• consensus
• incidence
• meta-analysis
• thoracic surgery
• vasoplegia

• Humans
• Vasoplegia/diagnosis
• Vasoplegia/etiology
• Vasoplegia/epidemiology
• Cardiac Surgical Procedures/adverse effects
• Cardiac Surgical Procedures/trends
• Postoperative Complications/diagnosis
• Postoperative Complications/epidemiology
• Treatment Outcome
• Length of Stay/trends
• Incidence
• Intensive Care Units/trends

• cardiac surgery
• cardiopulmonary bypass
• vasoplegia
• vasoplegic syndrome

• CABG
• GDMT
• Guidelines
• TAVI
• antibiotics
• antiplatelet
• antithrombotic
• atrial fibrillation
• beta-blockers
• cardiac surgery
• coronary artery bypass grafting
• evidence based practice
• glucose management
• guideline directed medical therapy
• pain
• perioperative medication
• risk reduction
• secondary prevention
• statins
• steroids
• transcatheter aortic valve implantation
• valve replacement

• cardiopulmonary bypass
• hydroxocobalamin
• methylene blue
• shock
• vasoplegia

• Humans
• Hydroxocobalamin/administration & dosage
• Hydroxocobalamin/therapeutic use
• Methylene Blue/therapeutic use
• Methylene Blue/administration & dosage
• Vasoplegia/drug therapy
• Vasoplegia/etiology
• Cardiopulmonary Bypass/adverse effects
• Retrospective Studies
• Treatment Outcome
• Postoperative Complications/drug therapy

• cardiothoracic transplantation
• cytokine adsorption
• cytosorb
• heart transplantation
• hemoadsorption
• lung transplantation

• Humans
• Pilot Projects
• Middle Aged
• Male
• Female
• Propensity Score
• Cytokines/metabolism
• Australia/epidemiology
• Intraoperative Care/methods
• Heart Transplantation/methods
• Adsorption
• Lung Transplantation/methods
• Lung Transplantation/adverse effects
• Adult
• Heart-Lung Transplantation/methods
• Postoperative Complications/epidemiology
• Postoperative Complications/prevention & control
• Treatment Outcome

• Bretschneider cardioplegia
• coronary artery bypass graft surgery
• extracorporeal circulation (ECC)
• vasoplegic syndrome
• warm blood cardioplegia

• Humans
• Nicardipine/therapeutic use
• Nicardipine/administration & dosage
• Nicardipine/economics
• Retrospective Studies
• Nitroprusside/therapeutic use
• Nitroprusside/administration & dosage
• Nitroprusside/economics
• Infant
• Heart Defects, Congenital/surgery
• Female
• Male
• Infant, Newborn
• Antihypertensive Agents/economics
• Antihypertensive Agents/therapeutic use
• Antihypertensive Agents/administration & dosage
• Postoperative Complications/prevention & control
• Postoperative Complications/economics
• Hypertension/drug therapy
• Calcium Channel Blockers/therapeutic use
• Calcium Channel Blockers/economics
• Calcium Channel Blockers/administration & dosage
• Cardiac Surgical Procedures/adverse effects
• Blood Pressure/drug effects
• Vasodilator Agents/therapeutic use
• Vasodilator Agents/administration & dosage
• Vasodilator Agents/economics
• Costs and Cost Analysis

• bilateral lung transplantation
• cardiopulmonary bypass
• cardiothoracic anesthesia
• cardiothoracic surgery
• cystic fibrosis
• lung transplantation
• vasoplegia
• vasoplegic syndrome

• Humans
• Male
• Vasoplegia/diagnosis
• Vasoplegia/epidemiology
• Vasoplegia/etiology
• Retrospective Studies
• Cystic Fibrosis/complications
• Incidence
• Lung Transplantation/adverse effects

• Age
• Cardioplegia
• Ischaemia tolerance
• Ischaemia/reperfusion

• Humans
• Cardiac Surgical Procedures/adverse effects
• Cardiac Surgical Procedures/methods
• Cardioplegic Solutions/therapeutic use
• Heart Arrest, Induced/methods
• Ischemia
• Myocardium

• Anaerobiosis
• Carbon dioxide
• Cardiac surgical procedures
• Perfusions

• immunosuppressive therapy
• primary graft dysfunction
• prophylaxis against infection
• pulmonary vascular resistance
• sinoatrial node dysfunction
• vasoplegia

• Humans
• Postoperative Care/methods
• Graft Rejection/prevention & control
• Heart Transplantation/adverse effects
• Heart Transplantation/methods
• Transplantation, Homologous
• Tissue Donors

• ACE inhibitor
• Hydroxycobalamin
• Hypotension
• Methylene blue
• Shock
• Vasoplegia syndrome
• Vasopressin

• Humans
• Vasoplegia/diagnosis
• Vasoplegia/therapy
• Cardiopulmonary Bypass
• Methylene Blue
• Cardiac Surgical Procedures
• Liver Transplantation

• Adult intensive & critical care
• Cardiothoracic surgery
• Heart failure

• Cardiac Surgical Procedures/adverse effects
• Cardiac Surgical Procedures/methods
• Heart Failure/complications
• Heart Failure/prevention & control
• Humans
• Inflammation Mediators
• Phenylephrine
• Randomized Controlled Trials as Topic
• Systemic Inflammatory Response Syndrome
• Vasoplegia

• CytoSorbents Europe GmbH
• Zabawas Foundation

Vasoplegia is a common complication of cardiac surgery but its causal relationship with preoperative use of renin angiotensin system (RAS) blockers [angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARB)] is still debated.

To update and summarize data on the effect of preoperative use of RAS blockers on incident vasoplegia.

All published studies from MEDLINE, EMBASE, and Web of Science providing relevant data through January 13, 2021 were identified. A random-effects meta-analysis method was used to pool estimates, and post-cardiac surgery shock was differentiated from vasoplegia.

Ten studies reporting on a pooled population of 15672 patients (none looking at ARBs exclusively) were included in the meta-analysis. All were case-control studies. Use of ACEIs was associated with an increased risk of vasoplegia [pooled adjusted odds ratio (Aor) of 2.06, 95%CI: 1.45-2.93] and increased inotropic/vasopressor support requirement (pooled aOR 1.19, 95%CI: 1.10-1.29). Post-cardiac surgery shock was increased in the presence of left ventricular dysfunction (pooled aOR 2.32, 95%CI: 1.60-3.36; I² 49%) but not increased by the use of beta blockers (pooled aOR 0.78, 95%CI: 0.36-1.69; I² 77%). Two randomized control trials (RCTs), not eligible for the meta-analysis, did not show an association between continuation of RAS blockers and vasoplegia.

Preoperative continuation of ACEIs is associated with an increased need for inotropic support postoperatively and with an increased risk of vasoplegia in observational studies but not in RCTs. The absence of a consensus definition of vasoplegia should lead to the use of perioperative cardiovascular monitoring when designing RCTs to better understand this discrepancy.

• Vasoplegia
• Cardiac surgery
• Coronary artery bypass graft
• Angiotensin converting enzyme inhibitors

The incidence of complications after heart surgery is a critical factor in disability, deaths, lengthening hospital stays, and increasing treatment costs. The metabolic balance of certain hormones and electrolytes is necessary for proper cardiac function. In children, various biochemical conditions may cause calcium depletion during heart surgery. The purpose of this study was to determine the effect of calcium gluconate administration during cardiopulmonary bypass on hemodynamic variables and clinical outcomes in infants undergoing open-heart surgery. This study was conducted at Rajaie Cardiovascular Medical and Research Center in 2021 using a controlled randomized clinical trial. A total of 60 patients with open-heart surgery weighing up to 10 kg were included in the study. The first group received an intravenous injection of calcium gluconate 20 min after opening the aortic clamp, and the second group was monitored as a control group. Data collection tools included checklists containing demographics, surgical information, and intensive care unit measures.

The Chi-square test or Fisher's exact test showed that the frequency distribution of gender, blood group, Rhesus factor (RH), and clinical diagnosis in the two groups of intervention and control was not statistically significant (p < 0.05). The mean and standard deviation of Ejection Fraction (EF) changes (before and after) were 13.27 ± 9.16 in the intervention group and 8.31 ± 9.80 in the control group (p = 0.065). The results of two-way repeated measures ANOVA showed that mean systolic blood pressure (p = 0.030), mean diastolic blood pressure (p = 0.021), mean heart rate (p = 0.025), mean arterial pressure (p = 0.020), mean pH (p < 0.001), and mean hemoglobin (p = 0.018) in the intervention, and control groups were statistically significant.

