Levosimendan in ECMO: A Paradigm Shift or an Adjunctive Option?

Levosimendan, a calcium-sensitizing inodilator, has emerged as a promising adjunctive therapy in patients undergoing veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Its pharmacodynamic profile, combining positive inotropy with vasodilation and mitochondrial protective effects, offers a unique therapeutic potential in the context of mechanical circulatory support. Despite growing interest, the clinical impact of Levosimendan in ECMO remains debated, with heterogeneous evidence regarding its efficacy in improving weaning success, reducing vasopressor requirements or mitigating ischemia-reperfusion injury. This narrative review aims to critically appraise the current literature on Levosimendan use in ECMO settings, exploring its mechanistic rationale, pharmacologic behavior under extracorporeal circulation and potential role in various clinical scenarios including post-cardiotomy shock and refractory cardiogenic failure. The limitations of existing studies are critically examined, underscoring the need for high-quality clinical trials to define appropriate patient selection, optimal timing of administration and dosing strategies. This review synthesizes current evidence to determine whether Levosimendan constitutes a true therapeutic asset or remains merely an adjunctive agent in the complex management of ECMO supported patients.