Intracoronary levosimendan for refractory coronary no-reflow during percutaneous coronary intervention: a case report

Background Coronary no-reflow during percutaneous coronary intervention (PCI) is associated with adverse clinical outcomes and remains difficult to treat when standard therapies fail. Although several pharmacological and mechanical treatment strategies have been proposed, management of refractory no-reflow remains largely empirical. Case summary In the first case, a 75-year-old man undergoing PCI of the right coronary artery for non-ST-elevation myocardial infarction developed persistent no-reflow despite thrombus aspiration, intracoronary adenosine, tirofiban, and intracoronary alteplase. In the second case, a 78-year-old man undergoing primary PCI for anterior ST-segment elevation myocardial infarction developed severe no-reflow despite balloon dilatation, thrombus aspiration, and repeated intracoronary adenosine administration. In both cases, intracoronary levosimendan was followed by rapid angiographic improvement in coronary flow from TIMI 0 to TIMI II. Discussion To our knowledge, intracoronary levosimendan for refractory coronary no-reflow during PCI has not previously been described in the clinical setting. Although causality cannot be established from two observations, the temporal association between intracoronary levosimendan administration and improvement in coronary flow suggests a potential therapeutic effect. These cases suggest that intracoronary levosimendan may be considered as an off-label rescue option in selected patients with refractory no-reflow, although its efficacy and safety require further investigation.