In the present study, unlike systolic pressure, mean diastolic blood pressure decreased, and mean arterial pressure increased significantly. As a result, the slope of changes during the study period was different in the intervention and control groups.

• Calcium gluconate
• Cardiopulmonary bypass
• Hemodynamics
• Open-heart surgery

• Adult
• Cardiac Surgical Procedures/adverse effects
• Cohort Studies
• Humans
• Methylene Blue/pharmacology
• Microcirculation
• Prospective Studies

A 68-year-old male has a significant past medical history of severe aortic stenosis, peripheral arterial disease, chronic kidney disease, and an abdominal aortic aneurysm treated with a bifurcated interposition aortobiiliac graft. He was admitted to the hospital for an elective one-vessel coronary artery bypass graft and placement of a bioprosthetic aortic valve. Postoperatively, he developed worsening abdominal pain, leukocytosis, and inability to tolerate nutrition by mouth. Computed tomography revealed moderately dilated loops of the small bowel with two transition points in the right lower quadrant. He was taken emergently to the operating room for an exploratory laparotomy, and a 28-cm necrotic jejunal loop was entrapped posterior to the right iliac segment of the graft. In a patient with an intra-abdominal synthetic vascular graft, a closed-loop bowel obstruction caused by entrapment by the vascular graft is exceptionally rare; however, it should be considered in the presence of bowel obstruction.

• abdominal aortic aneurysms
• abdominal radiology
• aortic surgery
• bowel ischemia
• bowel obstruction
• general and vascular surgery
• postoperative complications
• small bowel necrosis
• small bowel obstruction
• small bowel resection

• acute kidney injury
• cardiac surgery
• critical care score
• mortality prediction
• renal replacement therapy

• cardiac surgery
• high spinal
• neuraxial anessthesia
• spinal anesthesia

• Adult
• Analgesics, Opioid/therapeutic use
• Anesthesia, Spinal
• Anesthetics, Local/therapeutic use
• Bupivacaine
• Cardiac Surgical Procedures
• Double-Blind Method
• Hemodynamics
• Humans
• Injections, Spinal
• Morphine/therapeutic use
• Pain, Postoperative/drug therapy
• Pain, Postoperative/epidemiology
• Prospective Studies

• blood vessel
• cardiomyocyte
• heart failure
• α1-adrenoceptors

• Blood Vessels/metabolism
• Heart Failure/genetics
• Heart Failure/metabolism
• Humans
• Models, Biological
• Myocardium/metabolism
• Receptors, Adrenergic, alpha-1/genetics
• Receptors, Adrenergic, alpha-1/metabolism
• Signal Transduction

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.

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).

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.

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.

The online version of this article (10.1007/s10557-020-07098-3) contains supplementary material, which is available to authorized users.

Cardiovascular disease remains the leading cause of death in the United States, and cardiopulmonary bypass is a cornerstone in the surgical management of many related disease states. Pathophysiologic changes associated both with extracorporeal circulation and shock can beget a syndrome of low systemic vascular resistance paired with relatively preserved cardiac output, termed vasoplegia. While increased vasopressor requirements accompany vasoplegia, related pathophysiologic mechanisms may also lead to true catecholamine resistance, which is associated with further heightened mortality. The introduction of a second non-catecholamine vasopressor, angiotensin II, and non-specific nitric oxide scavengers offers potential means by which to manage this challenging phenomenon. This narrative review addresses both the definition, risk factors, and pathophysiology of vasoplegia and potential therapeutic interventions.

• Vasoplegia
• cardiopulmonary bypass
• hydroxocobalamin
• methylene blue
• surgical shock
• vasoconstrictor agents

• fluid bolus therapy
• fluid temperature
• iso-oncotic albumin
• post cardiac surgery
• postoperative care

Vasoplegic syndrome is a common occurrence following cardiothoracic surgery and is characterized as a high-output shock state with poor systemic vascular resistance. The pathophysiology is complex and includes dysregulation of vasodilatory and vasoconstrictive properties of smooth vascular muscle cells. Specific bypass machine and patient factors play key roles in occurrence. Research into treatment of this syndrome is limited and extrapolated primarily from that pertaining to septic shock, but is evolving with the expanded use of catecholamine-sparing agents. Recent reports demonstrate potential benefit in novel treatment options, but large clinical trials are needed to confirm.

