Hydropic decompensation with hyponatraemia in patients awaiting cardiac transplantation – effect of the calcium sensitizer levosimendan

Introduction: Hydropic decompensation in chronic heart failure patients (pts) associated with severe hyponatraemia due to chronic use of high doses of loop diuretics is a special therapeutic challenge. The aim of this case series was to evaluate the hemodynamics and renal effects of levosimendan in this setting.

Methods: Eight pts with a mean ejection fraction of 14±9% were included in the analysis. Mean cardiac output (CO) was 2,9±0,8l/min and the mean pulmonary wedge pressure (PCW) was 27±9mmHg. At time of decompensation all pts were on standard medical and high doses of loop diuretics (furosemide 340±45mg/d or torasemide 112±47mg/d, besides aldosterone antagonist 25mg (6/8 pts), and xipamide (in 4/8 pts) and presented with fluid retention, renal dysfunction (creatinine 2,4±0,5mg/dl) and severe hyponatraemia (126±12mmol/l). Levosimendan was administered 12,5mg/24 hours to all pts.

Results: Hemodynamics improved substantially with a mean increase in CO (1,9±0,7l/min) and a mean decrease in PCW (6±3mmHg). Additionally all pts developed spontaneous diuresis, with a urine output of 2,2 to 5,5l during the 24-hour levosimendan infusion. Within 4 days after the infusion, the serum sodium increased to >130mmol/l in all pts, the mean increase was 6±4mmol/l. The creatinine concentration fell to a mean of 1,8mg/dl.

Conclusion: In difficult clinical settings of chronic low output syndrome and acute hydropic decompensation in pts on high chronic doses of loop diuretics, an infusion of levosimendan, 12,5mg/24 hours not only improves hemodynamics but also demonstrates beneficial effects on renal function and sodium homeostasis, potentially delaying high urgent listing of cardiac transplantation candidates.