Among the inotropic agents used in the management of heart failure, levosimendan, in particular, has a selective venodilator property that appears to explain its clinical benefit during pulmonary hypertension (PH). Most of the evidence refers to patients with group 2 PH and consequent right ventricular (RV) dysfunction. In this scenario, the observed benefits may be due to the effect of levosimendan on RV contractility and pulmonary vessel dilation, or to the improvement of left ventricular function and consequent reduction of pulmonary congestion. What we have noticed is that more and more studies are being done on this action and applicability of the drug, appearing in small studies, reviews and formal indications.

Introduction : We know that patients with advanced heart failure with reduced ejection fraction (HFrEF) often have a reduced tolerance to disease-modifying agents, and inotropes are frequently used in emergency and intensive care settings for recovery of organ dysfunction and hemodynamic compensation, as well as in outpatient and palliative settings to improve symptoms and reduce hospitalizations. Among the inotropic agents, new indications for the use of levosimendan have been discussed, such as its use in patients with pulmonary hypertension (PH). Its action results in an increase in cardiac contractility through sensitization to calcium and promotes vasodilation through the opening of adenosine triphosphate-dependent potassium channels in vascular smooth muscle cells.

Case Description : Female patient, 61 years old, with advanced HF of ischemic etiology that began in 2018, history of hospitalization in 2022 for decompensated HFrEF in profile C. She evolved in INTERMACS 3, compensated with dobutamine, euvolemic, and then underwent evaluation for a heart transplant (Tx). Right heart catheterization was performed (Figure 1) with prohibitive values for conventional orthotopic Tx due to fixed PH. The etiology of PH was investigated, angiotomography was negative for pulmonary thromboembolism, and PH group 2 + 3 was assigned due to a previous history of significant smoking and obstructive sleep apnea, confirmed by polysomnography. With no possibility of HeartMate 3 implantation at the time, it was then decided to perform levosimendan to wean off dobutamine and the possibility of hospital discharge for outpatient follow-up with the HF group. Levosimendan was started in a day hospital, 0.05 mcg/ kg/min in 30 minutes and then 0.1 mcg/kg/min for 4 hours and repeated every 3 to 4 weeks or as per clinical evaluation, with significant improvement in symptoms, maintaining NYHA II outpatient functional class, using optimized drug treatment and undergoing cardiac rehabilitation. While undergoing treatment, she was hospitalized in November/2023 for evaluation of a ventricular assist device; the patient repeated right catheterization (Figure 2), showing improvement in gradients and pulmonary resistance, showing improvement in pulmonary vascular resistance, being listed for orthotopic heart transplantation on 05/28/24. The patient continues outpatient follow-up, listed and active on the heart transplant waiting list, without prioritization, maintaining intermittent levosimendan infusion when necessary, and cardiac rehabilitation.

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