Elderly patients with heart failure undergoing urgent major surgery suffer substantial cardiac morbidity and mortality. Levosimendan, a novel calcium sensitizer, enhances myocardial contractility while simultaneously having vasodilatory and cardioprotective properties. This could be advantageous in perioperative management of heart failure patients.

Ten consecutive patients with symptomatic heart failure and left ventricular ejection fraction <35% undergoing urgent hip fracture repair were studied. Levosimendan was administered with an infusion rate of 0.1 μg kg−1 min−1 in a total dose of 12.5 mg starting a minimum of 2 h prior to surgery. Haemodynamic parameters were obtained at baseline and at 4, 8, 12, 16, 20, 24, 28, 36 and 48 h after start of levosimendan. B-type natriuretic peptide was measured on admission and after 48 h.

Patients were 86 ± 7 yr (mean ± SD) of age. Levosimendan significantly increased cardiac index from 2.4 ± 0.3 L min−1 m−2 at baseline to 3.2 ± 0.6 L min−1 m−2 after 24 h by increases in stroke volume index (baseline 27 ± 5 mL m−2, after 24 h 37 ± 10 mL m−2, P < 0.05). Systemic vascular resistance index significantly decreased from 2718 ± 841 to 1964 ± 385 dyn s cm−5 m−2 within 24 h. Haemodynamic changes exerted by levosimendan persisted up to 48 h. B-type natriuretic peptide plasma concentrations decreased from 1143 ± 792 to 935 ± 724 ng L−1 after 48 h (P = 0.006).

In patients with heart failure, preoperative start of levosimendan infusion improves intraoperative and postoperative haemodynamics. These findings suggest that levosimendan is a useful drug for preoperative optimization of cardiac function in high-risk patients undergoing major surgery.

Levosimendan is a calcium-sensitizing drug that enhances myocardial contractility without increasing intracellular calcium. By activating adenosine triphosphate-dependent potassium channels it exerts cardioprotective and vasodilatory effects.

A retrospective matched pair analysis was performed in 52 patients undergoing emergency coronary artery bypass grafting for acute myocardial ischaemia with or without cardiogenic shock. A total of 27 patients received levosimendan (bolus 6 μg kg−1; continuous infusion 0.2 μg kg−1 min−1) in addition to catecholamines, while 25 patients were treated with catecholamines only.

Predicted mortality by logistic EuroSCORE was 42% (14–90%) in the levosimendan group and 38% (9–90%) in the control group (median, range). Cardiogenic shock was diagnosed in 52% of the patients in both groups. Compared to the control group, levosimendan-treated patients had fewer intra-aortic balloon pumps inserted (33% vs. 76%, P < 0.05) and were ventilated for a shorter period (39 ± 39 h vs. 106 ± 109 h, P < 0.05). In this limited number of patients, the reduction in mortality at day 30 (26% levosimendan; 44% control, P > 0.05) and need for dialysis (11% levosimendan; 32% control, P > 0.05) did not reach statistical significance. Length of hospital stay did not differ (14 ± 18 days, levosimendan; 13 ± 19 days, control; P > 0.05) between the two groups.

In this retrospective matched pair analysis of 52 patients undergoing emergency coronary artery bypass grafting for acute ischaemia, levosimendan reduced morbidity. The reduced morbidity did not translate into reductions in mortality or length of stay. A larger, prospective randomized trial is warranted to confirm the potentially beneficial effects of levosimendan in patients with acute ischaemia.