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Wang X, Zhao X, Wang X, Cao L, Lu B, Wang Z, Zhang W, Ti Y, Zhong M. Effect of levosimendan on ventricular remodelling in patients with left ventricular systolic dysfunction: a meta-analysis. ESC Heart Fail 2024; 11:1352-1376. [PMID: 38419326 PMCID: PMC11098670 DOI: 10.1002/ehf2.14714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 03/02/2024] Open
Abstract
Heart failure is the final stage of several cardiovascular diseases, and the key to effectively treating heart failure is to reverse or delay ventricular remodelling. Levosimendan is a novel inotropic and vasodilator agent used in heart failure, whereas the impact of levosimendan on ventricular remodelling is still unclear. This study aims to investigate the impact of levosimendan on ventricular remodelling in patients with left ventricular systolic dysfunction. Electronic databases were searched to identify eligible studies. A total of 66 randomized controlled trials involving 7968 patients were included. Meta-analysis results showed that levosimendan increased left ventricular ejection fraction [mean difference (MD) = 3.62, 95% confidence interval (CI) (2.88, 4.35), P < 0.00001] and stroke volume [MD = 6.59, 95% CI (3.22, 9.96), P = 0.0001] and significantly reduced left ventricular end-systolic volume [standard mean difference (SMD) = -0.52, 95% CI (-0.67, -0.37), P < 0.00001], left ventricular end-diastolic volume index [SMD = -1.24, 95% CI (-1.61, -0.86), P < 0.00001], and left ventricular end-systolic volume index [SMD = -1.06, 95% CI (-1.43, -0.70), P < 0.00001]. In terms of biomarkers, levosimendan significantly reduced the level of brain natriuretic peptide [SMD = -1.08, 95% CI (-1.60, -0.56), P < 0.0001], N-terminal pro-brain natriuretic peptide [SMD = -0.99, 95% CI (-1.41, -0.56), P < 0.00001], and interleukin-6 [SMD = -0.61, 95% CI (-0.86, -0.35), P < 0.00001]. Meanwhile, levosimendan may increase the incidence of hypotension [risk ratio (RR) = 1.24, 95% CI (1.12, 1.39), P < 0.0001], hypokalaemia [RR = 1.57, 95% CI (1.08, 2.28), P = 0.02], headache [RR = 1.89, 95% CI (1.50, 2.39), P < 0.00001], atrial fibrillation [RR = 1.31, 95% CI (1.12, 1.52), P = 0.0005], and premature ventricular complexes [RR = 1.86, 95% CI (1.27, 2.72), P = 0.001]. In addition, levosimendan reduced all-cause mortality [RR = 0.83, 95% CI (0.74, 0.94), P = 0.002]. In conclusion, our study found that levosimendan might reverse ventricular remodelling when applied in patients with left ventricular systolic dysfunction, especially in patients undergoing cardiac surgery, decompensated heart failure, and septic shock.
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Affiliation(s)
- Xia Wang
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Xiu‐Zhi Zhao
- Department of CardiologyPeople's Hospital of Lixia District of JinanJinanShandongChina
| | - Xi‐Wen Wang
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Lu‐Ying Cao
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Bin Lu
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Zhi‐Hao Wang
- Department of Geriatric MedicineShandong Key Laboratory of Cardiovascular Proteomics, Qilu Hospital, Cheeloo College of Medicine, Shandong UniversityJinanChina
| | - Wei Zhang
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Yun Ti
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
| | - Ming Zhong
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of CardiologyQilu Hospital of Shandong UniversityChina
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Wang D, Song M, Shen LF, Han L, Zhu P, Jia X, Shang GK, Cao Y, Zhang W, Zhong M, Wang ZH. Exercise Capacity Is Improved by Levosimendan in Heart Failure and Sarcopenia via Alleviation of Apoptosis of Skeletal Muscle. Front Physiol 2022; 12:786895. [PMID: 35126176 PMCID: PMC8811365 DOI: 10.3389/fphys.2021.786895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background Patients suffering from chronic heart failure (CHF) show an increased prevalence of sarcopenia. Levosimendan is an effective drug for the treatment of heart failure, but its effect on sarcopenia is still unclear. We aimed to explore whether levosimendan could enhance skeletal muscle contractibility, improve skeletal muscle atrophy, and thus improve exercise tolerance of individuals with heart failure. Methods C57BL6/J mice were used to establish the heart failure with sarcopenia model and injected of levosimendan. Mice were separated into control group, sham operation group, HF group, HF + solvent group, HF + levosimendan group, HF + sarcopenia group, HF + sarcopenia + solvent group, HF + sarcopenia + levosimendan group (n = 5–12). After the treatment, exercise capacity and cardiac function were evaluated. Muscle morphology, inflammation level and apoptosis levels were detected, in which mitochondrial function and oxidative stress level were also assessed. Result Levosimendan could increase forelimb grip strength/body weight, hanging impulse, maximum running distance and time in mice with HF and sarcopenia (P < 0.0001 for all), and these improvements were independent of EF (P = 0.0019 for hanging impulse, P < 0.001 for forelimb grip strength/body weight and maximum running distance). Levosimendan directly increased the CSA of gastrocnemius in mice with HF and sarcopenia (P < 0.0001). After levosimendan injection, the proportion of slow muscle fibers increased (P < 0.0001), but this improvement of muscle fiber typing might be attributed to improved cardiac function (P > 0.05). Levosimendan also maintained mitochondrial membrane potential, decreased cleaved caspase-3 (P = 0.034), cleaved caspase-9 (P < 0.0001), Bax expression (P < 0.0001), and increased Bcl2 expression (P = 0.0036). This effect is independent of improved cardiac function (P = 0.028 for bax, P < 0.001 for cleaved caspase-9 and Bcl2). IL-6, TNF-α expression (P < 0.0001 for both) decreased, and SOD activity (P = 0.0038), GSH/GSSG ratio (P = 0.002) significantly increased in skeletal muscle after injection of levosimendan. The improvement in oxidative stress level was attributed to improved cardiac function (P > 0.05). Conclusion Levosimendan reduce the loss of skeletal muscle mitochondrial membrane potential, decrease the apoptosis, alleviate the inflammation and oxidative stress, and ultimately improve the exercise capacity of mice with heart failure and sarcopenia. Therefore, levosimendan may be a potential drug for the treatment of heart failure with sarcopenia.
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Affiliation(s)
- Di Wang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Chinese National Health Commission and Chinese Academy of Medical Sciences, Jinan, China
| | - Ming Song
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Chinese National Health Commission and Chinese Academy of Medical Sciences, Jinan, China
| | - Long-fei Shen
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Chinese National Health Commission and Chinese Academy of Medical Sciences, Jinan, China
| | - Lu Han
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Chinese National Health Commission and Chinese Academy of Medical Sciences, Jinan, China
- Department of General Practice, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ping Zhu
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Chinese National Health Commission and Chinese Academy of Medical Sciences, Jinan, China
| | - Xu Jia
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Chinese National Health Commission and Chinese Academy of Medical Sciences, Jinan, China
| | - Guo-kai Shang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Chinese National Health Commission and Chinese Academy of Medical Sciences, Jinan, China
| | - Yuan Cao
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Chinese National Health Commission and Chinese Academy of Medical Sciences, Jinan, China
| | - Wei Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Chinese National Health Commission and Chinese Academy of Medical Sciences, Jinan, China
| | - Ming Zhong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Chinese National Health Commission and Chinese Academy of Medical Sciences, Jinan, China
| | - Zhi-hao Wang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Chinese National Health Commission and Chinese Academy of Medical Sciences, Jinan, China
- Department of Geriatric Medicine, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Jinan, China
- *Correspondence: Zhi-hao Wang,
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Long YX, Cui DY, Kuang X, Hu S, Hu Y, Liu ZZ. Effect of Levosimendan on Ventricular Systolic and Diastolic Functions in Heart Failure Patients: A Meta-Analysis of Randomized Controlled Trials. J Cardiovasc Pharmacol 2021; 77:805-813. [PMID: 34001722 DOI: 10.1097/fjc.0000000000001010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/15/2021] [Indexed: 12/20/2022]
Abstract