• Angiotensin II
• Cardiopulmonary bypass
• De-catecholaminization
• Hydroxocobalamin
• Shock
• Vasoplegic syndrome

• Hemodialysis
• Longer term
• Vasoplegic syndrome

• Cardiac Surgical Procedures/adverse effects
• Cohort Studies
• Female
• Humans
• Kidney Failure, Chronic/complications
• Kidney Failure, Chronic/therapy
• Male
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Renal Dialysis/adverse effects
• Retrospective Studies
• Risk Factors
• Stroke Volume
• Vasoplegia/epidemiology
• Vasoplegia/etiology
• Ventricular Function, Left

Postoperative clinical outcomes associated with the preoperative continuation or discontinuation of angiotensin‐converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) before cardiac surgery remain unclear.

In a single‐center, open‐label, randomized, registry‐based clinical trial, patients undergoing nonemergent cardiac surgery were assigned to ACEI/ARB continuation or discontinuation 2 days before surgery. Among the 584 patients screened, 261 met study criteria and 126 (48.3%) patients were enrolled. In total,121 patients (96% adherence; 60 to continuation and 61 to ACEI/ARB discontinuation) underwent surgery and completed the study protocol, and follow‐up was 100% complete. Postoperative intravenous vasopressor use (78.3% versus 75.4%, P=0.703), vasodilator use (71.7% versus 80.3%, P=0.265), vasoplegic shock (31.7% versus 27.9%, P=0.648), median duration of vasopressor (10 versus 5 hours, P=0.494), and vasodilator requirements (10 versus 9 hours, P=0.469) were not significantly different between the continuation and discontinuation arms. No differences were observed in the incidence of acute kidney injury (1.7% versus 1.6%, P=0.991), stroke (no events, mortality (1.7% versus 1.6%, P=0.991), median duration of mechanical ventilation (6 versus 6 hours, P=0.680), and median intensive care unit length of stay (43 versus 27 hours, P=0.420) between the treatment arms.

A randomized study evaluating the routine continuation or discontinuation of ACEIs or ARBs before cardiac surgery was feasible, and treatment assignment was not associated with differences in postoperative physiological or clinical outcomes. These preliminary findings suggest that preoperative ACEI/ARB management strategies did not affect the postoperative course of patients undergoing cardiac surgery.

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02096406.

• angiotensin receptor blocker
• angiotensin‐converting enzyme inhibitor
• cardiac surgery
• vasoplegia

• hemodynamics
• multi-scale modeling
• patient-specific modeling
• surgical planning
• virtual surgery

• Fulminant myocarditis
• Vasoplegic syndrome
• Ventricular assist device

Vasoplegia after routine cardiac surgery is associated with severe postoperative complications and increased mortality. It is also prevalent in patients undergoing implantation of pulsatile flow left ventricular assist devices (LVAD). However, less is known regarding vasoplegia after implantation of newer generations of continuous flow LVADs (cfLVAD). We aim to report the incidence, impact on outcome and predictors of vasoplegia in these patients.

Adult patients scheduled for primary cfLVAD implantation were enrolled into a derivation cohort (n = 118, 2006–2013) and a temporal validation cohort (n = 73, 2014–2016). Vasoplegia was defined taking into consideration low mean arterial pressure and/or low systemic vascular resistance, preserved cardiac index and high vasopressor support. Vasoplegia was considered after bypass and the first 48 h of ICU stay lasting at least three consecutive hours. This concept of vasoplegia was compared to older definitions reported in the literature in terms of the incidence of postoperative vasoplegia and its association with adverse outcomes. Logistic regression was used to identify independent predictors. Their ability to discriminate patients with vasoplegia was quantified by the area under the receiver operating characteristic curve (AUC).

The incidence of vasoplegia was 33.1% using the unified definition of vasoplegia. Vasoplegia was associated with increased ICU length-of-stay (10.5 [6.9–20.8] vs 6.1 [4.6–10.4] p = 0.002), increased ICU-mortality (OR 5.8, 95% CI 1.9–18.2) and one-year-mortality (OR 3.9, 95% CI 1.5–10.2), and a higher incidence of renal failure (OR 4.3, 95% CI 1.8–10.4). Multivariable analysis identified previous cardiothoracic surgery, preoperative dopamine administration, preoperative bilirubin levels and preoperative creatinine clearance as independent preoperative predictors of vasoplegia. The resultant prediction model exhibited a good discriminative ability (AUC 0.80, 95% CI 0.71–0.89, p <  0.01). Temporal validation resulted in an AUC of 0.74 (95% CI 0.61–0.87, p <  0.01).

