Extended administration of levosimendan in the cardiac intensive care unit: a single-center experience

Levosimendan, an inodilator, offers hemodynamic benefits by reducing afterload and enhancing contractility, thus increasing cardiac output, and possibly improving renal perfusion, and promoting diuresis(1). Hypotension, a potential side effect, often limits full-dose administration (2). In our experience, in patients in whom initial dose is reduced, an extended levosimendan administration may be feasible.

This retrospective single-center study aimed to compare the clinical outcomes of patients receiving levosimendan over an extended duration versus those receiving standard dose within 24 hours.

The analysis included all patients who received levosimendan in the cardiac intensive care unit at our hospital between January 2022 and August 2024. Of 39 patients, 37 had sufficient data for analysis. Data were extracted from electronic medical records and therapeutic archives. Diuresis was compared at 24, 48,72 and 96 hours, and episodes of ventricular tachycardia (VT) or ventricular fibrillation (VF) and new-onset atrial fibrillation (AF) were recorded.

A total of 11 patients received full dose of levosimendan within 24 hours, while 26 received full dose through slower infusion requiring more than 24 hours. The groups were similar in terms of left ventricular ejection fraction (LVEF, median for both groups 20% (15%-25%), age (63 (60 – 68) for patients receiving full dose within 24 hours vs 59.5 (53 – 67), comorbidities, and concurrent use of dobutamine. There were no significant differences in diuresis between the two groups at 24 hours (2600 ml vs. 3200 ml, p = 0.053), 48 hours (3200 ml vs. 3700 ml, p = 0.6), 72 hours (2615 ml vs. 2950 ml, p = 0.72), or 96 hours (3050 ml vs. 2805 ml, p = 0.42). Additionally, there were no significant differences in the incidence of malignant arrhythmias, including hemodynamically unstable VT (2 patients (18%) vs. 4 patients (15.4%), p = 0.83), and no cases of ventricular fibrillation. The incidence of new-onset AF was also comparable between groups (2 episodes (18%) vs. 4 episodes (15.4%), p = 0.83). When patients with hypokalemia were excluded, only one patient in the extended administration group experienced hemodynamically unstable VT.

Extended levosimendan administration achieved similar diuresis to standard full-dose regimen within 24 hours (although numerically higher diuresis was achieved with extended administration), with no increase in the incidence of malignant arrhythmias. These findings suggest that extended infusion may be a viable alternative, particularly when electrolyte imbalances are appropriately managed. These results should be interpreted with caution, as this is a small sample single-center study; further randomized clinical trials are needed to confirm these findings.