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

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 6, November/December 2021 AFRICA 341 and increasing body weight. Levosimendan was administered at a dose of 12.5 mg/24 hours. The response and the tolerance of the treatment was satisfactory. LVEF increased to 25% and BNP level dropped to 1 143 pg/ml. The patient was discharged in a stable state in NYHA class II. After 42 days, a deterioration in the clinical state occurred, with increasing exertional dyspnoea, orthopnoea and abdomen perimeter. At admission, the LVEF was 20% and BNP level was 2 787pg/ml.Due to the previous satisfying response, levosimendan (12.5mg/24 hours) was administered. The patient’s condition improved, as well as the LVEF (25%). The BNP value dropped to 2 154 pg/ml. The patient was discharged from hospital in a stable condition in NYHA class II. Another decompensation event followed after 52 days, in December 2019. The patient presented in NYHA class IV, with oedema of the lower limbs, ascites and an increase in body weight of about 9 kg. LVEF was at 20%. At admission, the BNP value was 2 991 pg/ml. Due to the severe state, the patient required an intensification of the diuretic and inotropic treatment with furosemide and dobutamine. Given the poor response to the treatment, the patient received a levosimendan infusion (12.5 mg/24 hours). His LVEF improved to 25% and the BNP value decreased to 1 803 pg/ml. The patient was discharged from hospital in a stable condition. His NYHA class improved from IV to III. This case proves that levosimendan is very potent and more effective than intravenous diuretics, even if combined with dobutamine. Levosimendan infusions result in rapid clinical improvement. Discussion The prevalence of advanced HF is increasing, 6 and is associated with high morbidity and mortality rates. 7 According to the Heart Failure Association of the European Society of Cardiology, advanced HF is defined as a stage where conventionally used treatments are insufficient to control the patient’s symptoms, and advanced or palliative therapies are needed to obtain fluid volume control and end-of-life comfort care. 8 Solutions to improve the patients’ clinical state and to prevent hospitalisations and death are being investigated. Repetitive infusions of levosimendan may offer an advantage of a prolonged inotropic effect with the possibility of improving the clinical state. There are very limited data regarding the effectiveness of such a treatment. 9-13 Use of levosimendan has gained popularity in intermittent use, since the haemodynamic effect may last more than seven days after infusion. Probably the reason is the long half-life of the pharmacologically active metabolite. 12 Nevertheless, the heterogeneity of the evidence seems to show potential. 14 The LevoRep study evaluated the effect of four injections of levosimendan (0.2 μg/kg/min) over six hours at two-week intervals in 120 advanced HF patients, 15 and the results concerning event- free survival favoured the levosimendan group versus placebo. The Lion-Heart study, involving 69 patients with advanced HF, replicated the above methodology with a longer-duration study (12 weeks), 5 showing a reduction in NT-proBNP level and readmission rate during the 12 months. Based on the available data, the strategy of repetitive infusions can be considered in alleviation of the symptoms and improvement of the quality of life in patients with advanced HF. What is more, on the basis of the research results, levosimendan, as one of the inodilators, was included in the recommendations for the treatment of advanced HF. The questions of how many levosimendan doses can be administered and the interval length between the doses is still unknown. Conclusions Repetitive levosimendan infusions are safe and effective. They seem to prolong the time of clinical stability, even though they do not alter the eventual natural history of HF, with increasing frequency of hospitalisations and rising NT-proBNP level. References 1. Savarese G, Lund LH. Global Public Health Burden of Heart Failure. Card Fail Rev 2017; 3 (1): 7–11. 2. Ponikowski P, Voors AA, Anker SD, et al . 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016; 37 (27): 2129–2200 3. Pollesello P, Parissis J, Kivikko M, et al . 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