Incidence and predictors of vasoplegia after heart failure surgery

Vessem, Marieke E. van; Palmen, Meindert; Couperus, Lotte E.; Mertens, Bart; Berendsen, Remco R.; Tops, Sophie; Verwey, Harriëtte F.; Jonge, Evert de; Klautz, Robert J.M.; Schalij, Martin J.; Beeres, Saskia L.M.A.

doi:10.1093/ejcts/ezw316

Cited by 29 publications

(58 citation statements)

References 20 publications

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“…Having a prior sternotomy has also been associated with the development of vasoplegia among heart transplant patients; however, this relation was not detected in our LVAD recipient cohort . Vasoplegia development has been directly associated with angiotensin‐converting enzyme inhibitors and heparin, whereas the use of β‐blockers exhibits an indirect relation (ie, a protective effect) . We did not confirm the associations between those drugs and vasoplegia; however, patients in the previous studies were treated with angiotensin‐converting enzyme inhibitors and β‐blockers at much different rates than in our study.…”

Section: Discussioncontrasting

confidence: 82%

“…For example, vasoplegia defined as norepinephrine ≥0.2 μg/kg per minute for 12 to 24 hours in the intensive care unit was observed in 20% of HF patients undergoing elective cardiac surgery compared with 0% of similarly matched patients without HF undergoing the same surgery . A recent retrospective analysis reported a vasoplegia occurrence of 29%; however, only a small portion of that sample was comprised patients undergoing surgery for LVAD implantation (most had left ventricle restoration or CorCap [Acorn Cardiovascular] implantation) . Furthermore, that study defined vasoplegia as the need for norepinephrine ≥0.2 μg/kg per minute and/or any dose of terlipressin combined with a cardiac index ≥2.2 L/min per m 2 for at least 12 consecutive hours within the first 3 postoperative days.…”

Section: Discussionmentioning

confidence: 99%

“…Also found to be predictive of vasoplegia severity in this study were CVP and SBP, which may be modified during the days of hospitalization before surgery. Relatedly, those who develop vasoplegia are less likely to have baseline hypertenstion . Alternatively, another study failed to detect a difference in baseline CVP; however, it utilized patients with congenital heart defects and only 10 patients had vasoplegia, which raises concerns about statistical power and the appropriateness of generalization to the advanced HF population of interest …”

Section: Discussionmentioning

confidence: 99%

“…The development of a reliable prediction tool is critical because vasoplegia has repeatedly been associated with poor surgical outcomes. Patients who developed vasoplegia following elective cardiac surgery, for example, had significantly worse 90‐day survival outcomes than those who did not develop vasoplegia (29% versus 9%) . Another study reported a mortality rate of 50% for dialysis‐dependent patients who underwent CPB and subsequently developed vasoplegia .…”

Section: Discussionmentioning

confidence: 99%

“…6 A recent retrospective analysis reported a vasoplegia occurrence of 29%; however, only a small portion of that sample was comprised patients undergoing surgery for LVAD implantation (most had left ventricle restoration or CorCap [Acorn Cardiovascular] implantation). 7 Furthermore, that study defined vasoplegia as the need for norepinephrine ≥0.2 lg/kg per minute and/or any dose of terlipressin combined with a cardiac index ≥2.2 L/min per m 2 for at least 12 consecutive hours within the first 3 postoperative days. In another study, %48% and 34% of patients undergoing CPB developed vasoplegia immediately and 24 hours following surgery, respectively, based on mean arterial pressure <50 mm Hg and the need for noradrenaline perfusion >0.08 lg/kg per minute.…”

Section: Discussionmentioning

confidence: 99%

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Determinants and Outcomes of Vasoplegia Following Left Ventricular Assist Device Implantation

Tecson

Lima

Lee

et al. 2018

JAHA

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BackgroundVasoplegia is associated with adverse outcomes following cardiac surgery; however, its impact following left ventricular assist device implantation is largely unexplored.Methods and ResultsIn 252 consecutive patients receiving a left ventricular assist device, vasoplegia was defined as the occurrence of normal cardiac function and index but with the need for intravenous vasopressors within 48 hours following surgery for >24 hours to maintain a mean arterial pressure >70 mm Hg. We further categorized vasoplegia as none; mild, requiring 1 vasopressor (vasopressin, norepinephrine, or high‐dose epinephrine [>5 μg/min]); or moderate to severe, requiring ≥2 vasopressors. Predictors of vasoplegia severity were determined using a cumulative logit (ordinal logistic regression) model, and 1‐year mortality was evaluated using competing‐risks survival analysis. In total, 67 (26.6%) patients developed mild vasoplegia and 57 (22.6%) developed moderate to severe vasoplegia. The multivariable model for vasoplegia severity utilized preoperative Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile, central venous pressure, systolic blood pressure, and intraoperative cardiopulmonary bypass time, which yielded an area under the curve of 0.76. Although no significant differences were noted in stroke or pump thrombosis rates (P=0.87 and P=0.66, respectively), respiratory failure and major bleeding increased with vasoplegia severity (P<0.01). Those with moderate to severe vasoplegia had a significantly higher risk of mortality than those without vasoplegia (adjusted hazard ratio: 2.12; 95% confidence interval, 1.08–4.18; P=0.03).ConclusionsVasoplegia is predictive of unfavorable outcomes, including mortality. Risk factors for future research include preoperative INTERMACS profile, central venous pressure, systolic blood pressure, and intraoperative cardiopulmonary bypass time.

