1
|
Kumar N, Fitzsimons MG, Iyer MH, Essandoh M, Kumar JE, Dalia AA, Osho A, Sawyer TR, Bardia A. Vasoplegic syndrome during heart transplantation: A systematic review and meta-analysis. J Heart Lung Transplant 2024; 43:931-943. [PMID: 38428755 DOI: 10.1016/j.healun.2024.02.1458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/20/2023] [Accepted: 02/19/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Vasoplegic syndrome (VS) is a common occurrence during heart transplantation (HT). It currently lacks a uniform definition between transplant centers, and its pathophysiology and treatment remain enigmatic. This systematic review summarizes the available published clinical data regarding VS during HT. METHODS We searched databases for all published reports on VS during HT. Data collected included the incidence of VS in the HT population, patient and intraoperative characteristics, and postoperative outcomes. RESULTS Twenty-two publications were included in this review. The prevalence of VS during HT was 28.72% (95% confidence interval: 27.37%, 30.10%). Factors associated with VS included male sex, higher body mass index, hypothyroidism, pre-HT left ventricular assist device or venoarterial extracorporeal membrane oxygenation (VA-ECMO), pre-HT calcium channel blocker or amiodarone usage, longer cardiopulmonary bypass time, and higher blood product transfusion requirement. Patients who developed VS were more likely to require postoperative VA-ECMO support, renal replacement therapy, reoperation for bleeding, longer mechanical ventilation, and a greater 30-day and 1-year mortality. CONCLUSIONS The results of our systematic review are an initial step for providing clinicians with data that can help identify high-risk patients and avenues for potential risk mitigation. Establishing guidelines that officially define VS will aid in the precise diagnosis of these patients during HT and guide treatment. Future studies of treatment strategies for refractory VS are needed in this high-risk patient population.
Collapse
Affiliation(s)
- Nicolas Kumar
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Michael G Fitzsimons
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Manoj H Iyer
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Michael Essandoh
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Julia E Kumar
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Adam A Dalia
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Asishana Osho
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tamara R Sawyer
- Central Michigan University College of Medicine, Mt. Pleasant, Michigan
| | - Amit Bardia
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
2
|
Nesseler N, Mansour A, Cholley B, Coutance G, Bouglé A. Perioperative Management of Heart Transplantation: A Clinical Review. Anesthesiology 2023; 139:493-510. [PMID: 37458995 DOI: 10.1097/aln.0000000000004627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
In this clinical review, the authors summarize the perioperative management of heart transplant patients with a focus on hemodynamics, immunosuppressive strategies, hemostasis and hemorrage, and the prevention and treatment of infectious complications.
Collapse
Affiliation(s)
- Nicolas Nesseler
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, France; National Institute of Health and Medical Research, Center of Clinical Investigation, Nutrition, Metabolism, Cancer Mixed Research Unit, University Hospital Federation Survival Optimization in Organ Transplantation, Rennes, France
| | - Alexandre Mansour
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, France; National Institute of Health and Medical Research, Center of Clinical Investigation, Nutrition, Research Institute for Environmental and Occupational Health Mixed Research Unit, Rennes, France
| | - Bernard Cholley
- Department of Anesthesiology and Intensive Care Medicine, European Hospital Georges Pompidou, Public Hospitals of Paris, Paris, France; Paris Cité University, National Institute of Health and Medical Research Mixed Research Unit, Paris, France
| | - Guillaume Coutance
- Sorbonne University, Public Hospitals of Paris, Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrière Hospital, Paris, France
| | - Adrien Bouglé
- Sorbonne University, Clinical Research Group in Anesthesia, Resuscitation, and Perioperative Medicine, Public Hospitals of Paris, Department of Anesthesiology and Critical Care, Cardiology Institute, Pitié-Salpêtrière Hospital, Paris, France
| |
Collapse
|
3
|
Trachtenberg B, Cowger J. HFSA Expert Consensus Statement on the Medical Management of Patients on Durable Mechanical Circulatory Support. J Card Fail 2023; 29:479-502. [PMID: 36828256 DOI: 10.1016/j.cardfail.2023.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 02/24/2023]
Abstract
The medical management of patients supported with durable continuous flow left ventricular assist device (LVAD) support encompasses pharmacologic therapies administered in the preoperative, intraoperative, postoperative and chronic LVAD support stages. As patients live longer on LVAD support, the risks of LVAD-related complications and progression of cardiovascular and other diseases increase. Using existing data from cohort studies, registries, randomized trials and expert opinion, this Heart Failure Society of America Consensus Document on the Medical Management of Patients on Durable Mechanical Circulatory Support offers best practices on the management of patients on durable MCS, focusing on pharmacological therapies administered to patients on continuous flow LVADs. While quality data in the LVAD population are few, the utilization of guideline directed heart failure medical therapies (GDMT) and the importance of blood pressure management, right ventricular preload and afterload optimization, and antiplatelet and anticoagulation regimens are discussed. Recommended pharmacologic regimens used to mitigate or treat common complications encountered during LVAD support, including arrhythmias, vasoplegia, mucocutaneous bleeding, and infectious complications are addressed. Finally, this document touches on important potential pharmacological interactions from anti-depressants, herbal and nutritional supplements of relevance to providers of patients on LVAD support.
Collapse
Affiliation(s)
- Barry Trachtenberg
- Houston Methodist Heart and Vascular Center, Methodist J.C. Walter Transplant Center.
| | - Jennifer Cowger
- Medical Director, Mechanical Circulatory Support Program, Codirector, Cardiac Critical Care, Henry Ford Advanced Heart Failure Program.
| |
Collapse
|
4
|
Qin TX, Yao YT. Vasoplegic syndrome in patients undergoing heart transplantation. Front Surg 2023; 10:1114438. [PMID: 36860952 PMCID: PMC9968842 DOI: 10.3389/fsurg.2023.1114438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/11/2023] [Indexed: 02/16/2023] Open
Abstract
Objectives To summarize the risk factors, onset time, and treatment of vasoplegic syndrome in patients undergoing heart transplantation. Methods The PubMed, OVID, CNKI, VIP, and WANFANG databases were searched using the terms "vasoplegic syndrome," "vasoplegia," "vasodilatory shock," and "heart transplant*," to identify eligible studies. Data on patient characteristics, vasoplegic syndrome manifestation, perioperative management, and clinical outcomes were extracted and analyzed. Results Nine studies enrolling 12 patients (aged from 7 to 69 years) were included. Nine (75%) patients had nonischemic cardiomyopathy, and three (25%) patients had ischemic cardiomyopathy. The onset time of vasoplegic syndrome varied from intraoperatively to 2 weeks postoperatively. Nine (75%) patients developed various complications. All patients were insensitive to vasoactive agents. Conclusions Vasoplegic syndrome can occur at any time during the perioperative period of heart tranplantation, especially after the discontinuation of bypass. Methylene blue, angiotensin II, ascorbic acid, and hydroxocobalamin have been used to treat refractory vasoplegic syndrome.
Collapse
Affiliation(s)
- Tong-xin Qin
- Department of Anesthesiology, Shanxian Central Hospital, Heze, China
| | - Yun-tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China,Correspondence: Qin T-x, Yao Y-t
| | | |
Collapse
|
5
|
Desphpande SR, Bearl DW, Eghtesady P, Henderson HT, Auerbach S, Jeewa A, Bansal N, Amdani S, Richmond ME, Sacks LD, Shih R, Townsend M, Conway J. Clinical approach to vasoplegia in the transplant patient from the Pediatric Heart Transplant Society. Pediatr Transplant 2022; 26:e14392. [PMID: 36377326 DOI: 10.1111/petr.14392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/04/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022]
Abstract
This manuscript outlines a clinical approach to vasoplegia incorporating the current state of knowledge regarding vasoplegia in pediatric patients immediately post-transplant and to identify modifiable factors both pre- and post-transplant that may reduce post-operative morbidity, end-organ dysfunction, and mortality. Centers participating in the Pediatric Heart Transplant Society (PHTS) were asked to provide their internal protocols and rationale for vasoplegia management, and applicable adult and pediatric data were reviewed. The authors synthesized the above protocols and literature into the following description of clinical approaches to vasoplegia highlighting areas of both broad consensus and of significant practice variation.
