Objective To observe the efficacy and safety of levosimendan in the treatment of very elderly patients with acute exacer-bation of chronic heart failure. Methods A total of 47 very elderly patients with acute exacerbation of chronic heart failure admitted to the Zhangzhou Zhengxing Hospital and No.909 Hospital of PLA from January 2016 to February 2019 were recruited in this study. They were randomly divided into control group (conventional treatment, n=23) and treatment group (conventional treatment+levosimendan, n=24). All patients were followed up for at least three months. The results of echocardiography, serum level of N-terminal pro-brain natriuretic peptide (NT-proBNP), New York Heart Association (NYHA) Functional Classification at acute attack, and heart failure readmission during 3-month follow-up were compared between the two groups. SPSS statistics 17.0 was used for data processing. Results There were no statistic differences in systolic blood pressure and heart rate immediately and in 3 month after treatment between the 2 groups (P>0.05). At 5 d and 3 months after treatment, the results of echocardiography revealed that left ventricular ejction fraction were better in the treatment than the control group [(48.6±11.9)% vs (44.5±11.4)%; (47.8±12.1)% vs (43.6±11.7)%, P<0.05]. At the same time point, serum NT-proBNP level was significantly lower in the treatment group than the control group (2437.5±1104.8 vs 2926.3±1248.2 pg/L; 2649.1±1155.6 vs 3 327.8±1 293.7 pg/L, P<0.05). And the treatment group obtained better NYHA class than the control group (P<0.05). During the 3-month follow-up, the readmission rate due to heart failure was obviously lower in the treatment group than the control group (4.2% vs 30.4%, 1 vs 7 cases, P<0.05). Conclusion Levosimendan is effective and safe in the treatment of very elderly patients with acute exacerbation of chronic heart failure.