ABSTRACT Levosimendan, a calcium sensitizer, exerts inotropic action through improving left ventricular ejection fraction. We noticed that only few clinical studies are published in which the effects of levosimendan on cardiac function are studied by echocardiography. When screening the literature (PubMed, Embase, and CENTRAL, from inception to August 2020), we found 29 randomized controlled trials on levosimendan containing echocardiographic data. We included those studies, describing a total of 574 heart failure patients, in our meta-analysis and extracted 14 ultrasonic parameters, pooling the effect estimates using a random-effect model. Our analysis of the diastolic parameters of the left ventricle shows that levosimendan reduce the early/late transmitral diastolic peak flow velocity ratio [standardized mean difference (SMD) -0.45 to 95% confidence interval (CI) (-0.87 to -0.03), P = 0.037] and E/e' (e': mitral annulus peak early diastolic wave velocity using tissue-doppler imaging) [SMD -0.59, 95% CI (-0.8 to -0.39), P < 0.001]. As it regards the systolic parameters of the right ventricle, levosimendan increased tricuspid annular plane systolic excursion [SMD 0.62, 95% CI (0.28 to 0.95), P < 0.001] and tricuspid annular peak systolic velocity [SMD 0.75, 95% CI (0.35 to 1.16), P < 0.001], and reduced systolic pulmonary artery pressure [SMD -1.02, 95% CI (-1.32, -0.73), P < 0.001]. As it regards the diastolic parameters of the right ventricle, levosimendan was associated with the decrease of Aa (peak late diastolic tricuspid annular velocity using tissue-doppler imaging) [SMD -0.38, 95% CI (-0.76 to 0), P = 0.047] and increase of Ea (peak early diastolic tricuspid annular velocity using tissue-doppler imaging) [SMD 1.03, 95% CI (0.63 to 1.42), P < 0.001] and Ea/Aa [SMD 0.86, 95% CI (0.18 to 1.54), P = 0.013]. We show that levosimendan is associated with an amelioration in the diastolic and systolic functions of both ventricles in heart failure patients.
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Affiliation(s)
- Yu-Xiang Long
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Cameli M, Incampo E, Navarri R, Mandoli GE, Sciaccaluga C, Righini FM, Palmerini E, Sisti N, Mondillo S, Lunghetti S. Effects of levosimendan in heart failure: The role of echocardiography. Echocardiography 2019; 36:1566-1572. [DOI: 10.1111/echo.14419] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/01/2019] [Accepted: 06/06/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
- Matteo Cameli
- Department of Cardiovascular Diseases University of Siena Siena Italy
| | - Eufemia Incampo
- Department of Cardiovascular Diseases University of Siena Siena Italy
| | - Romina Navarri
- Department of Cardiovascular Diseases University of Siena Siena Italy
| | | | | | | | | | - Nicolò Sisti
- Department of Cardiovascular Diseases University of Siena Siena Italy
| | - Sergio Mondillo
- Department of Cardiovascular Diseases University of Siena Siena Italy
| | - Stefano Lunghetti
- Department of Cardiovascular Diseases University of Siena Siena Italy
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Cornejo-Avendaño J, Azpiri-López J, Ramírez-Rosales A. Levosimendan in acute decompensated heart failure: Systematic review and meta-analysis. MEDICINA UNIVERSITARIA 2017. [DOI: 10.1016/j.rmu.2017.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Levosimendan beyond inotropy and acute heart failure: Evidence of pleiotropic effects on the heart and other organs: An expert panel position paper. Int J Cardiol 2016; 222:303-312. [PMID: 27498374 DOI: 10.1016/j.ijcard.2016.07.202] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/28/2016] [Indexed: 02/04/2023]
Abstract
Levosimendan is a positive inotrope with vasodilating properties (inodilator) indicated for decompensated heart failure (HF) patients with low cardiac output. Accumulated evidence supports several pleiotropic effects of levosimendan beyond inotropy, the heart and decompensated HF. Those effects are not readily explained by cardiac function enhancement and seem to be related to additional properties of the drug such as anti-inflammatory, anti-oxidative and anti-apoptotic ones. Mechanistic and proof-of-concept studies are still required to clarify the underlying mechanisms involved, while properly designed clinical trials are warranted to translate preclinical or early-phase clinical data into more robust clinical evidence. The present position paper, derived by a panel of 35 experts in the field of cardiology, cardiac anesthesiology, intensive care medicine, cardiac physiology, and cardiovascular pharmacology from 22 European countries, compiles the existing evidence on the pleiotropic effects of levosimendan, identifies potential novel areas of clinical application and defines the corresponding gaps in evidence and the required research efforts to address those gaps.
