Levosimendan and Low Cardiac Output After Cardiac Surgery: Analysis of Trial Data

Low-cardiac-output syndrome (LCOS) after cardiac surgery is characterized by myocardial dysfunction requiring inotropic and mechanical circulatory support, and is associated with high morbidity and mortality. Levosimendan, an inodilator that facilitates calcium sensitization of troponin C, has been identified as a potential prophylactic cardioprotective treatment for LCOS in patients undergoing cardiac surgery. 1 Nieminen MS Fruhwald S Heunks LM et al. Levosimendan: Current data, clinical use and future development. Heart Lung Vessel. 2013; 5: 227-245 PubMed Google Scholar Recent randomized control trials, LEVO-CTS, LICORN, and CHEETAH, have not demonstrated prophylactic levosimendan mortality benefit; however, there may be decreased incidence of LCOS with its use. 2 Mehta RH Leimberger JD van Diepen S et al. Levosimendan in patients with left ventricular dysfunction undergoing cardiac surgery. N Engl J Med. 2017; 376: 2032-2042 Crossref PubMed Scopus (199) Google Scholar , 3 Cholley B Caruba T Grosjean S et al. Effect of levosimendan on low cardiac output syndrome in patients with low ejection fraction undergoing coronary artery bypass grafting with cardiopulmonary bypass: The LICORN randomized clinical trial. JAMA. 2017; 318: 548-556 Crossref PubMed Scopus (139) Google Scholar , 4 Landoni G Lomivorotov VV Alvaro G et al. Levosimendan for hemodynamic support after cardiac surgery. N Engl J Med. 2017; 376: 2021-2031 Crossref PubMed Scopus (196) Google Scholar It is also possible that there remains a therapeutic window of levosimendan in mitigating LCOS that should be investigated. These trials suggested that LCOS mortality may be driven by prolonged cardiopulmonary bypass (CPB) and aortic cross-clamp time, as well as coronary artery bypass graft surgery with the addition of valvular intervention. Minimizing surgical risk and identifying risk factors for LCOS are imperative for mortality reduction in cardiac surgery.