Utilization of levosimendan in the cardiac ICU: case series

Introduction

Levosimendan, a novel calcium sensitizer, has been shown to improve hemodynamic function in patients with acute heart failure [1]. The aim of the study was to assess the hemodynamic effects of levosimendan as a rescue medication in addition to conventional therapy in patients with low cardiac output (LCO) after cardiac surgery or myocardial infarction.

Methods

Forty-one patients with LCO admitted to the cardiac ICU between June 2004 and November 2008 were included in this observational hemodynamic study. Thirty-four patients were admitted after open heart surgery and seven patients for ischemic acute heart failure. Levosimendan (0.1 μg/kg/min × 24 hours, without bolus) was added to conventional inotropes and/or intraaortic balloon pump (IABP) support. The measured parameters were: cardiac output/index, pulmonary artery occlusion pressure (PaoP), left ventricular ejection fraction (LVEF), and mixed venous oxygen saturation (SvO₂). Baseline data were collected before levosimendan administration and the following datasets were obtained at 6, 24 and 48 hours. Length of stay (LOS) in the cardiac ICU and inhospital mortality were also registered. Data were expressed as the mean ± SD. Fisher's exact test and a nonpaired t test were used when appropriate. P < 0.05 was considered significant.

Results

All patients were on dobutamine and epinephrine. IABP support was used in 28 (68%) of cases. The addition of levosimendan significantly improved cardiac index (from 2.27 ± 0.9 l/min/m² to 3.05 ± 0.9 l/min/m² at 6 hours (P < 0.01); 2.93 ± 0.8 l/min/m² at 24 hours (P < 0.02) and 2.93 ± 1.0 l/min/m² at 48 hours (P < 0.05)). LVEF increased with 19.8% (from 30 ± 8% to 37 ± 9% at 48 hours (P < 0.05)). SvO₂ improved significantly from 57 ± 13% to 69 ± 8% at 48 hours (P < 0.01). PaoP decreased significantly only in the first 6 hours from 19 ± 5 mmHg to 15 ± 4 mmHg (P < 0.05). The mean LOS in the cardiac ICU was 14 ± 13 days. Inhospital mortality was 24.4%.

Conclusion

In our case series, addition of levosimendan following ineffective conventional therapy resulted in substantial hemodynamic improvement. These preliminary results support the use of levosimendan in patients with LCO as a rescue medication with favorable short-term effects.