Guzman-Bofarull, JoanMartín-Centellas, AlbaCouto-Mallon, DavidBorràs, RogerArenas-Loriente, AndreaRivas-Lasarte, MercedesSegovia-Cubero, JavierCrespo-Leiro, María GGarcía-Álvarez, AnaFarrero, Marta2025-12-152025-12-152025-10Clin Transplant. 2025 Oct;39(10):e70327.https://hdl.handle.net/20.500.12105/27033Levosimendan, 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. 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, systemic vascular resistance <1000 dyn·s·cm, 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. 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. Pre-HT levosimendan use was not associated with increased early post-transplant complications and appears to be a safe strategy. 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.J.G.-B., D.C.-M., M.R.-L., J.S.-C., M.C.-L., and M.F. received funding from the Spanish Society of Cardiology (Heart Transplant Research Project Grant from the “Asociación de Insuficiencia Cardíaca”). J.G.- B. also received a research grant from the Fundación Alfonso Martín Escudero. Some of the authors of this study are members of the “Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)”, of the Carlos III Institute of Health of the Spanish Ministry of Science.engVoRhttp://creativecommons.org/licenses/by-nc-sa/4.0/heart transplantationlevosimendanprimary graft dysfunctionvasoplegiaAttribution-NonCommercial-ShareAlike 4.0 International41131777CLINICAL TRANSPLANTATIONopen access