Experience with levosimendan in cardiogenic shock: inotrope weaning and clinical outcomes in a real-world cohort

Background Cardiogenic shock (CS) remains associated with high mortality and frequent dependence on inotropes. Levosimendan has been proposed to facilitate weaning from inotropes and mechanical circulatory support (MCS), but real-world evidence is limited. Objectives To describe our institutional experience with levosimendan use in CS, focusing on inotrope weaning, safety, and prognostic factors. Methods We conducted a retrospective observational study including 77 patients treated with levosimendan for CS between January 2017 and August 2025. Data collected included demographics, etiology, timing and success of catecholamine and/or MCS withdrawal, maximum tolerated dose, adverse events, and contraindications. Between-group comparisons were performed using chi-square or Fisher’s exact tests for categorical variables and Student’s t-test or Mann–Whitney U test for continuous variables, as appropriate. One-year mortality was assessed using Kaplan–Meier survival analysis and compared between groups using the log-rank (Mantel–Cox) test. Results Mean age was 64±16 years; 78% were male. CS etiologies: post-acute myocardial infarction 51%, acute non-ischemic 13%, acute-on-chronic 36%. The main indication for levosimendan was inotrope weaning (67.5%), followed by combined inotrope and mechanical circulatory support (MCS) weaning (24.7%), and hypoperfused acute decompensated heart failure (7.8%). Complete inotrope withdrawal was achieved within 48 hours in 44.2% of patients, within one week in an additional 29.9%, while 26.0% remained inotrope-dependent. 11 patients (15%) required repeated infusions; 4 were referred to a levosimendan day-hospital program. During hospitalization, 30 patients died, 10 underwent heart transplantation, and 4 received a left ventricular assist device (LVAD). 12 patients experienced a cardiovascular-related hospital readmission; among them, 9 (75%) were readmitted for decompensated HF, and 4 of these (33%) required a new levosimendan infusion cycle. The maximum infusion rate (0.2mcg/kg/min) was tolerated in 88% of cases. Adverse events occurred in 13%, mainly arrhythmias (11.7%). No severe adverse events occurred. 48 patients (62%) had no relative contraindications. Among those with relative contraindications, the most frequent were elevated ALT (24.7%) and renal replacement therapy (6.5%). None of these factors were significantly associated with 1-year mortality: maximum dose tolerance (49.3% vs. 44.4%; p = 0.958), occurrence of adverse events (42.9% vs. 50.8%; p = 0.751), or presence of a relative contraindication (57.1% vs. 45.8%; p = 0.291). Conclusions Levosimendan appears to be a well-tolerated and safe option in cardiogenic shock, with modest efficacy in facilitating inotrope withdrawal. Failure to tolerate the maximum dose, occurrence of adverse events, or presence of relative contraindications were not significant predictors of worse 1-year mortality outcomes.