Impact of Pre‐Heart Transplant Levosimendan Administration on Post‐Transplant Vasoplegia and Primary Graft Dysfunction

ABSTRACT Introduction Levosimendan, a calcium‐sensitizing inotropic agent, is used in patients with advanced heart failure (HF) awaiting heart transplantation (HT). Its prolonged effects, due to an active metabolite, may influence post‐transplant vasodilation, particularly when administered shortly before HT. However, its impact on post‐HT complications such as vasoplegia and primary graft dysfunction (PGD) remains unclear. This study aimed to evaluate whether preoperative levosimendan affects these outcomes. Methods This retrospective, multicenter observational study included adult HT recipients from 2010 to 2022 across three Spanish centers. Patients were grouped based on whether they received levosimendan within 1 month prior to HT. Main outcomes were post‐HT vasoplegia (defined as cardiac index ≥2.5 L/min/m 2 , systemic vascular resistance <1000 dyn·s·cm −5 , and either a vasoactive‐inotropic score (VIS) > 20 or norepinephrine administration >0.1 µg/kg/min at 24 h post‐HT) and severe PGD, as defined by the 2014 ISHLT criteria. Secondary outcomes included all‐cause mortality. Subgroup analyses were performed for patients receiving levosimendan within 1 week of HT and by sex. Statistical analyses included propensity score (PS) matching, Kaplan–Meier curves, and multivariate Cox regression models. Results Among 598 HT recipients, 94 (15.7%) received levosimendan preoperatively. After PS adjustment, no significant differences were found in the incidence of vasoplegia (40.0% vs. 39.2%, OR 0.99, p  = 0.98) or severe PGD (10.6% vs. 10.3%, OR 1.25, p  = 0.63) between groups. Post‐HT mortality was also not different (HR 0.78, p  = 0.37). Vasoplegia did not affect mortality, while severe PGD was linked to higher mortality. Subgroup and sex‐based analyses revealed no significant outcome differences. Conclusions Pre‐HT levosimendan use was not associated with increased early post‐transplant complications and appears to be a safe strategy. Summary This study evaluated whether giving levosimendan before HT affects early post‐transplant complications. Among 598 patients, 94 received levosimendan within a month before surgery. Results showed no significant differences in rates of vasoplegia, severe primary graft dysfunction, or mortality. Levosimendan use appears safe in the immediate pre‐transplant setting.