Repeated levosimendan administration guided by invasive hemodynamic assessment in postcardiotomy cardiogenic shock after off-pump coronary artery bypass grafting: a case report

Postcardiotomy cardiogenic shock is a life-threatening complication after coronary artery bypass grafting (CABG), especially in patients with severely impaired left ventricular systolic function. Management remains challenging, and criteria for repeated levosimendan administration in this setting are not well defined. We report the case of a 74-year-old man with ischemic cardiomyopathy and severely reduced preoperative left ventricular ejection fraction who underwent preoperative levosimendan optimization followed by off-pump CABG. Despite initial improvement, the patient developed postcardiotomy cardiogenic shock in the early postoperative period with progressive hypoperfusion, lactate elevation, worsening ventricular dysfunction, and a low cardiac index confirmed by Swan-Ganz catheterization. Intra-aortic balloon pump support was initiated in the early postoperative period, and norepinephrine was the only vasoactive agent used before repeated levosimendan administration. Because of persistent low-output physiology, invasive hemodynamic findings, and a previously favorable response to levosimendan, repeated levosimendan infusion was administered. Subsequent reassessment showed improvement in cardiac index, filling pressures, vascular resistance, ventricular function, and biochemical markers of hypoperfusion and organ dysfunction. This case illustrates that repeated levosimendan administration, guided by invasive hemodynamic assessment, was associated with hemodynamic improvement in postcardiotomy cardiogenic shock after CABG. These findings are hypothesis-generating and should be interpreted with caution. Further prospective studies are required to define patient selection criteria, optimal timing, and the role of repeated levosimendan administration in this setting.