative optimization of HF therapy could help in prevention, and/or mitigation of RHF. Levosimendan (LEVO) is a non-conventional inotropic agent that works by amplifying calcium sensitivity of troponin C in cardiac myocytes, without increasing the intra-cellular calcium or exacerbating ischemia. LEVO acts as an inodilator, which reduces the cardiac pre-, and after-load. LEVO administration is associated with hemodynamic improvements. Despite decades long of the use of LVAD and more than two decades of the use of LEVO for HF, the literature on LEVO use in LVAD is very limited. In this paper, we sought to conduct a systematic review to synthesize evidence related to the use of LEVO for the mitigation and/or prevention of RHF in patients undergoing LVAD implantation.

Preoperative Levosimendan therapy reduces postoperative right ventricular failure in patients undergoing left ventricular assist device implantation

“…Until today, literature on preconditioning LVAD candidates with Levosimendan before surgery remains scarce [ 20 ]. Sponga et al reported a cases series of 21 patients demonstrating that preoperative Levosimendan therapy might be profitable for improving preoperative patient condition by reducing pulmonary artery pressure and central venous pressure, although it had no impact on postoperative RV-F [ 21 ].…”

“…Due to the longstanding vasodilatation effects of Levosimendan, patients with preoperative Levosimendan therapy required higher doses of catecholamines postoperatively, which however did not affect postoperative outcomes, as beneficial effects of Levosimendan on RV-F seem to outweigh the potentially deteriorating effects of higher postoperative catecholamines with regard to outcome in our patient cohort. Hence, as preoperative Levosimendan therapy can be safely employed in patients undergoing LVAD implantation [ 20 ] and it seems to be associated with lower incidence of peri- and postoperative RV-F, it should be discussed to include it in the preoperative management of LVAD candidates.…”

Right ventricular dysfunction in left ventricular assist device candidates: is it time to change our prospective?

“…Furthermore, Kocabeyoglu et al showed that patient’s optimization through levosimendan infusion improved impaired end-organ functions and preoperative hemodynamic status in patients awaiting LVAD [ 42 ]. However, as mentioned above, so far, no survival benefits have been shown for the use of levosimendan before LVAD patients, mainly because of underpowered studies [ 43 ].…”

Use of Levosimendan in Patients with Advanced Heart Failure: An Update

“…Moreover, a recent meta-analysis of 106 patients with advHFrEF who underwent LVAD implant [ 57 ] showed that levosimendan administration was associated with hemodynamic improvements and improved organ perfusion. However, such hemodynamic benefits are not associated with a reduction in mortality, which is likely a result of the low statistical power of the studies conducted to date.…”