Levosimendan or Milrinone for Ventricular Septal Defect Repair With Pulmonary Arterial Hypertension

J Cardiothorac Vasc Anesth. 2023 Jun;37(6):972-979. doi: 10.1053/j.jvca.2023.01.032. Epub 2023 Feb 6.


Objective: Both milrinone and levosimendan have been used in patients undergoing surgical closure of ventricular septal defects (VSD) with pulmonary artery hypertension (PAH); however, the evidence base for their use is limited. In the present study, the authors sought to compare the role of levosimendan and milrinone in the prevention of low-cardiac-output syndrome in the early postoperative period.

Design: A prospective, randomized, controlled trial.

Setting: At a tertiary-care center.

Participants: Children between 1 month and 12 years presenting with VSD and PAH between 2018 and 2020.

Interventions: A total of 132 patients were randomized into the following 2 groups: Group L (levosimendan group) and Group M (milrinone group).

Measurements and main results: In addition to conventional hemodynamic parameters, the authors also included a myocardial performance index assessment to compare the groups. The levosimendan group had significantly lower mean arterial pressure while coming off cardiopulmonary bypass, after shifting to intensive therapy unit, as well as at 3 and 6 hours postoperatively. The duration of ventilation (29.6 ± 13.9 hours v 23.2 ± 13.3 hours; p = 0.012), as well as postoperative intensive care unit stay, were significantly prolonged in the levosimendan group (5.48 ± 1.2 v 4.7 ± 1.3 days, p = 0.003). There were 2 (1.6%) in-hospital deaths in the entire cohort, 1 in each arm. There was no difference in the myocardial performance index of the left or right ventricle.

Conclusions: In patients undergoing surgical repair for VSD with PAH, levosimendan does not confer any additional benefit compared to milrinone. Both milrinone and levosimendan appear to be safe in this cohort.

Keywords: Congenital heart surgery; Postoperative care; Pulmonary vascular resistance/hypertension; Ventricular septal defect.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Cardiotonic Agents / therapeutic use
  • Child
  • Heart Septal Defects, Ventricular* / surgery
  • Heart Ventricles
  • Humans
  • Hydrazones / therapeutic use
  • Milrinone / therapeutic use
  • Prospective Studies
  • Pulmonary Arterial Hypertension* / drug therapy
  • Pyridazines* / therapeutic use
  • Simendan


  • Simendan
  • Milrinone
  • Cardiotonic Agents
  • Hydrazones
  • Pyridazines