Case Report
Pre-operative Use of Levosimendan in Two Patients with Severe Aortic Stenosis and Left Ventricular Dysfunction

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We describe two patients with severe aortic stenosis, coronary artery disease, severe left ventricular dysfunction and heart failure in which the calcium-sensitising agent, levosimendan was administered prior to aortic valve replacement and coronary artery bypass graft surgery. In both cases, drug infusion was well tolerated at the doses used, heart failure improved significantly prior to surgery and peri-operative management was relatively uncomplicated in cases that would traditionally be considered high risk. Further investigation of the use of levosimendan both for treating heart failure in the presence of severe aortic stenosis and as pre-operative therapy is warranted.

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Case 1

A 63-year-old male was transferred to our hospital with refractory heart failure. Echocardiography performed 3 years earlier, whilst asymptomatic, showed severe AS, but normal LV systolic function and the patient declined valve surgery at that time. He recently developed worsening dyspnoea and in the last 3 months was admitted to a local hospital on three occasions with heart failure. On examination, heart rate was 86 and blood pressure 110/90 mmHg. Jugular venous pressure (JVP) was markedly

Discussion

This is the first report we are aware of in which levosimendan has been used in the setting of severe AS. Although the use of levosimendan has been shown to be beneficial for decompensated chronic heart failure,7 patients with significant AS have been specifically excluded from studies. Despite being shown to be beneficial in the treatment of heart failure due to LV systolic dysfunction, it has been conventionally accepted that drugs with vasodilator activity are contra-indicated in the

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Cited by (10)

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    2016, American Heart Journal
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    These results suggest that levosimendan is associated with better weaning from CPB, lower inotropic use, lower incidence of periprocedural MI, and lower lactate levels resulting from better tissue perfusion.18 Smaller randomized trials have further supported the efficacy of levosimendan in the treatment and prevention of LCOS in high-risk patients undergoing cardiac surgery.5,6,8,18-23 No increase in myocardial oxygen consumption or impairment of diastolic function was observed.17

  • Levosimendan: Molecular mechanisms and clinical implications: Consensus of experts on the mechanisms of action of levosimendan

    2012, International Journal of Cardiology
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    The latter mechanism is particularly interesting because agonists of mitochondrial ATP-sensitive K+ channels appear to confer protection against a variety of potentially lethal stressful conditions [66]. Short-term cardioprotection by levosimendan have been verified by a large number of clinical investigations [67–74], where the effects resembled those observed in experiments mimicking myocardial pre- or postconditioning [75–78] and/or myocardial stunning [79–81]. Longer-term cardioprotection has been also intimated by preclinical studies where levosimendan and/or OR-1896 mitigated cardiomyocyte apoptosis, cardiac remodeling and myocardial inflammation [82–86].

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