Letter to the Editor Perioperative levosimendan therapy is not associated with lower mortality in patients undergoing cardiac surgery Michael Spartalis a, ⁎, Eleni Tzatzaki a , Dimitrios Dimitroulis b , Eleftherios Spartalis c a Division of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece b 2nd Department of Propedeutic Surgery, University of Athens Medical School, Athens, Greece c Laboratory of Experimental Surgery and Surgical Research, University of Athens, Medical School, Athens, Greece article info Article history: Received 24 October 2017 Received in revised form 26 December 2017 Accepted 8 January 2018 Keywords: Levosimendan Cardiac surgery Mortality Perioperative Infusion Dear Editor, We read with great interest the article by Putzu et al. [1]. The authors present a meta-analysis to assess benefits and harms of perioperative levosimendan therapy in cardiac surgery and conclude that there is not high-quality evidence to discourage the systematic use of levosimendan [1]. Recent studies though demonstrate with consistent effects that peri- operative administration of levosimendan does not affect overall short- and long-term outcome in patients undergoing cardiac surgery [2–5]. Mehta et al. compared the administration of levosimendan in pa- tients with ejection fraction ≤35% who were undergoing cardiac surgery with placebo [2]. Levosimendan did not result in a significant difference in the composite endpoint of death [2]. These results were recently verified by Cholley et al. in a randomized multicenter trial [3]. Landoni et al. investigated patients after cardiac surgery and reported that levosimendan in addition to standard care did not result in lower 30-day mortality than placebo [4]. A recent meta-analysis by Chen et al. also resulted that in patients undergoing cardiac surgery, the benefit of levosimendan regarding survival was not shown in multi- center or high-quality trials [5]. The meta-analysis by Putzu et al. is based on studies, which are char- acterized by great variety and heterogeneity in the treatments delivered to patients, the lack of a standardized drug administration, and possible inappropriate comparisons between the use of levosimendan versus placebo or other drugs. At present, large trials do not support the use of levosimendan ther- apy as a prophylactic or therapeutic treatment in patients undergoing cardiac surgery, as levosimendan showed no beneficial effect. Conflict of interest None declared. References [1] A. Putzu, S. Clivio, A. Belletti, T. Cassina, Perioperative levosimendan in cardiac surgery: a systematic review with meta-analysis and trial sequential analysis, Int. J. Cardiol. (2017). https://doi.org/10.1016/j.ijcard.2017.10.077. [2] R.H. Mehta, J.D. Leimberger, S. van Diepen, J. Meza, A. Wang, R. Jankowich, et al., Levosimendan in patients with left ventricular dysfunction undergoing cardiac sur- gery, N. Engl. J. Med. 376 (2017) 2032–2042. [3] B. Cholley, T. Caruba, S. Grosjean, J.Amour, A. Ouattara, J. Villacorta, et al., Effect of levosimendan on low cardiac output syndrome in patients with low ejection fraction undergoing coronary artery bypass grafting with cardiopulmonary bypass: the LICORN randomized clinical trial, JAMA 318 (2017) 548–556. [4] G. Landoni, V.V. Lomivorotov, G. Alvaro, R. Lobreglio, A. Pisano, F. Guarracino, et al., Levosimendan for hemodynamic support after cardiac surgery, N. Engl. J. Med. 376 (2017) 2021–2031. [5] Q.H. Chen, R.Q. Zheng, H. Lin, J. Shao, J.Q. Yu, H.L. Wang, Effect of levosimendan on prognosis in adult patients undergoing cardiac surgery: a meta-analysis of random- ized controlled trials, Crit. Care 21 (253) (2017). International Journal of Cardiology 260 (2018) 51 DOI of original article: https://doi.org/10.1016/j.ijcard.2017.10.077. ⁎ Corresponding author at: 356 Syggrou Ave, Athens 176 74, Greece. E-mail address: msparta@med.uoa.gr (M. Spartalis). https://doi.org/10.1016/j.ijcard.2018.01.040 0167-5273/© 2018 Elsevier B.V. All rights reserved. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard