You are on page 1of 27

Penyaji :

Antonius Catur S

Pembimbing :
dr. Prieta Adriane, Sp.An. KAKV, M.Kes
INTRODUCTION
• Vasoplegia, is defined by hypotension and the
continuous need of vasopressors, despite a normal or
high cardiac output
• Previous observational studies reported that 5–25% of
the patients undergoing cardiac surgery on
cardiopulmonary bypass develop vasoplegia
Purpose
• Provide more insight in the incidence, survival and
preoperative factors associated with the occurrence of
vasoplegia after heart failure surgery and to develop a
risk model.
MATERIALS AND METHODS

Study design
Retrospective cohort study all heart failure patients with a
LVEF < 35% who underwent surgical left ventricular
restoration, CorCap implantation or left ventricular assist
device (LVAD) implantation at the Leiden University
Medical Center between 2006 and 2015
End-points and data collection

Vasoplegia, defined as the continuous need of


vasopressors [norepinephrine >0.2 mg/kg/min and/or
terlipressin (any dose)] combined with a cardiac index
>2.2 l/min/m2 for at least 12 consecutive hours, starting
within the first 3 days postoperatively.

Haemodynamic, laboratory, clinical and survival data


were collected prospectively in the patient information
systems
Surgical procedures
• Surgical left ventricular restoration :
CorCap (Acorn Cardiovascular Inc, St Paul, MN)
implantation and LVAD (HeartWare Inc, Framingham,
MA) implantation
Patients received an arterial line and a pulmonary artery
catheter for intra- and postoperative monitoring of blood
pressure, cardiac output and pulmonary pressure.
Statistical analysis
• Vasoplegic and non-vasoplegic patients were compared.
Comparison of continuous data was performed using two-
tailed unpaired Student’s t-test for normally distributed variables
or otherwise the Mann–Whitney U-test.
• To explore the association of variables with the occurrence of
vasoplegia, univariable logistic regression analysis was
performed.
RESULTS
Study population
Vasoplegia
• A total of 66 patients (29%) developed vasoplegia after heart
failure surgery
• 66 vasoplegic patients, 28 (42%) underwent surgical left
ventricular restoration, 18 (27%) CorCap implantation and 20
(30%) LVAD implantation
• Cross-clamp time and cardiopulmonary bypass timewere similar
in vasoplegic and non-vasoplegic patients.
• The length of ICU stay was 8 (IQR 5, 15) days in vasoplegic patients and 2
(IQR 1, 5) days in non-vasoplegic patients (P< 0.001).
• 90-day survival rate was 71% in vasoplegic patients as compared to 91% in
non-vasoplegic patients (P < 0.001).
• 19 vasoplegic patients that died, the cause of death was assessed by post-
mortem examination in 8 (42%) patients,caused by vasoplegia-induced
multi-organ failure (N= 6) or infection related to the vasoplegia-induced
prolonged ICU admission (N= 2).
Preoperative factors associated with vasoplegia
• https://hartlongcentrum.nl/research/vasoplegia-risk-calculator/
• Higher thyroxine level is associated with a decreased systemic
vascular resistance
• Haemoglobin is known to be a nitric oxide scavenger.
• Surgical trauma and the cardiopulmonary bypass causes a
release of vasoactive factors
Omar,et al, 2015
Omar,et al, 2015
Levy,2018
Those with
vasoplegia
were
randomized to
receive
1.5 mg/Kg of
methylene blue
or a placebo.
Omar,et al, 2015
Current recommendations
• Norepinephrine as a first line-agent
• Vasopressin as a second line agent or a catecholamine sparing
• agent

Levy, et al, 2018


• The VANCS trial compared norepinephrine to vasopressin in treating
vasoplegia syndrome after cardiac surgery
• The primary endpoint was a composite of mortality or severe complications
(stroke, requirement for mechanical ventilation for longer than 48 h, deep
sternal wound infection, reoperation, or acute renal failure) within 30 days.
• The primary outcome occurred in 32 % of vasopressin patients compared to
49 % of norepinephrine patients (unadjusted hazard ratio 0.55; 95 % CI 0.38 to
0.80; p = 0.0014). With regard to adverse events, the authors found a lower
occurrence of atrial fibrillation in the vasopressin group (63.8 vs 82.1 %; p =
0.0004) and no difference between groups with regard to rates of digital
ischemia, mesenteric ischemia, hyponatremia, or myocardial infarction. These
results thus suggest that vasopressin can be used as a first-line vasopressor
agent in postcardiac surgery vasoplegic shock and improves clinical
outcomes.

Levy, et al, 2018


• VANISH study, assessing vasopressin versus norepinephrine with or
without adding hydrocortisone (factorial 2X2 study) as initial
therapy in septic shock, demonstrated no improvement in the
number of kidney failure-free days

Levy, et al, 2018


Sumary
• Vasoplegia after heart failure surgery is common and results in a
lower survival rate.
• Anaemia and a higher thyroxine level are associated with an
increased risk on vasoplegia.
• In contrast, a higher creatinine clearance and beta-blocker use
decrease the risk on vasoplegia.
TERIMA KASIH