The Potential Beneficial Effect of Levosimendan in Milrinone-treated Advanced Heart Failure Patients

Background Routine, short-term use of inotropic agents is still applied in advanced heart failure (HF) patients either as a bridge to definitive treatment or as a mean to improve quality of life, despite the paucity of scientific evidence. Intermittent levosimendan was shown to be efficacious compared to placebo in advanced HF patients, however no prospective data comparing it to other inotropes and in particular, to milrinone are available. We aimed to assess the clinical effects of intermittent levosimendan in a small group of milrinone-treated advanced HF patients. Methods This was a prospective, un-blinded study. Consecutive ambulatory advanced HF patients intermittently treated with ≥ 4 cycles of once-weekly 6-hours 0.25–0.5 mg/kg/min milrinone at our HF outpatient clinic, were switched to levosimendan. All patients were evaluated using B-natriuretic peptide (BNP) levels, echocardiography, cardio-pulmonary exercise test and HF questionnaire before and after 4 weeks of intermittent once-weekly 6-hours therapy with levosimendan 0.1–0.2 mcg/kg/min. Results The cohort included 11 patients, 10 men, mean age 76±12 years. After 4 weeks of levosimendan therapy, Vo 2 max improved by a mean of 2.28 ml/kg [95% CI -0.22-3.38, p = 0.05], BNP levels decreased from a median of 1015 ng/l [261–1035] to 719 ng/l [294–739], (p < 0.01) and the sum scores of EQ-5D-5L non-significantly improved by a median of 2 points [95% CI -4.17-0.37, p = 0.09]. On echocardiography, tricuspid annulus tissue Doppler increased by an average of 3 cm/s [95% CI 0.16–2.10, p = 0.03]. In addition, HF-related hospitalizations numerically decreased after switching to levosimendan. Conclusion In this small-scale, prospective study, we observed improvement in laboratory, echocardiographic and exercise capacity parameters in milrinone-treated advanced HF patients who were switched to levosimendan.