Levosimendan was first approved for clinic use in 2000, when authorisation was granted by Swedish regulatory authorities for the haemodynamic stabilisation of patients with acutely decompensated chronic heart failure. In the ensuing 20 years, this distinctive inodilator, which enhances cardiac contractility through calcium sensitisation and promotes vasodilatation through the opening of adenosine triphosphate-dependent potassium channels on vascular smooth muscle cells, has been approved in more than 60 jurisdictions, including most of the countries of the European Union and Latin America. Areas of clinical application have expanded considerably and now include cardiogenic shock, takotsubo cardiomyopathy, advanced heart failure, right ventricular failure and pulmonary hypertension, cardiac surgery, critical care and emergency medicine. Levosimendan is currently in active clinical evaluation in the US. Levosimendan in IV formulation is being used as a research tool in the exploration of a wide range of cardiac and non-cardiac disease states. A levosimendan oral form is at present under evaluation in the management of amyotrophic lateral sclerosis. To mark the 20 years since the advent of levosimendan in clinical use, 51 experts from 23 European countries (Austria, Belgium, Croatia, Cyprus, Czech Republic, Estonia, Finland, France, Germany, Greece, Hungary, Italy, the Netherlands, Norway, Poland, Portugal, Russia, Slovenia, Spain, Sweden, Switzerland, UK and Ukraine) contributed to this essay, which evaluates one of the relatively few drugs to have been successfully introduced into the acute heart failure arena in recent times and charts a possible development trajectory for the next 20 years.

2nd Department of Cardiology Attikon University Hospital National and Kapodistrian University of Athens Athens Greece

Advanced Heart Failure and Transplantation Centre Department of Cardiology University Clinical Centre Ljubljana Slovenia

Anaesthesia and Intensive Care Division San Camillo Forlanini Hospital Rome Italy

Cardiology Department Centro Hospitalar Universitario Lisboa Norte CCUI Faculdade de Medicina Universidade de Lisboa Lisbon Portugal

Cardiothoracic Anaesthesiology and Intensive Care Department of Anaesthesiology and Intensive Care Medicine Institute for Clinical and Experimental Medicine Prague Czech Republic

Complexo Hospitalario Universitario A Coruña La Coruña Spain

Critical Care Proprietary Products Orion Pharma Espoo Finland

Department of Anaesthesiology and Critical Care Medicine AP HP Saint Louis and Lariboisière University Hospitals Paris France

Department of Anaesthesiology and Intensive Care Medicine Division of Anaesthesiology for Cardiovascular Surgery and Intensive Care Medicine Medical University of Graz Graz Austria

Department of Anaesthesiology and Intensive Care Medicine Medical University of Graz Graz Austria

Department of Anaesthesiology and Intensive Care Medicine University of Lübeck Lübeck Germany

Department of Anaesthesiology and Intensive Care Sahlgrenska University Hospital Gothenburg Sweden

Department of Anaesthesiology Perioperative Medicine and Intensive Care Masaryk Hospital J E Purkinje University Usti nad Labem Czech Republic

Department of Anaesthesiology Reanimatology and Intensive Care University Hospital Centre Zagreb Croatia

Department of Anaesthesiology University Hospital Ghent Belgium

Department of Cardiac Intensive Care Petrovskii National Research Centre of Surgery Sechenov University Moscow Russia

Department of Cardiology and Internal Medicine Nicolaus Copernicus University Torun Poland

Department of Cardiology Campus Virchow Klinikum Charité University Medicine Berlin Berlin Germany

Department of Cardiology Faculty of Medicine University of Debrecen Debrecen Hungary

Department of Cardiology Medical School University of Cyprus Nicosia Cyprus

Department of Cardiology Myokardiale Energetik und Metabolismus Research Unit Medical University of Graz Graz Austria

Department of Cardiology Niguarda Ca'Granda Hospital Milan Italy

Department of Cardiology North Estonia Medical Centre Tallinn Estonia

Department of Cardiology Oslo University Hospital Ullevaal Oslo Norway

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

Department of Clinical Sciences and Community Health Centro Cardiologico Monzino IRCCS Milan Italy

Department of Intensive Care Hôpital Erasme Brussels Belgium

Department of Intensive Care Medicine Amsterdam UMC Amsterdam the Netherlands

Department of Internal Medicine 3 Cardiology and Angiology Medical University of Innsbruck Innsbruck Austria

Department of Medicine Spittal Limmattal Schlieren Switzerland

Department of Surgery School of Medicine University of Santiago de Compostela Santiago de Compostela Spain

Departments of Cardiology and Transplantation Sahlgrenska University Hospital Gothenburg Sweden

Dipartimento di Anestesia e Terapie Intensive Azienda Ospedaliero Universitaria Pisana Pisa Italy

Emergency Cardiology Department National Scientific Centre MD Strazhesko Institute of Cardiology Kiev Ukraine

Emergency Medicine Meilahti Central University Hospital University of Helsinki Helsinki Finland

Global Medical Affairs R and D Orion Pharma Espoo Finland

Heart Diseases Institute Hospital Universitari de Bellvitge Barcelona Spain

Heart Failure and Transplant Program Cardiology Department University Hospital 12 Octubre Madrid Spain

Heart Failure Clinic São Francisco Xavier Hospital CHLO Lisbon Portugal

Institute of Anaesthesiology University Hospital of Zurich Zurich Switzerland

Institute of Medical Sciences Uppsala University Uppsala Sweden

Intensive Care Department Consorci Sanitari Integral University of Barcelona Barcelona Spain

Intensive Care Unit National Health Service Leeds UK

Klinik für Innere Medizin 3 Kardiologie Universitätsklinikum Schleswig Holstein Kiel Germany

Lomonosov Moscow State University Medical Centre Moscow Russia

Medizinische Klinik 2 Klinikum Weiden Teaching Hospital of University of Regensburg Weiden Germany

MTA SZTE Research Group of Cardiovascular Pharmacology Hungarian Academy of Sciences University of Szeged Szeged Hungary

Statistical Services R and D Orion Pharma Espoo Finland

Struttura Complessa di Anestesia 1 Policlinico di Modena Modena Italy

Sydäntutkimussäätiö Helsinki Finland

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