Use of Levosimendan in patients with INTERMACS 3 profile: weaning from inotropic support and short- to medium-term evolution

None.

Patients with advanced heart failure (HF) in cardiogenic shock (CS) present a markedly high mortality rate. For CS patients dependent on inotropes, management is difficult with few therapeutic options available, especially in the absence of a suitability for heart transplantation (HTX) or left ventricular assist device implantation (LVAD), thus associating an even worse prognosis.

With our study we aim to analyse the rate of weaning from inotropic support when Levosimendan, a calcium sensitizer with positive inotropic effects, is used in INTERMACS 3 CS patients and their short to medium-term evolution. We then evaluate if the absence of right ventricular dysfunction, of renal dysfunction, non-ischemic aetiology and QRS width could be predicting factors of a successful weaning from inotropes.

We conducted a monocentric retrospective analysis of patients from a tertiary cardiac intensive care unit that have received a 24 hours Levosimendan infusion in the context of INTERMACS 3 cardiogenic shock between August 2015 – April 2023.

Of the 137 subjects included in the analysis, 62 patients received Levosimendan for INTERMACS 3 CS. The median age was 59±15.3 and 91.9% (n=57) were male. Baseline LVEF was 19±6%, cardiac index 1.67±0.4L/min/m2, median NTproBNP 13 378 ± 11 126ng/L. 51.6% (n=32) had ischemic heart disease and 40.3% (n=25) had dilated cardiomyopathy. After Heart Team discussion, only 37% (n=23) were considered eligible for HTX or LVAD.

Successful inotrope weaning was experienced in 68% (n=42). Amongst patients with weaning failure, most outcomes resulted in either death (45%), ambulatory continuous Dobutamine infusion (30%), or benefited from a HTX if eligible (15%). The weaning failure rates were similar amongst patients eligible and non-eligible to HTX or LVAD with different outcomes after weaning failure as shown in Figure 1. The overall survival rates at 1 month and 6 months were of 83.8% and 53.2% respectively, with a significant difference between survival rates according to inotrope weaning success or failure as shown in Figure 2. We found no clinical, biological, or echocardiographic parameter to be significantly associated with an increased probability of weaning.

Levosimendan use in INTERMACS 3 CS patients provides a good rate of success in weaning from inotropic support and could be a useful tool in allowing treatment optimization and stabilization in non HTX or LVAD eligible patients, as well as being a "bridge to transplantation" alternative. No predicting factors for successful weaning have been identified.