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OBJECTIVE To review the literature on a novel calcium sensitizer, levosimendan. DATA SOURCES Articles were identified through searches of MEDLINE (1966–June 2005), International Pharmaceutical Abstracts (1970–June 2005), and EMBASE (1992–June 2005) using the key words levosimendan, simendan, calcium sensitizer, calcium sensitiser, and congestive heart failure. STUDY SELECTION AND DATA EXTRACTION Clinical trials and pharmacokinetic studies evaluating the safety and efficacy of levosimendan were selected. DATA SYNTHESIS Levosimendan 6–24 μg/kg intravenous bolus followed by a 24-hour continuous infusion of 0.05—0.2 μg/kg/min improved cardiac output and reduced pulmonary capillary wedge pressure in a dose-dependent manner. Dose-ranging and randomized clinical trials have demonstrated improvement in symptoms and hemodynamics and short-term survival outcomes in the treatment of acute, decompensated heart failure. Clinical trials evaluating retrospective mortality data and combined endpoints (mortality, rehospitalization) have demonstrated better outcomes with levosimendan compared with dobutamine. The incidence of hypotension with levosimendan is not significantly different than with dobutamine, but there is a dose-related increase in heart rate. CONCLUSIONS Levosimendan is useful in moderate to severe low-output heart failure in patients who have failed to respond to diuretics and vasodilators. Based on current studies, levosimendan appears to be a safe alternative to dobutamine for treatment of acute, decompensated heart failure. Prospective clinical trials are needed to confirm the effect of levosimendan on long-term survival and its role in heart failure in the setting of myocardial infarction.

Background Despite the high number of admissions for acute decompensated heart failure (ADHF), there are no specific criteria for discharge readiness. A number of patients have implantable devices that might provide data to assist in determining readiness for discharge. Methods and Results The 3D-HF (Diagnostic Data for Discharge in Heart Failure Patients) study was a prospective observational pilot study enrolling HF patients with Optivol-capable cardiac devices within 48 hours of a hospital admission characterized by worsening HF symptoms. The primary end point was the difference in times from admission to 50% improvement in impedance and to when patient was medically ready for discharge. The nonparametric sign test was used to determine if the difference was significant. A total of 20 subjects were enrolled over a 24-month period. The median ADHF length of stay was 7 days. Of the 20 subjects, 18 achieved the intrathoracic impedance improvement threshold before discharge. The time to reach the threshold for improvement was 2.5 days (interquartile range 2.0–6.0). The difference between days to 50% impedance and days to provider’s discharge decision was 3.0 ( P = .0072). Conclusions Intrathoracic impedance changes were evident over a short duration in the majority of patients admitted for ADHF and may be a potential criterion for discharge readiness.

Introduction Strongyloides is a helminthic intestinal parasite that is common in tropical regions. In immunosuppressed individuals it may cause a hyperinfection syndrome with fatal complications. We present one such case. Case Report A 60 year old Hispanic male presents 2 months after heart transplantation (HT) with fatigue. His post transplant course was complicated by recurrent rejection requiring intravenous steroids. His immunosuppression included tacrolimus, mycophenolate mofetil and prednisone. On presentation, he underwent endomyocardial biopsy which demonstrated 1R rejection. Echocardiography revealed normal allograft function. He developed respiratory distress requiring intubation, followed by profound hypotension necessitating vasopressor and broad spectrum antimicrobial support. Due to difficulty with oxygenation, he underwent urgent bronchoscopy. Over the next 72 hours, he became increasingly unstable. On hospital day 4, Papanicolaou staining identified Strongyloides in the bronchoalveolar lavage specimen. [ figure 1 ] Ivermectin 200mg was initiated and on hospital day 7 with the patient continuing to do poorly, albendazole was added. This resulted in improvement in his hemodynamic and respiratory status, however, his mental status failed to recover. Lumbar puncture revealed Strongyloides in the cerebro-spinal fluid. On hospital day 26 life sustaining support was withdrawn and the patient passed away. Summary Atypical symptoms and rapid deterioration in HT patients without a clear cause should prompt an early investigation for strongyloides. Screening of high risk populations, such as those from endemic areas, of both potential donors and recipients should be discussed as pre-treatment may prevent catastrophic complications.