Affiliation:
1. Cardiac Surgery F.U., Experimental and Clinical Medicine Department, University of Florence, 50134 Firenze, Italy
2. Cardiac Surgery Department, St. Boniface Hospital, University of Manitoba, Winnipeg, MB R2H 2A6, Canada
Abstract
Background: Vasoplegic shock syndrome (VSS) after an off-pump coronary artery bypass graft (OPCABG) is an extremely rare condition. Inotropic support is usually the first-line therapy, though it can precipitate several complications or be ineffective. We report the first case of severe refractory VSS after OPCABG successfully treated with hydroxycobalamin. Methods: A 77-year-old gentleman underwent OPCABG for three vessels coronary artery disease. Preoperative LV ejection fraction was 28%, and the patient before surgery started sacubitril/valsartan titrated, then, at the highest dose. Surgery was uneventful and, by the end of the procedure, TEE showed improved biventricular contractility. Results: The patient was transferred to the ICU without inotropic support, but soon developed hypotension. TEE ruled out pericardial tamponade and confirmed fair contractility. Norepinephrine was titrated to a medium-high dose, vasopressin was started and a Swan-Ganz catheter was placed. SVR was 480 dyn·s·cm−5. Despite aggressive pharmacologic treatment (including methylprednisolone and methylene blue), no improvements were noticed. Ten grams of hydroxycobalamin were administered. One hour later, hemodynamic status re-assessment showed SVR > 800 dyn·s·cm−5. Afterward, vasopressors were gradually reduced. Conclusions: Our case demonstrated the importance of adequate early treatment in VSS after OPCABG. This case report shows, for the first time, that hydroxycobalamin was effectively used to restore homeostasis.
Reference37 articles.
1. Ltaief, Z., Ben-Hamouda, N., Rancati, V., Gunga, Z., Marcucci, C., Kirsch, M., and Liaudet, L. (2022). Vasoplegic Syndrome after Cardiopulmonary Bypass in Cardiovascular Surgery: Pathophysiology and Management in Critical Care. J. Clin. Med., 11.
2. A systematic approach to the treatment of vasoplegia based on recent advances in pharmacotherapy;Ortoleva;J. Cardiothorac. Vasc. Anesth.,2019
3. Vasoplegic syndrome: A new dilemma;Gomes;J. Thorac. Cardiovasc. Surg.,1994
4. Early on-cardiopulmonary bypass hypotension and other factors associated with vasoplegic syndrome;Levin;Circulation,2009
5. Is incidence of postoperative vasoplegic syndrome different between off-pump and on-pump coronary artery bypass grafting surgery?;Sun;Eur. J. Cardiothorac. Surg.,2008