Vasoplegic Syndrome After Cardiovascular Surgery: A Review of Pathophysiology and Outcome Oriented Therapeutic Management

Abstract

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 (CI). It occurs in 9- 44% of cardiac surgery patients after cardiopulmonary bypass (CPB) and is associated with significant morbidity and mortality. The pathogenesis of VPS is multifactorial involving the activation of contact, coagulation, and complement systems and the activation of leukocytes. platelets and endothelial cells resulting in an imbalance in the regulation of the vascular tone; inducible nitric oxide synthase [iNOS] triggered by inflammatory cytokines during CPB produces nitric oxide (NO), which increases vascular levels of cyclic guanosine monophosphate (cGMP), resulting in vasodilation. leading to postcardiac surgery VPS. Standard treatment options for severe refractory VPS are extremely limited and include vasopressor support. latest Surviving Sepsis Campaign guidelines also consider that the best therapeutic management of vascular hypo- responsiveness to vasopressors could be a combination of multiple vasopressors, including norepinephrine (NE) and early prescription of vasopressin. This review will address the various definitions, risk factors, pathophysiology, potential cardiac candidates, and potential therapeutic interventions for VPS following cardiac surgery focussed on the outcome. This review did not require any ethical approval or consent from the patients.

Methylene Blue Use in Pediatrics

“…Vasoplegia after cardiopulmonary bypass has 30 to 50% mortality, 25 while refractory septic shock in children has greater than 50% mortality. 5 Similarly, in our cohort of highacuity patients, seven patients (46.7%) required ECMO support during their hospital stay.…”

Preliminary Experience of Extracorporeal Cytokine Hemoadsorption during Left Ventricular Assist Device Implantation in Cardiogenic Shock Patients

“…15 Additionally, elevated serum levels of pro-inflammatory cytokines after CPB, potentially promote SIRS and vasoplegia, which in turn leads to catecholamine refractory hypotension and poor clinical outcome. 8,9 Most notably, INTERMACS profiles 1 and 2 LVAD recipients, suffering from end-stage heart failure, show increased preoperative levels of Il-6, which is associated Extracorporeal Cytokine Hemoadsorption during LVAD Implantation Pausch et al…”

“…6,7 Furthermore, the unspecific release of proinflammatory cytokines during onpump cardiac surgery represents a detrimental side effect of cardiopulmonary bypass (CPB) potentially leading to vasoplegia, which is associated with postoperative catecholamine refractory hypotension, impaired right ventricular (RV) function, multiorgan failure, and poor clinical outcome. 8,9 Therefore, attenuating systemic inflammation after cardiac surgery, particularly in patients with preexisting cardiogenic shock and consequently elevated levels of proinflammatory cytokines, remains a promising therapeutic target potentially improving postoperative patient outcomes. 10 Extracorporeal hemoadsorption filters, which contain biocompatible sorbent beads coated with polyvinylpyrrolidone, conduct the removal of hydrophobic middle molecular weight molecules-such as pro-and anti-inflammatory cytokines (e.g., IL-6).…”

The Significance of Simple Inflammatory Markers in Off Pump Surgery—Review

“…The off-pump surgery advantages are related to diminish inflammatory activation during the procedure [36]. The perioperative inflammatory activation is postulated to possess detrimental effect related to vasoplegic syndrome [37], mortality [38] and morbidity [39], including stroke risk [40], kidney failure [41] and liver dysfunction [42]. Crucial role of systemic inflammatory limitation in early perioperative morbidity is postulated [43] once the off-pump surgery is performed.…”