Cardiovascular Journal of Africa: Vol 32 No 6 (NOVEMBER/DECEMBER 2021)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 6, November/December 2021 AFRICA 339 Case Reports Repetitive use of levosimendan in clinical practice: a case series Michał Wawrzyniak, Jacek Migaj, Ewa Straburzy ń ska-Migaj, Magdalena Dudek, Marta Kału ż na-Oleksy Abstract Levosimendan was developed as a treatment for acute decom- pensation of severe heart failure (HF). Its use has evolved during recent years, and new HF treatment strategies in differ- ent settings have been developed. This case series aimed to show indications for the use of levosimendan and to discuss the treatment response in various settings. Repetitive levosi- mendan infusions were found to be safe and effective. They seemed to prolong the time of clinical stability, although they did not alter the eventual natural history of HF, with increasing frequency of hospitalisations and rising natriuretic peptide levels. Keywords: heart failure, advanced heart failure, drugs in cardiol- ogy, intensive care Submitted 27/6/20, accepted 1/12/20 Published online 15/1/21 Cardiovasc J Afr 2021; 32 : 339–342 www.cvja.co.za DOI: 10.5830/CVJA-2020-058 Heart failure (HF) is a global problem affecting approximately 26 million people worldwide. 1 Because of aging populations, the HF morbidity rate is expected to rise, thus generating more hospitalisations and costs for healthcare systems. 1 Moreover, with the number of HF patients, the number of patients with advanced HF requiring therapy due to multiple HF decompensations is rising as well. HF treatment should focus on reduction in mortality and hospitalisation rates and improvement in the quality of life. 2 Acute decompensated HF requires treatment with diuretics, vasodilators and inotropes. 2 Levosimendan acts as a calcium (Ca 2+ ) sensitiser and has a positive cardiac inotropic effect. It also shows a vasodilatory effect due to its mechanism of opening potassium channels in the vasculature and cardiomyocytes. 3,4 These result in increased stroke volume and heart rate, consequently increasing the cardiac output. According to the Lion-Heart trial, levosimendan significantly reduced N-terminal B-type natriuretic peptide (NT-proBNP) concentration in comparison with placebo. 5 This effect translates into reduction in the risk of hospitalisation 5 and death, 4 and is explained by both the haemodynamic and cardioprotective properties of levosimendan. The indications for levosimendan in HF have been changing throughout the years. Nowadays they include acute decompensated HF and repetitive use in chronic HF patients to prevent decompensation. However, the treatment strategy for repetitive use of levosimendan has not been clearly defined. This case series aimed to show indications for levosimendan use and to discuss the treatment response in various settings. Case report 1 A 61-year-old man presented to the clinic (August 2018) due to decompensation of chronic HF, diagnosed 12 years earlier. His co-morbidities included ischaemic heart disease (IHD), acquired after an antero-lateral ST-segment elevation myocardial infarction (STEMI), treated with percutaneous coronary intervention (PCI) of the left anterior descending coronary artery (LAD) in 2008, and non-ST-segment elevation myocardial infarction (NSTEMI) treated with percutaneous balloon angioplasty (POBA) of the right coronary artery (RCA) in 2014. Since 2009 the patient has had an implantable cardioverter–defibrillator (ICD), which was upgraded to cardiac resynchronisation therapy (CRT-D) in 2019. Additionally, the patient suffers from chronic kidney disease (stage 3a). At admission, he presented with severe dyspnoea, orthopnoea and abdominal pain. Echocardiography (echo) showed a general impairment of the left ventricular (LV) function with reduced LV ejection fraction (LVEF), estimated at 15%. The brain natriuretic peptide (BNP) value was 2 422 pg/ml. Due to a poor response to diuretics and standard inotropic treatment with dobutamine (7–15 mcg/kg/min), levosimendan was administered. After a 12.5-mg/24-hour infusion of levosimendan, LVEF improvement to 25% was observed, and the BNP value decreased to 1 779 pg/ ml. After a spectacular improvement of the patient’s condition, he was discharged home in a stable state (New York Heart Association: NYHA class II). Subsequent decompensation occurred after nine months from baseline (May 2019). The patient presented in NYHA class III and the LVEF was measured at 15%. At admission, the NT-proBNP value was 5 844 pg/ml. Despite intensification of the diuretic and inotropic treatment with dobutamine (7–15 mcg/kg/min), the NT-proBNP level continued increasing up to 1st Department of Cardiology, University of Medical Sciences, Poznan, Poland Michał Wawrzyniak, MD, michalw.47@gmail.com Jacek Migaj, MD Ewa Straburzy ń ska-Migaj, MD Magdalena Dudek, MD Marta Kału ż na-Oleksy, MD