In the era of the new generation of cfLVADs, vasoplegia remains a prevalent (33%) and critical condition with worse short-term outcomes and survival. We identified previous cardiothoracic surgery, preoperative treatment with dopamine, preoperative bilirubin levels and preoperative creatinine clearance as independent predictors.

The online version of this article (10.1186/s12871-018-0645-y) contains supplementary material, which is available to authorized users.

• Cardiac Vasoplegia syndrome
• Incidence
• Mechanical circulatory support
• Morbidity
• Mortality
• Outcome
• Prediction

• Shock
• Vasoplegia

• Anaphylaxis/classification
• Anaphylaxis/physiopathology
• Free Radicals/analysis
• Free Radicals/blood
• Humans
• Hydrogen Sulfide/analysis
• Hydrogen Sulfide/blood
• Prostaglandins/analysis
• Prostaglandins/blood
• Shock, Septic/classification
• Shock, Septic/physiopathology
• Vascular Resistance/physiology
• Vasoplegia/complications
• Vasoplegia/physiopathology

• Cardiac power
• cardiac power output
• cardiac stunning
• stroke work

• Aged
• Cardiac Output
• Coronary Artery Bypass/adverse effects
• Female
• Heart/physiopathology
• Humans
• Male
• Middle Aged
• Postoperative Complications/physiopathology

• cardiac surgical procedures
• fluid balance
• mortality
• outcome
• postoperative management

• left ventricular assist device
• vasoplegia

The use of cardiopulmonary bypass (CPB) in cardiac surgery often leads to a systemic inflammatory response. Up to 25% of patients undergoing CPB for cardiac surgery are reported to develop vasoplegic syndrome in the acute postoperative period, in which the patients are refractory to vasopressors. The purpose of this study is to assess vitamin D deficiency as a risk factor for vasoplegia after using CPB. We performed a retrospective review of 1322 patients undergoing adult cardiac surgery requiring CPB. Forty-six patients with previously recorded 25-hydroxy vitamin D (25(OH)D) levels within 6 months of surgery met the conditions of this study. The mean level of 25(OH)D was 32.7 ng/mL (standard deviation [SD] = 15.1). The mean age of patients was 67 (SD = 10.1) years old, most were male (63%) and white (78%). Average CPB time was 140 ± 44 minutes. Postoperative vasopressor use was compared to individual preoperative 25(OH)D levels. As a secondary end point, postoperative vasopressor use and vasoplegia were analyzed between 3 groups: Vitamin D deficient defined as 25(OH)D ≤20 ng/mL (n = 7), vitamin D insufficient defined as 25(OH)D between 20 and 29 ng/mL (n = 15), and vitamin D sufficient defined as 25(OH)D ≥30 ng/mL (n = 24). There was no correlation between vitamin D levels and postoperative vasopressor use. The mean doses of postoperative vasopressor use were 0.088 µg/kg/min (standard error of the mean [SEM] = 0.032), 0.085 µg/kg/min (SEM = 0.037), and 0.072 µg/kg/min (SEM = 0.024) of norepinephrine equivalents for the vitamin D deficient, insufficient, and sufficient groups, respectively. Incidence of vasoplegia for each group was the following: 0.143 for vitamin D deficient, 0.067 for vitamin D insufficient, and 0.125 for vitamin D sufficient. In this pilot study, there does not appear to be a relationship between vitamin D and vasopressor use following cardiac surgery utilizing CPB; however, there appears to be a trend toward an increased vasopressor usage in patients with decreased vitamin D levels. A larger sample size and a prospective analysis are warranted to further assess the significance of the relationship between vasoplegia and vitamin D deficiency. With further investigation, vitamin D has the potential to become a low-cost, low-risk therapeutic for improving outcomes in CPB surgery.

• 25(OH)D
• cardiac surgery
• cardiopulmonary bypass
• vasoplegia
• vasopressor
• vitamin D

• cardiac surgery
• cytosorb
• heart transplantation
• hemoadsorption
• inflammatory response
• procalcitonin