Early Levosimendan Administration Improved Weaning Success Rate in Extracorporeal Membrane Oxygenation in Patients With Cardiogenic Shock

Effect of Levosimendan Use on All-Cause Mortality in Out-of-Hospital Cardiac Arrest Survivors After Extracorporeal Cardiopulmonary Resuscitation

Background: Survivors of out-of-hospital cardiac arrest (OHCA) after external cardiopulmonary resuscitation (ECPR) have a mortality rate as high as 50-70%. The use of vasoactive inotropes worsen the mortality rate at admission. The administration of levosimendan within 72 h of ECPR facilitates extracorporeal membrane oxygenation (ECMO) weaning, so it is important to determine whether levosimendan improves mortality. Methods: This retrospective cohort study included 158 patients with OHCA of cardiac origin who had undergone ECPR and were hospitalized between January 2015 and December 2024. This study was conducted in the intensive care unit of China Medical University Hospital, Taichung, Taiwan. Twenty-three patients received levosimendan within 72 h, whereas the others did not receive levosimendan. Primary endpoints included ECMO weaning failure rate and 90-day all-cause mortality rate. Kaplan-Meier survival curve analysis was also performed. Covariates for all-cause mortality were estimated and adjusted by using Cox regression modeling. Results: The levosimendan group exhibited lower rates of ECMO weaning failure and 90-day all-cause mortality than the control group (13.0% vs. 52.6% and 17.4% vs. 57.0%, respectively; both p < 0.001). The 90-day survival curve analysis revealed that the levosimendan and control groups had survival rates of 82.6% and 43.0%, respectively (log-rank p < 0.001). Administration of levosimendan within 72 h resulted in a odds ratio of 0.36 (95% confidence interval: 0.18-0.79, p = 0.01). Conclusions: Administering levosimendan within 72 h of ECPR could be a protective factor in improving all-cause mortality.

Levosimendan, a Promising Pharmacotherapy in Cardiogenic Shock: A Comprehensive Review

Cardiogenic shock (CS) is a critical condition with high mortality rate, as the current management of CS presents significant challenges. Exploration of more effective therapies is necessitated. This review article comprehensively examines the efficacy and safety of levosimendan in the management of CS. By synthesising evidence from numerous studies, a comparison of levosimendan over traditional inotropic agents, such as enoximone, dobutamine, dopamine and norepinephrine, is highlighted. The unique mechanism of action of levosimendan enhances myocardial contractility without increasing oxygen demand, offering a promising alternative for patients with CS. This review also delves into comparative studies that demonstrate the superiority of levosimendan in improving survival rates, haemodynamic parameters, and reducing the incidence of CS complications. Safety profiles and adverse effects are critically assessed to provide a balanced view of the therapeutic window provided by levosimendan. The review concludes that levosimendan is a valuable addition to the therapeutic strategy against CS, with the potential to improve patient outcomes.

Effects of levosimendan on the outcome of veno-arterial extracorporeal membrane oxygenation: a systematic review and meta-analysis

OBJECTIVES

For patients with severe cardiopulmonary failure, such as cardiogenic shock, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is primarily utilized to preserve their life by providing continuous extracorporeal respiration and circulation. However, because of the complexity of patients' underlying diseases and serious complications, successful weaning from ECMO is often difficult. At present, there have been limited studies on ECMO weaning strategies, so the principal purpose of this meta-analysis is to examine how levosimendan contributes to the weaning of extracorporeal membrane oxygenation.

METHODS

The Cochrane Library, Embase, Web of Science, and PubMed were browsed for all potentially related research about clinical benefits of levosimendan in weaning patients receiving VA-ECMO and included 15 of them. The main outcome is success of weaning from extracorporeal membrane oxygenation, with the secondary outcomes of 1-month mortality (28 or 30 days), ECMO duration, hospital or intensive care unit (ICU) length of stay, and use of vasoactive drugs.

RESULTS

1772 patients altogether from 15 publications were incorporated in our meta-analysis. We used fixed and random-effect models to combine odds ratio (OR) and 95% confidence interval (CI) for dichotomous outcomes and standardized mean difference (SMD) for continuous outcomes. The weaning success rate in the levosimendan group was considerably higher in contrast to the comparison (OR = 2.78, 95% CI 1.80-4.30; P < 0.00001; I2 = 65%), and subgroup analysis showed that there was less heterogeneity in patients after cardiac surgery (OR = 2.06, 95% CI, 1.35-3.12; P = 0.0007; I2 = 17%). In addition, the effect of levosimendan on improving weaning success rate was statistically significant only at 0.2 mcg/kg/min (OR = 2.45, 95% CI, 1.11-5.40; P = 0.03; I2 = 38%). At the same time, the 28-day or 30-day proportion of deaths in the sample receiving levosimendan also decreased (OR = 0.47, 95% CI, 0.28-0.79; P = 0.004; I2 = 73%), and the difference was statistically significant. In terms of secondary outcomes, we found that individuals undergoing levosimendan treatment had a longer duration of VA-ECMO support.

CONCLUSIONS

In patients receiving VA-ECMO, levosimendan treatment considerably raised the weaning success rate and helped lower mortality. Since most of the evidence comes from retrospective studies, more randomized multicenter trials are required to verify the conclusion.