Effects of Levosimendan on Systemic Perfusion in Patients with Low Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Score: Experience from a Single Center in Taiwan

Abstract

Background: Patients with cardiogenic shock have a high risk of mortality. Intravenous levosimendan can provide pharmacologic inotrope support.

Objectives: We aimed to investigate the effect of levosimendan in patients with extremely severe cardiogenic shock and low Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) score with or without mechanical circulatory support.

Methods: From January 2017 to May 2019, 24 patients with INTERMACS 1-4 were enrolled in this retrospective study. All patients had systemic malperfusion and were treated with levosimendan. Biochemistry data related to systemic perfusion were recorded and compared before and at 24 and 72 hours after levosimendan administration. Echocardiography and Kansas City Cardiomyopathy Questionnaire (KCCQ) were completed 2 months later to assess left ventricular ejection fraction (LVEF) and quality of life (QoL), respectively.

Results: Arterial pressure and heart rate did not significantly differ before and after levosimendan administration. Atrial fibrillation and ventricular premature complex increased without significance. The dose of inotropes could be significantly tapered down. There were no significant differences in blood urea nitrogen, creatinine, and lactate levels. Urine output significantly increased (p = 0.018), and liver-related enzymes improved but without significance. B-type natriuretic peptide significantly decreased (p = 0.007) at 24 hours after levosimendan administration. Echocardiography showed significantly improved LVEF 2 months later (22.43 ± 8.13% to 35.87 ± 13.4%, p = 0.001). KCCQ showed significantly improved physical activity and greater relief of symptoms (p = 0.003). The survival-to-discharge rate was 75%.

Conclusions: We observed a decrease in B-type natriuretic peptide, better urine output, and alleviated hepatic injury in the levosimendan group. Most patients who survived without transplantation had significantly improved LVEF and better QoL after levosimendan administration.

Keywords: Cardiogenic shock; End-stage heart failure; Levosimendan; Systemic perfusion.

Figure 1

The algorithm of patients enrolled in this study. ECMO, extracorporeal membrane oxygenation; INTERMACS score, Interagency Registry for Mechanically Assisted Circulatory Support score; VAD, ventricular assist device.

Figure 2

(A) Mean with standard deviation bars of inotrope variation and mean hemodynamic status between data obtained at baseline, 24 hours after levosimendan administration, and 72 hours after levosimendan administration are presented in a line chart. The total inotrope dosage could be tapered down without hemodynamic compromise. (B) p-value of mean with standard deviation bars hemodynamic status and inotrope variation between data obtained at baseline, 24 hours after levosimendan administration, and 72 hours after levosimendan administration in the analysis of variance and post hoc test.