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Abstract

Unlike conventional inotropes, levosimendan does not increase myocardial oxygen demand and its use in patients undergoing cardiac surgery raised great expectations. Results from a trial [1] have dampened the initial enthusiasm, however, showing no clinical benefit of prophylactic use of levosimendan. This lack of efficacy has also been confirmed in a meta-analysis by Elbadawi and colleagues [2], which nonetheless leaves considerable room for debate regarding the selection of studies included in their analysis.The main issue relates to timing of levosimendan infusion, which should be administered preoperatively to patients with severely reduced ventricular contractility. In order to ensure its prophylactic action, levosimendan should be administered at least 12 hours before cardiac surgery to pretreat the heart. In most studies, however, levosimendan infusion was started in the operating room and in many patients it was discontinued at the discretion of the treating physician [1]. Among the 2,273 patients included in the meta-analysis of Elbadawi and coworkers [2], levosimendan infusion was started 24 hours before operation in only 16 patients. In addition, levosimendan was administered to some patients with preserved ventricular function, making it unlikely that any further improvement of cardiac performance could be obtained. Despite such heterogeneity due to differences in the patients enrolled in the meta-analysis, the prophylactic use of levosimendan was associated with a significant reduction in acute kidney injury, suggesting improved renal perfusion with less need for conventional inotropic agents and/or vasopressors.According to our experience, in 100 coronary patients with severely depressed ventricular function, who underwent a complete revascularization strategy associated with mitral valve or ventricular restoration surgery when indicated, the use of levosimendan (low-dose infusion without bolus administered at least 12 hours before cardiac surgery without vasoconstrictors) may still have a role, but further studies evaluating the effects of "true" and "complete" prophylactic treatment with this inotropic agent are warranted.