BACKGROUND: The intravenous inodilator levosimendan was developed for the treatment of patients with acutely decompensated heart failure. In the last decade scientific and clinical interest has arisen for its repetitive or intermittent use in patients with advanced chronic, but not necessarily acutely decompensated, heart failure. Recent studies have suggested long-lasting favourable effects of levosimendan when administered repetitively, in terms of haemodynamic parameters, neurohormonal and inflammatory markers, and clinical outcomes. The existing data, however, requires further exploration to allow for definitive conclusions on the safety and clinical efficacy of repetitive use of levosimendan. METHODS AND RESULTS: A panel of 30 experts from 15 countries convened to review and discuss the existing data, and agreed on the patient groups that can be considered to potentially benefit from intermittent treatment with levosimendan. The panel gave recommendations regarding patient dosing and monitoring, derived from the available evidence and from clinical experience. CONCLUSIONS: The current data suggest that in selected patients and support out-of-hospital care, intermittent/repetitive levosimendan can be used in advanced heart failure to maintain patient stability. Further studies are needed to focus on morbidity and mortality outcomes, dosing intervals, and patient monitoring. Recommendations for the design of further clinical studies are made.

'A De Gasperis' Cardiac Failure and Transplantology Department Niguarda Ca'Granda Hospital Milan Milan Italy

2nd Cardiology Department and Heart Failure Unit Attikon Teaching Hospital Athens Greece

Cardiology Clinic of the Gennimatas General Hospital of Athens Athens Greece

Cardiology Department AHEPA University Hospital Thessaloniki Greece

Cardiology Department of Experimental and Applied Medicine University of Brescia Brescia Italy

Cardiology Institute of Medical Sciences Uppsala University Uppsala Sweden

Clinical Department of Cardiology University Clinical Centre Ljubljana Ljubljana Slovenia

Department of Cardiology Hospital Universitario de Canarias San Cristóbal de La Laguna Sta Cruz de Tenerife Spain

Department of Cardiovascular Respiratory Nephrology and Geriatric Sciences 'La Sapienza' University of Rome Rome Italy

Department of Cardiovascular Science University of Insubria Circolo Hospital and Macchi Foundation Varese Italy

Department of Internal Medicine 3 University of Innsbruck Austria

Emergency Cardiology Services Cardiac Intensive Care Unit Beilinson Hospital Rabin Medical Center Petah Tikva Israel

Heart Center Kuopio University Hospital Kuopio Finland

Heart Failure Program Cardiology Department Hospital del Mar Barcelona Spain

Heart Failure Unit and Heart Transplant Clinic Rabin Medical Center Petah Tikva Israel

Heart Failure Unit Hospital S Francisco Xavier CHLO Faculdade de Ciências Médicas Universidade Nova de Lisboa Lisbon Portugal;

Helsinki University Hospital Helsinki Finland

Institut klinické a experimentální medicíny klinika kardiologie IKEM oddělení akutní kardiologie KK IKEM Vídeňská Prague Czech Republic

Institute of Cardiology Medical and Health Center University of Debrecen Debrecen Hungary

LK Krems Abteilung für Innere Medizin mit kardiologischem Schwerpunkt Krems Austria

Medizinische Klinik 2 Klinikum Weiden Akademisches Lehrkrankenhaus der Universität Regensburg Germany

Orion Pharma Espoo Finland

Pensionsversicherungsanstalt SKA RZ Großgmain für Herz Kreislauf und neurologische Erkrankungen Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversitaet Großgmain Austria

Scientific Centre of Cardiovascular Surgery of Bakulev Moscow Russia

Stavanger University Hospital University of Bergen Stavanger Norway

Strazhesko Institute of Cardiology National Scientific Centre Kiev Ukraine

Unfallkrankenhaus Berlin Klinik für Innere Medizin Berlin Germany

Unidad de Insuficiencia Cardiaca Trasplante e Hipertensión Pulmonar So Cardiología Hospital Univ Puerta de Hierro Madrid Spain

Unit of Cardiology Department of Medicine Karolinska Institutet Stockholm Sweden

References provided by Crossref.org

Levosimendan Efficacy and Safety: 20 Years of SIMDAX in Clinical Use

Levosimendan Efficacy and Safety: 20 years of SIMDAX in Clinical Use