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Section: Discussioncontrasting

confidence: 82%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Determinants and Outcomes of Vasoplegia Following Left Ventricular Assist Device Implantation

Tecson

Lima

Lee

et al. 2018

JAHA

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Use of intraoperative haemoadsorption in patients undergoing heart transplantation: a proof‐of‐concept randomized trial

Nemeth,

Soltesz,

Kovacs

et al. 2023

ESC Heart Failure

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AimsThe aim of this trial was to compare the clinical effects of intraoperative haemoadsorption versus standard care in patients undergoing orthotopic heart transplantation (OHT).Methods and resultsIn a randomized, controlled trial, OHT recipients were randomized to receive intraoperative haemoadsorption or standard care. Outcomes were vasoactive‐inotropic score (VIS), frequency of vasoplegic syndrome (VS) in the first 24 h; post‐operative change in procalcitonin (PCT) and C‐reactive protein (CRP) levels; intraoperative change in mycophenolic acid (MPA) concentration; frequency of post‐operative organ dysfunction, major complications, adverse immunological events and length of in‐hospital stay and 1‐year survival. Sixty patients were randomized (haemoadsorption group N = 30, control group N = 25 plus 5 exclusions). Patients in the haemoadsorption group had a lower median VIS and rate of VS (VIS: 27.2 [14.6–47.7] vs. 41.9 [22.4–63.2], P = 0.046, and VS: 20.0% vs. 48.0%, P = 0.028, respectively), a 6.4‐fold decrease in the odds of early VS (OR: 0.156, CI: 0.029–0.830, P = 0.029), lower PCT levels, shorter median mechanical ventilation (MV: 25 [19–68.8] hours vs. 65 [23–287] hours, P = 0.025, respectively) and intensive care unit stay (ICU stay: 8.5 [8.0–10.3] days vs. 12 [8.5–18.0] days, P = 0.022, respectively) than patients in the control group. Patients in the haemoadsorption versus control group experienced lower rates of acute kidney injury (AKI: 36.7% vs. 76.0%, P = 0.004, respectively), renal replacement therapy (RRT: 0% vs. 16.0%, P = 0.037, respectively) and lower median per cent change in bilirubin level (PCB: 2.5 [−24.6 to 71.1] % vs. 72.1 [11.2–191.4] %, P = 0.009, respectively) during the post‐operative period. MPA concentrations measured at pre‐defined time points were comparable in the haemoadsorption compared to control groups (MPA pre‐cardiopulmonary bypass: 2.4 [1.15–3.60] μg/mL vs. 1.6 [1.20–3.20] μg/mL, P = 0.780, and MPA 120 min after cardiopulmonary bypass start: 1.1 [0.58–2.32] μg/mL vs. 0.9 [0.45–2.10] μg/mL, P = 0.786). The rates of cardiac allograft rejection, 30‐day mortality and 1‐year survival were similar between the groups.ConclusionsIntraoperative haemoadsorption was associated with better haemodynamic stability, mitigated PCT response, lower rates of post‐operative AKI and RRT, more stable hepatic bilirubin excretion, and shorter durations of MV and ICU stay. Intraoperative haemoadsorption did not show any relevant adsorption effect on MPA. There was no increase in the frequency of early cardiac allograft rejection related to intraoperative haemoadsorption use.

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The Use of Angiotensin II for the Treatment of Post-cardiopulmonary Bypass Vasoplegia

Papazisi

Palmen

Danser

2020

Cardiovasc Drugs Ther

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Purpose Vasoplegia is a common complication after cardiac surgery and is related to the use of cardiopulmonary bypass (CPB). Despite its association with increased morbidity and mortality, no consensus exists in terms of its treatment. In December 2017, angiotensin II (AII) was approved by the Food and Drug Administration (FDA) for use in vasodilatory shock; however, except for the ATHOS-3 trial, its use in vasoplegic patients that underwent cardiac surgery on CPB has mainly been reported in case reports. Thus, the aim of this review is to collect all the clinically relevant data and describe the pharmacologic mechanism, efficacy, and safety of this novel pharmacologic agent for the treatment of refractory vasoplegia in this population. Methods Two independent reviewers performed a systematic search in PubMed, Embase, Web of Science, and Cochrane Library using relevant MeSH terms (Angiotensin II, Vasoplegia, Cardiopulmonary Bypass, Cardiac Surgical Procedures). Results The literature search yielded 820 unique articles. In total, 9 studies were included. Of those, 2 were randomized clinical trials (RCTs) and 6 were case reports and 1 was a retrospective cohort study. Conclusions AII appears to be a promising means of treatment for patients with post-operative vasoplegia. It is demonstrated to be effective in raising blood pressure, while no major adverse events have been reported. It remains uncertain whether this agent will be broadly available and whether it will be more advantageous in the clinical management of vasoplegia compared to other available vasopressors. For that reason, we should contain our eagerness and enthusiasm regarding its use until supplementary knowledge becomes available.

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Incidence and predictors of vasoplegia after heart failure surgery

Cited by 29 publications

References 20 publications

Determinants and Outcomes of Vasoplegia Following Left Ventricular Assist Device Implantation

Determinants and Outcomes of Vasoplegia Following Left Ventricular Assist Device Implantation

Use of intraoperative haemoadsorption in patients undergoing heart transplantation: a proof‐of‐concept randomized trial

The Use of Angiotensin II for the Treatment of Post-cardiopulmonary Bypass Vasoplegia

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