 Livosumandan has been used in Europe for over 15 years in patients with acute heart failure and when inotropic support is needed. The drug makes heart muscles more sensitive to calcium, allowing them to contract without the need for increased intracellular calcium and oxygen consumption, and also opens potassium channels inducing vasodilation. Because of these effects, Livosumandan is considered helpful for patients undergoing cardiac surgery. Over 40 clinical trials have studied the drug in perioperative settings, and meta-analyses have suggested an overall beneficial outcome, particularly in patients with low ejection fraction. But recently, three large multi-center studies were neutral or inconclusive. To understand these conflicting results, a group of experts from eight European countries, including investigators from each of the three trials, meant to discuss the discrepancies. The group reviewed each of the trials and searched for subgroup differences. In the recent trials, there were some promising signs. In the Lycorne study for instance, patients treated with Livosumandan didn't need to stay on catecholamines for as long, and had reduced post-operative low cardiac output syndrome. And in the LivoCTS study, the Livosumandan group had fewer overall deaths, fewer low cardiac output syndrome events, and took fewer inotropic drugs. Further analysis of the LivoCTS data suggests that Livosumandan may be protective in patients who just need coronary bypass surgery and not additional valve surgery. In the bypass-only group, nearly 8% of placebo patients died within three months of the surgery, compared to just 2.1% of patients who got the drug. There may be other reasons why Livosumandan did not achieve its intended effects in the latest and larger studies. In the Cheetah study, the drug was not diluted according to the approved recommendations, which could have lowered the effective dose. And in both the Lycorne and LivoCTS studies, the Livosumandan therapy began an hour or less before surgery. So it's possible that more time is needed for the drug to bring about a protective effect. Importantly, none of the studies reported increases in serious adverse events, and several recent meta-analyses, including the three larger studies, suggest the drug may reduce mortality, particularly in patients with low ejection fraction. As a result, the group determined that although the three large trials couldn't rule out their null hypotheses, Livosumandan is safe and may reduce mortality in select patients, such as those just getting bypass surgery. An upcoming sub-analysis of the LivoCTS study will shed more light.