Defining Vasoplegia Following Durable, Continuous Flow Left Ventricular Assist Device Implantation

Abstract

This study aimed to develop a definition of vasoplegia that reliably predicts clinical outcomes. Vasoplegia was evaluated using data from the electronic health record for each 15-minute interval for 72 hours following cardiopulmonary bypass. Standardized definitions considered clinical features (systemic vascular resistance [SVR], mean arterial pressure [MAP], cardiac index [CI], norepinephrine equivalents [NEE]), threshold strategy (criteria occurring in any versus all measurements in an interval), and duration (criteria occurring over multiple consecutive versus separated intervals). Minor vasoplegia was MAP < 60 mm Hg or SVR < 800 dynes⋅sec⋅cm −5 with CI > 2.2 L/min/m 2 and NEE ≥ 0.1 µg/kg/min. Major vasoplegia was MAP < 60 mm Hg or SVR < 700 dynes⋅sec⋅cm −5 with CI > 2.5 L/min/m 2 and NEE ≥ 0.2 µg/kg/min. The primary outcome was incidence of vasoplegia for eight definitions developed utilizing combinations of these criteria. Secondary outcomes were associations between vasoplegia definitions and three clinical outcomes: time to extubation, time to intensive care unit discharge, and nonfavorable discharge. Minor vasoplegia detected anytime within a 15-minute period (MINOR_ANY_15) predicted the highest incidence of vasoplegia (61%) and was associated with two of three clinical outcomes: 1 day delay to first extubation (95% CI: 0.2 to 2) and 7 day delay to first intensive care unit discharge (95% CI: 1 to 13). The MINOR_ANY_15 definition should be externally validated as an optimal definition of vasoplegia. ASAIO

Predictors and Impact of Prolonged Vasoplegia After Continuous-Flow Left Ventricular Assist Device Implantation

“… 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 However, to our knowledge, few studies have focused specifically on the CF-LVAD population to capture the evolution of vasoplegia over time or have used immediate postoperative hemodynamic parameters to identify patients with postoperative vasoplegia. Our cohort of 600 patients compares favorably with the number of CF-LVAD patients in 4 previous studies of postoperative vasoplegia ( Supplemental Table 1 ), 2 , 4 , 10 , 16 which had samples ranging from 33 to 252 patients.…”

“…This may be problematic because the combination of SVR and a low MAP, as used in the current analysis, is essential for differentiating vasoplegic shock from shock of other causes. For example, in the recent study by Swan et al, 16 38% of the patients with vasoplegia had concomitant RVF.…”

“…In contrast, SVR varied significantly across the studies. Tecson et al 2 and van Vessem et al 10 each had no SVR requirement in their definitions of vasoplegia, whereas de Waal et al 4 and Swan et al 16 included either a MAP or an SVR threshold, rather than using both, to identify patients with vasoplegia. This may be problematic because the combination of SVR and a low MAP, as used in the current analysis, is essential for differentiating vasoplegic shock from shock of other causes.…”

FLAVOUR Study: FLow profiles And postoperative VasOplegia after continUous-flow left ventriculaR assist device implantation

“…Vasoplegia is a common immediate postoperative complication after LVAD implantation characterized by severe hypotension unresponsive to vasopressor therapy due to a loss in vasomotor tone [ 14 – 17 ]. Different flow profiles of the various assist devices may play a role in this vasodilatory state of the vessels.…”

“…However, the exact pathophysiological mechanisms in the development of vasoplegia are still unknown. This is clinically highly relevant, since vasoplegia may affect early postoperative outcomes and survival [ 15 – 17 ]. Recent literature on the incidence of immediate postoperative vasoplegia associated with different cfLVAD types with unique flow profiles is lacking.…”