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Tasal A, Demir M, Kanadasi M, Bacaksiz A, Vatankulu MA, Sahin DY, Eker RA, Bozkurt A, Acarturk E. Comparison of single-dose and repeated levosimendan infusion in patients with acute exacerbation of advanced heart failure. Med Sci Monit 2014; 20:276-82. [PMID: 24549281 PMCID: PMC3937020 DOI: 10.12659/msm.889767] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 11/08/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Levosimendan (LS) is a novel inodilator that improves cardiac performance, central hemodynamics, and symptoms of patients with decompensated chronic heart failure. The aim of this study was to compare the effects of single and repeated LS infusion on left ventricular performance, biomarkers, and neurohormonal activation in patients with acute heart failure. MATERIAL AND METHODS Twenty-nine consecutive patients with acute exacerbation of advanced heart failure were included in this study. LS was initiated as a bolus of 6 μg/kg followed by a continuous infusion of 0.1 μg/kg/min for 24 hours in both groups who received intravenous single and repeated (baseline and at 1 and 3 months) treatment. Physical examination, echocardiography, and biochemical tests (brain natriuretic peptide, tumour necrosis factor-alpha, interleukin-1beta, 2, and 6) were performed before treatment and on 3 day of the treatment. The last evaluation was performed at 6 month after the baseline treatment. RESULTS Twenty male and 9 female patients with mean age of 60.2 ± 7.4 years were included in this study. A significant improvement in New York Heart Association functional status and myocardial performance index was detected only in the repeated LS treated patients at 6 month compared to the pretreatment status (p=0.03 and p<0.001; respectively). In addition, a significant decrease in brain natriuretic peptide (p<0.01) and plasma interleukin-6 (p=0.05) levels were also achieved only in patients who were given repeated LS. CONCLUSIONS Our study showed that repeated LS treatment is more effective compared to the single dose LS treatment in improving clinical status, hemodynamic and laboratory parameters in patients with acute exacerbation of advanced heart failure.
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Affiliation(s)
- Abdurrahman Tasal
- Department of Cardiology, Bezmialem Vakif University, Istanbul, Turkey
| | - Mesut Demir
- Department of Cardiology, Cukurova University, Adana, Turkey
| | - Mehmet Kanadasi
- Department of Cardiology, Cukurova University, Adana, Turkey
| | - Ahmet Bacaksiz
- Department of Cardiology, Bezmialem Vakif University, Istanbul, Turkey
| | | | - Durmus Yıldıray Sahin
- Department of Cardiology, Adana Numune Education and Research Hospital, Adana, Turkey
| | | | - Abdi Bozkurt
- Department of Cardiology, Cukurova University, Adana, Turkey
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Jalanko M, Kivikko M, Harjola VP, Nieminen MS, Laine M. Oral levosimendan improves filling pressure and systolic function during long-term treatment. SCAND CARDIOVASC J 2011; 45:91-7. [DOI: 10.3109/14017431.2011.557779] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Heart failure is a relatively important public health problem due to its increasing incidence, poor prognosis, and frequent need of re-hospitalization. Intravenous positive inotropic agents play an important role in treating acute decompensation of patients with heart failure due to left ventricular systolic dysfunction. Although frequently used, the inotropic agents β-adrenergic agonists and phosphodiesterase inhibitors seem effective for improving symptoms in the short term; it has been shown that they increase morbidity and mortality by elevating intracellular cyclic adenosine monophosphate (cAMP) and calcium levels. Levosimendan is a new positive inotropic agent having ATP-dependent potassium-channel-opening and calcium-sensitizing effects. In studies on its effects without increasing intracellular calcium concentrations and on its effects that depend on available intracellular calcium levels, it has been shown to have favorable characteristics different from those of current inotropic agents, which exert their effects by increasing calcium concentrations. This study aims to review other important studies about levosimendan by revealing the underlying mechanisms of its activity, efficiency, and safety.
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Kasikcioglu HA, Uyarel H, Tartan Z, Kasikcioglu E, Ozturk R, Cam N. Do calcium sensitizers affect right ventricular functions in patients with chronic heart failure? Int J Cardiol 2006; 118:246-8. [PMID: 17011057 DOI: 10.1016/j.ijcard.2006.06.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2006] [Accepted: 06/19/2006] [Indexed: 10/24/2022]
Abstract
Calcium sensitizers also improve cardiac function by increasing the contraction of the myocardium without significantly increasing intracellular calcium levels. Although right ventricular function is an important role for better cardiac global function, there is no study about effects of levosimendan on right ventricular function measured by tissue Doppler imaging. The aim of the present study was to evaluate changes of myocardial properties in patients with idiopathic dilated cardiomyopathy using tissue Doppler imaging after levosimendan infusion. This tissue Doppler study shows that levosimendan also affects myocardial especially systolic waves of right ventricle and those of left ventricle.
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