1. Recent advances – levosimendan
Dr. S. Parthasarathy
MD., DA., DNB, MD (Acu), Dip. Diab. DCA,
Dip. Software statistics,
PhD(physiology)

2. Inodilators Increase contractility
But slightly vasodilate to cause decreased afterload
Dobutamine , phophodiesterase inhibitors
Levosimendan

3. Increased intracellular calcium with others – - - arrhythmias
But this is a calcium sensitizer
Especially in systole

4. The first action
It binds to cardiac troponin C in a calcium-dependent manner and stabilises troponin C.
This causes actin-myosin cross-bridges, without increasing myocardial consumption of adenosine triphosphate (ATP).
The cardiac performance and contractility are significantly improved with no increase in the total myocardial energy demand and oxygen consumption.

5. No effect in diastole
Normal relaxation
Normal diastolic function
Less arrhythmias

6. The second action
Levosimendan also causes venous, arterial and coronary vasodilation, probably by opening ATP sensitive potassium channels in smooth muscle.
Dose-dependant hypotension may occur.
Levosimendan reduces pulmonary vascular resistance- benefit in RV strains

7. Elimination half life – one hour
Active metabolite – 70 hours may be
Hence after infusion – may have action

8. We can stop catecholamines in between
Tolerance settled
Children with alpha blockers – no catecholamines – but this is ok

9. Decompensated chronic heart failure !!
The usual dosage of intravenous levosimendan used in clinical trials of patients with heart failure is 6 to 12 µg/kg loading dose over 10 minutes
followed by 0.05 to 0.2 µg/kg/min as a continuous infusion
Levosimendan is available in the strength of 2.5 mg per 5 mL per ampoule and 10mL per ampoule
Post CABG LCOS
Rs 427 / 12.5 mg

10. Liver dysfunction
Not much studied – can use with normal dose and titrate
Severe renal dysfunction – levels are high a 50 % dose reduction is OK
But no clear cut studies

11. Side effects Usually well tolerated Headache Hypotension
Rarely arrhythmias
No interaction with digoxin, frusemide and amiodarone , other inotropes
Stop other vasodilators if possible

12. Levosimendan has been found to be a safe and useful drug when given to the sickest children with acute heart failure refractory to standard anti-failure medications.
Even in septic shock in children
But do we need long acting drugs ?

13. Tips ??
Chronic heart failure – trigger – fluid imbalance, infection, drug non compliant etc, decompensation
Stabilize
Infusion of levosimendan – 24 hours
Discharge the patient
Stable for one week – by the time the trigger is undone

14. Summary Enantiomer of simendan
Inotrope without increasing oxygen consumption of heart
Vasodilation – mechanisms
No action through adrenergic receptors
Decompensated Chronic heart failure , septic shock in children, RV strain, LCOS etc..
6-12 and 0.2 microgram
Headache hypotension
Prolonged action