Abstract
Preoperative levosimendan in heart failure patients undergoing hip fracture repair: a preliminary report. 

INTRODUCTION:
Elder patients with heart failure undergoing noncardiac surgery  suffer substantial cardiac morbidity and mortality. 
Levosimendan is a promising adjunct in our therapeutic repertoire for the treatment of cardiac failure. It´s  a novel calcium sensitizer, enhances myocardial contractility while simultaneously has vasodilatory and cardioprotective properties. This could be advantageous in perioperative management of heart failure patients.
Our objective was to evaluate the safety and efficiency of prophylactic preoperative levosimendan administration in these patients.

METHODS: We studied 12 patients with heart failure and left ventricular ejection fraction <45% undergoing hip fracture repair. Levosimendan was administrated with an infusion rate of 0.1 μg/kg/min in a total dose of 12.5 mg in the 24 hours prior to surgery. Hemodynamic and tissue perfusion  parameters were obtained at baseline, 24 hours, 48 hours and 7 days after initiation of levosimendan.

RESULTS: 
Twelve patients (7 female and 5 male) were investigated. The mean ± standard deviation age was 86 ± 7 year, and the mean ejection fraction (EF) was 29 ± 5%. Patient´s characteristics are given in Table 1. 
The administration of levosimendan  caused a significant increment of the left ventricular ejection fraction (LVEF) from 36 ± 6 to 43 ± 15 % after 7 days (p 0,05), as well as aortic velocity time integral (VTI) from 16 ± 6 cm at baseline to 18 ± 7  cm after 7 days (p 0,03), cardiac index from 3 ± 0.6 l/min/m2 at baseline to 3.6 ± 0.7 l/min/m2 after 24 h and after 48h  3,7± 0.8   from increases in stroke volume index (baseline 35 ± 11 ml/m2, after 24 h 42  ± 9 ml/ m2, after 48 h 43  ± 8 ml/ m2 (P < 0.02). 
Mean arterial pressure decreased significantly from 86 ± 14 to 77 ± 13 mmHg in 48 h. Hemodynamic changes exerted by levosimendan persisted up to 48 h (P 0,016). Administration of norepinephrine was necessary in a dose of 0.05–0.3 µg/kg/min to prevent hypotension in 4 patients. Levosimendan significantly improved oxygen saturation in venous blood 60 ± 7 % at baseline  68 ± 8 % after 48 hours (P 0,01). NT-proBNP plasma concentrations decreased from 9253 ± 11864 pg/L to 7961 ± 10808 pg/L after 48 h (P 0.04). The course of patient´s haemodynamics is presented in Table 2. 
Severe adverse effects of levosimendan were not observed during the study.

CONCLUSION: In patients with heart failure, preoperative initiation of levosimedan  infusion improves perioperative haemodynamic parameters. These findings suggest that levosimendan could be an inotropic of great utility in preoperative  optimization of cardiac function in high-risk patients undergoing major surgery due to its mechanism of action and its substained hemodynamic after having finished its infusión.