The effect of Levosimendan in weaning from veno-arterial extracorporeal membrane oxygenation in patients with postcardiotomy shock

Background Current evidence on Levosimendan use for both surgical and non-surgical patients undergoing weaning from veno-arterial extracorporeal membrane oxygenation (vaECMO) is controversial. Purpose This study aimed to evaluate the effect of Levosimendan infusion on the success of weaning from vaECMO in patients with postcardiotomy shock in a single-center retrospective analysis. Methods Patients undergoing weaning from vaECMO for postcardiotomy shock between January 2009 and April 2025 at our institution were retrospectively analyzed. Patients requiring mechanical circulatory support prior to the index surgery, those undergoing heart transplantation, ventricular device implantation, and descending aortic or thoracoabdominal aortic surgery, as well as patients administered Levosimendan under other circumstances than prior to vaECMO weaning, were excluded from the study. Statistical adjustment for clinical differences was performed using 1:1 nearest neighbour propensity score matching (PSM). Results Of 483 patients included, 71 were administered Levosimendan (LS group) prior to ECMO weaning. Nineteen (26.8%) LS patients were female. Intraoperative vaECMO implantation was required in 27 (38.0%) cases in the LS group and 181 (43.9%) cases in the control group. Implantation of vaECMO during cardiopulmonary resuscitation was performed in 8 (11.3%) and 55 (13.3%) patients in the LS and control groups, respectively. After PSM, no differences in perioperative and ECMO-related data were observed between the two groups (Table 1). Successful vaECMO weaning was observed in 30 (42.3%) cases in LS group vs. 245 (59.5%) patients in the control group (unadjusted p=0.007). Similar trend with lower rates of successful weaning in LS group was observed after PSM: 25 (40.3%) in LS vs. 34 (54.8%) in the control group (adjusted p=0.072). No statistically significant difference in in-hospital mortality was observed between the groups (unadjusted: 37 (52.1%) in the LS group vs. 172 (41.7%) in the control group, p=0.10; after PSM: 33 (53.2%) vs. 28 (45.2%), p=0.34). During vaECMO weaning, no statistically significant difference in the rate of inotropic or vasopressor support was observed between the two groups. Adjusted estimated survival was 39.1% vs. 40.3% at 1 year, and 30.5% vs. 28.5% at 5 years (stratified p=0.40) in the LS and control groups. Levosimendan therapy was not associated with reduced risk of long-term mortality (adjusted HR 0.99; 95% CI 0.67 – 1.49, p=0.99). Conclusions Levosimendan infusion prior to vaECMO weaning was not associated with facilitated ECMO weaning or improved survival. Prospective randomized trials are required in order to justify the clinical use of Levosimendan in patients with postcardiotomy shock.