Vasoplegia after cardiopulmonary bypass: A narrative review of pathophysiology and emerging targeted therapies

Barnes, Theresa J.; Hockstein, Maxwell A.; Jabaley, Craig S.

doi:10.1177/2050312120935466

Cited by 33 publications

(48 citation statements)

References 88 publications

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“…Hydroxocobalamin (5–10 g) has been recommended as a rescue therapy in multiagent resistant VPS after cardiac surgery 12 . An adjuvant therapy comprising a combination of high dosage (as described above) of ascorbic acid, thiamine, and hydrocortisone has been used successfully as and when required to restore the perfusion pressure, and to make the vasopressors therapy more effective and balanced, considering the potential benefits and low risk associated with these therapies 17 …”

Section: Methodsmentioning

confidence: 99%

“…Also, opening of the K ATP channel which is a strong intracellular vasodilator mediator and opening of Ca sensitive K-efflux (K-Ca efflux) decreases cytoplasmic calcium levels and blunts the vasoconstriction effect (Figure 1). 1,[15][16][17] DATT ET AL.…”

Section: Pathophysiology Of Vps Following Cpbmentioning

confidence: 99%

“…AT II is considered in patients who fail to respond to high-dose conventional vasoconstrictors in VPS due to ACE-I. 13,17,36 dicates that the effect of hydroxocobalamin outside of the NO system is significant or that the two drugs have a synergistic effect in one or multiple mechanisms. 12 Recently, case reports and series have demonstrated a significant increase in MAP in patients with VPS on hydroxocobalamin administration at a dose of 5 g over 15 min.…”

Section: Angiotensin IImentioning

confidence: 99%

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

Datt

Wadhhwa

Sharma

et al. 2021

Journal of Cardiac Surgery

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Background: Vasoplegic syndrome (VPS) is defined as systemic hypotension due to profound vasodilatation and loss of systemic vascular resistance (SVR), despite normal or increased cardiac index, and characterized by inadequate response to standard doses of vasopressors, and increased morbidity and mortality. It occurs in 9%-44% of cardiac surgery patients after cardiopulmonary bypass (CPB). The underlying pathophysiology following CPB consists of resistance to vasopressors (inactivation of Ca 2+ voltage gated channels) on the one hand and excessive activation of vasodilators (SIRS, iNOS, and low AVP) on the other. Use of angiotensinconverting enzyme inhibitor (ACE-I), calcium channel blockers, amiodarone, heparin, low cardiac reserve (EF < 35%), symptomatic congestive heart failure, and diabetes mellitus are the perioperative risk factors for VPS after cardiac surgery in adults. Till date, there is no consensus about the outcome-oriented therapeutic management of VPS. Vasopressors such as norepinephrine (NE; 0.025-0.2 µg/kg/min) and vasopressin (0.06 U/min or 6 U/h median dose) are the first choice for the treatment. The adjuvant therapy (hydrocortisone, calcium, vitamin C, and thiamine) and rescue therapy (methylene blue [MB] and hydroxocobalamin) are also considered when perfusion goals (meanarterial pressure [MAP] > 60-70 mmHg) are not achieved with nor-epinephrine and/or vasopressin.Aims: The aims of this systematic review are to collect all the clinically relevant data to describe the VPS, its potential risk factors, pathophysiology after CPB, and to assess the efficacy, safety, and outcome of the therapeutic management with catecholamine and non-catecholamine vasopressors employed for refractory vasoplegia after cardiac surgery. Also, to elucidate the current and practical approach for management of VPS after cardiac surgery.Material and Methods: "PubMed," "Google," and "Medline" weresearched, and over 150 recent relevant articles including RCTs, clinical studies, meta-analysis, reviews, case reports, case series and Cochrane data were analyzed for this systematic review. The filter was applied specificallyusing key words like VPS after cardiac surgery, perioperative VPS following CPB, morbidity, and mortality in VPS after cardiac surgery, vasopressors for VPS that improve outcomes, VPS after valve surgery, VPS after CABG surgery, VPS following complex congenital cardiac anomalies corrective surgery, rescue therapy for VPS, adjuvant therapy for VPS, definition of VPS, outcome in VPS after cardiac surgery, etiopathology of VPS following CPB. This review did not require any ethical approval or consent from the patients.Results: Despite the recent advances in therapy, the mortality remains as high as 30%-50%. NE has been recommended the most frequent used vasopressor for VPS.It restores and maintain the MAP and provides the outcome benefits. Vasopressin rescue therapy is an alternative approach, if catecholamines and fluid infusions fail to improve hemodynamics. It effectively increases vascular tone and lowe...

