Effect Levosimendan Administration on Postoperative NT-proBNP in Cardiac Risk Patients

Inclusion Criteria: All patients need to meet all of the following criteria for inclusion (1-4): 1. Undergoing major surgery planned for more than 2 hours 2. ≥ 65 years of age and ≤ 85 years of age 3. Provide written informed consent AND 4. Fulfill ≥ 2 of the following criteria (A-E) A) NT-proBNP ≥ 200 ng/L B) History of coronary artery disease defined as 1 of the following 7 criteria (I to VII): * I) History of angina * II) History of myocardial infarction or acute coronary syndrome * III) History of a segmental cardiac wall motion abnormality on echocardiography/radionuclide imaging * IV) History of positive myocardial stress test (echocardiographic or radionuclide) * V) History of a coronary artery stenosis \> 50% * VI) ECG with pathological Q waves in any two contiguous leads * VII) History of previous artery revascularizations C) History of permanent/paroxysmal atrial fibrillation diagnosed by physician/specialist D) History of peripheral arterial disease as defined by a physician/specialist diagnosis of a current, or prior history of any 1 of the following 5criteria (I-V) * I) Intermittent claudication * II) Stenosis ≥ 70 % detected by angiography or doppler * III) Stenosis ≤ 70% detected by angiography or doppler AND requiring medical treatment e.g. ASA or other platelet inhibitor * IV) History of stroke or TIA - diagnosed by physician or CT/MRI * V) Diagnosed cerebral arteriovascular disease (cAVK) diagnosed by a physician/specialist E) Any 3 of 10 of the following risk criteria (i - x). * i. History of congestive heart failure defined as a physician diagnosis of a current or prior episode of congestive heart failure OR prior radiographic evidence of vascular redistribution, interstitial pulmonary edema, or frank alveolar pulmonary edema; * ii. History of a transient ischemic attack; * iii. Diabetes and currently taking an oral hypoglycemic agent or insulin; * iv. History of hypertension; * v. Hyperlipidemia and currently taking a lipid lowering agent; * vi. Documented chronic kidney disease diagnosed by physician/specialist and creatinine clearance \> 30 ml/min * vii. History of smoking within 2 years of surgery * viii. Diastolic dysfunction (≥ grade 1) documented by echocardiography * ix. Age ≥ 70 years * x. Preoperative Troponin T (5th generation) ≥ 25ng/dL Exclusion Criteria: A) Previous adverse response and/or allergy to levosimendan B) ICU Patients undergoing surgery C) Preoperative Sepsis/SIRS needing ICU treatment D) Preoperative hemodynamically instable patients, who requirevasopressor or inotropic support E) Renal or liver transplantation F) History of severe heart failure (e.g. LVEF \< 30%) G) Patients undergoing surgery for pheochromocytoma H) Liver cirrhosis I) Pulmonary hypertension (mPAP \> 25 mmHg) J) Severe Renal Failure defines as creatinine clearance ≤ 30ml/min