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

Abstract

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.

Vasoplegic syndrome after cardiovascular surgery: A review of pathophysiology and outcome‐oriented therapeutic management

“…These processes result in increased oxygen-free radicals, endothelins, NO, platelet-activating factors, thromboxane A2, prostaglandins, a variety of cytokines, and other vasoactive substances. 1,13 The relative plasma concentrations of the abovementioned substances determine vascular relaxation. In addition, these factors are also involved in the development of a systemic inflammatory response syndrome (SIRS), that further exaggerates the generalized vascular dilatation.…”

Commentary: Angiotensin II: Expanding the rescue options for vasoplegia

“…5 This vasopressor-sparing effect may minimize the ischemic risk by supporting a more balanced restoration of vascular tome. [7][8][9] Although this report expands the therapeutic armamentarium for vasoplegia, it also highlights some important caveats with this vasopressor. [5][6][7][8][9] The first caveat is that we know very little about adverse events associated with angiotensin II, owing to the limited evidence base.…”

“…[7][8][9] Although this report expands the therapeutic armamentarium for vasoplegia, it also highlights some important caveats with this vasopressor. [5][6][7][8][9] The first caveat is that we know very little about adverse events associated with angiotensin II, owing to the limited evidence base. [5][6][7][8] Although the evidence has established angiotensin II as a therapeutic option in vasoplegia, further clinical trials are needed to delineate its therapeutic window.…”

“…[5][6][7][8][9] The first caveat is that we know very little about adverse events associated with angiotensin II, owing to the limited evidence base. [5][6][7][8] Although the evidence has established angiotensin II as a therapeutic option in vasoplegia, further clinical trials are needed to delineate its therapeutic window. 9 The second caveat is that the current evidence base has a distinct adult focus.…”

“…3 Detailed investigation of the biochemical mechanisms may explain the observed efficacy of angiotensin II in vasoplegia, likely framed by the kinetics within the renin-angiotensin-aldosterone cascade. [4][5][6][7][8][9][10] The bedside approach to inquiry would include further clinical trials to define the roles and safety of angiotensin II in the management of systemic vascular tome for both pediatric and adult cardiothoracic practice, perhaps with a focus on high-risk patients. 5 These dual approaches are complementary and so together may offer us the best way to integrate angiotensin II into our clinical practice.…”