Stabilizing the unstable: characterization of advanced heart failure patients under intermittent levosimendan therapy

Advanced heart failure (HF) remains a therapeutic challenge, frequently associated with recurrent decompensations, poor quality of life, and high mortality. Levosimendan, a calcium sensitizer with inodilator properties, has been used intermittently to improve hemodynamic stability and functional status.

Describe clinical profile and short-term outcomes of patients with advanced HF treated with regular cycles of levosimendan.

We performed a retrospective observational analysis of AdHF patients included in an ILC program between March 2019 and January 2023. The demographic, clinical, and laboratory data were collected. Levosimendan was infused at 0.05-0.2 mg/Kg/min doses without bolus for 6h (every two weeks) or 24 h (monthly) infusion duration.

The cohort included 46 men (77%), with a mean age of 67 ± 12.9 years and a median BMI of 25 (IQR 21–27) kg/m². All patients had HFrEF, most commonly ischemic etiology (33 patients, 55%), followed by idiopathic dilated cardiomyopathy (16 patients, 27%). Baseline left ventricular ejection fraction was 24.6% (IQR 19.5–29.5), and NT-proBNP was 9,805 pg/mL (IQR 3,292–12,310). Before therapy, 97% of patients were in NYHA class III. The median number of HF hospitalizations significantly decreased from 1 (IQR 0–2) in the 6 months prior to therapy to 0 (IQR 0–1) at 6 months (p < 0.001). Similarly, there was a significant improvement in functional class (NYHA) after 6 months (p < 0.001). At follow-up, median NT-proBNP decreased to 4,696 pg/mL (IQR 1,284–6,700). Most patients (84%) received monthly cycles. By October 2025, 19 patients (31.7%) were dead, 9 (15%) due to HF. Among 17 patients initially considered for advanced therapies (transplant or LVAD), 3 underwent cardiac transplant and 1 received a left ventricular assistance device (LVAD), while 43 patients (72%) were treated with palliative intent for symptomatic improvement.

In this cohort of advanced HF patients, intermittent levosimendan therapy was associated with significant reductions in HF hospitalizations and NYHA functional class (both p < 0.001), along with decreased NT-proBNP levels at 6 months. These findings reinforce the potential role of levosimendan as an adjunctive strategy for clinical stabilization and symptomatic improvement in patients with advanced HF.