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Section: Methodsmentioning

confidence: 99%

Section: Pathophysiology Of Vps Following Cpbmentioning

confidence: 99%

Section: Angiotensin IImentioning

confidence: 99%

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

Datt

Wadhhwa

Sharma

et al. 2021

Journal of Cardiac Surgery

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“…For patients with reduced preoperative EF, any EF measured below preoperative levels or a regional wall motion abnormality not present preoperatively was also accepted as Vasoplegia was defined as patients with normal cardiac contractility, hypotension, low CVP, volume replacement requirement, and longer than six hours of noradrenaline support. 14,15 Patients with CVP below 10 mmHg at the end of CPB with coexisting hypotension and without low cardiac contractility received 15 ml/kg of colloid fluids or blood products or 20 ml/kg of crystalloid fluids after cessation of CPB. CVP was measured continuously during fluid replacement following weaning off CPB.…”

Section: Methodsmentioning

confidence: 99%

Risk factors for vasoplegia after coronary artery bypass and valve surgery

Baştopçu

Sarğın

Kuplay

et al. 2021

Journal of Cardiac Surgery

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Introduction Vasoplegia denotes a state of low tissue perfusion characterized by hypotension, tachycardia, and low systemic vascular resistance. This state results in increased mortality and morbidity following cardiac surgery. A better understanding of the associated risk factors will guide the surgical team in patient management. The aim of this study is to determine which risk factors are involved in its emergence. Methods This prospective observational study included adult cardiac surgery patients between February ‐ September 2018 at a single cardiothoracic surgery center. Patients were evaluated for cardiac contractility, surgical drainage, inotrope, and vasopressor requirement perioperatively. The groups were compared for demographic, echocardiographic, and operative variables. Variables significant in univariate analysis were carried on to binary logistic regression for risk factor analysis. Results A total of 31 patients were vasoplegic among a total of 487 included patients, resulting in a 6.37% incidence. In the vasoplegia group, chronic kidney failure, use of angiotensin‐converting enzyme (ACE) inhibitors, use of angiotensin receptor blockers, and use of diuretics were more frequent, cardiopulmonary bypass (CPB) and aortic cross‐clamp durations were longer, and mean Euroscore II was higher. Vasoplegia was more frequent in valve surgery and resternotomy patients. CPB duration, use of ACE inhibitors, use of angiotensin receptor blockers, and chronic renal failure were independent risk factors. Conclusion Patients with long CPB duration, preoperative use of ACE inhibitors or Angiotensin receptor blockers, and a history of renal failure requiring dialysis are under increased risk of vasoplegia. Vasoplegia necessitates large‐scale studies for a better understanding of its risk factors.

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“…Approximately 5% of patients undergoing cardiac surgery may experience degrees of VS. When shock develops, it has a mortality of up to 25% [2,3]. The usual clinical presentation is during prolonged CPB with an increasing tolerance to vasoconstrictors over time.…”

Section: Introductionmentioning

confidence: 99%

Vasoplegic Syndrome Post-cardiopulmonary Bypass in a Renal Transplant Patient: The Brain Is Not the Index Organ

Bennett¹,

Gonzalez²,

Fernández³

2022

Cureus

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Vasoplegia syndrome (VS) is seen in cardiac surgery post-cardiopulmonary bypass (CPB) and defined by increasing requirements for more than one vasoactive agent to which the patient's response is reduced. It is also associated with normal or high cardiac output (CO). Prolonged CPB time is the second commonest precipitating factor. Here, we describe a young adult, with good right ventricular (RV) and left ventricular (LV) function, who previously was a renal transplant recipient with a functioning kidney who developed VS and shock after CPB to replace the mitral and aortic valves. During the first two hours of CPB, his mean arterial blood pressure (MAP) was never lower than 50 mmHg. His brain regional cerebral oxygen saturation (rSO 2 ) remained above baseline, and his body temperature was kept at 33°C. Urine output was constant at 40 ml/hr. He came off CPB requiring two inotropes and two vasoconstrictors. Even so, his systolic blood pressure was low, and his pulse pressure narrows. He was then started on methylene blue which improved his MAP. On arrival to the intensive care unit (ICU), he immediately required continuous veno-veno haemodialysis (CVVHD) and developed acute liver failure. At 16 hours, he showed a clinically fair neurological recovery. Forty-eight hours post-surgery, he suffered multiorgan failure and developed an intractable arrhythmia and died. The unusual components were as follows: he was normally responsive to phenylephrine during CPB; despite normal rSO 2 and a clinically neurological recovery, he suffered multiorgan failure; and his serial high-sensitivity (HS) troponin I levels never fell below 500,000 pg/ml (normal <14 pg/ml).

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Vasoplegia after cardiopulmonary bypass: A narrative review of pathophysiology and emerging targeted therapies

Cited by 33 publications

References 88 publications

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

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

Risk factors for vasoplegia after coronary artery bypass and valve surgery

Vasoplegic Syndrome Post-cardiopulmonary Bypass in a Renal Transplant Patient: The Brain Is Not the Index Organ

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