Collapse
Affiliation(s)
- Shriprasad R Desphpande
- Department of Cardiology and Cardiovascular Surgery, Children's National Hospital, The George Washington University, Washington, DC, USA
| | - David W Bearl
- Department of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee, USA
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, St Louis Children's Hospital and School of Medicine, Washington University, St Louis, Michigan, USA
| | - Heather T Henderson
- Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Scott Auerbach
- Pediatrics, Division of Cardiology, University of Colorado, Denver Anschutz Medical Campus, Children's Hospital Colorado Aurora, Aurora, Colorado, USA
| | - Aamir Jeewa
- Department of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Neha Bansal
- Children's Hospital at Montefiore, Bronx, New York, USA
| | | | - Marc E Richmond
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University College of Physician and Surgeons, Morgan Stanley Children's Hospital, New York, New York, USA
| | - Loren D Sacks
- Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Renata Shih
- Congenital Heart Center, Division of Pediatric Cardiology, University of Florida, Gainesville, Florida, USA
| | | | - Jennifer Conway
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
6
|
Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 99] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|
7
|
Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|
8
|
Ltaief Z, Ben-Hamouda N, Rancati V, Gunga Z, Marcucci C, Kirsch M, Liaudet L. Vasoplegic Syndrome after Cardiopulmonary Bypass in Cardiovascular Surgery: Pathophysiology and Management in Critical Care. J Clin Med 2022; 11:6407. [PMID: 36362635 PMCID: PMC9658078 DOI: 10.3390/jcm11216407] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 09/13/2023] Open
Abstract
Vasoplegic syndrome (VS) is a common complication following cardiovascular surgery with cardiopulmonary bypass (CPB), and its incidence varies from 5 to 44%. It is defined as a distributive form of shock due to a significant drop in vascular resistance after CPB. Risk factors of VS include heart failure with low ejection fraction, renal failure, pre-operative use of angiotensin-converting enzyme inhibitors, prolonged aortic cross-clamp and left ventricular assist device surgery. The pathophysiology of VS after CPB is multi-factorial. Surgical trauma, exposure to the elements of the CPB circuit and ischemia-reperfusion promote a systemic inflammatory response with the release of cytokines (IL-1β, IL-6, IL-8, and TNF-α) with vasodilating properties, both direct and indirect through the expression of inducible nitric oxide (NO) synthase. The resulting increase in NO production fosters a decrease in vascular resistance and a reduced responsiveness to vasopressor agents. Further mechanisms of vasodilation include the lowering of plasma vasopressin, the desensitization of adrenergic receptors, and the activation of ATP-dependent potassium (KATP) channels. Patients developing VS experience more complications and have increased mortality. Management includes primarily fluid resuscitation and conventional vasopressors (catecholamines and vasopressin), while alternative vasopressors (angiotensin 2, methylene blue, hydroxocobalamin) and anti-inflammatory strategies (corticosteroids) may be used as a rescue therapy in deteriorating patients, albeit with insufficient evidence to provide any strong recommendation. In this review, we present an update of the pathophysiological mechanisms of vasoplegic syndrome complicating CPB and discuss available therapeutic options.
Collapse
Affiliation(s)
- Zied Ltaief
- Service of Adult Intensive Care, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Nawfel Ben-Hamouda
- Service of Adult Intensive Care, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Valentina Rancati
- Service of Anesthesiology, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Ziyad Gunga
- Service of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Carlo Marcucci
- Service of Anesthesiology, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Matthias Kirsch
- Service of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| | - Lucas Liaudet
- Service of Adult Intensive Care, Lausanne University Hospital and University of Lausanne, 1010 Lausanne, Switzerland
| |
Collapse
|
9
|
The Roles of Antidotes in Emergency Situations. Emerg Med Clin North Am 2022; 40:381-394. [DOI: 10.1016/j.emc.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
10
|
Sathianathan S, Bhat G, Dowling R. Vasoplegia from Continuous Flow Left Ventricular Assist Devices. Curr Cardiol Rep 2021; 23:101. [PMID: 34196837 DOI: 10.1007/s11886-021-01534-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW The contribution of continuous flow left ventricular assist devices (c-LVAD) to vasoplegic syndrome and postoperative outcomes after orthotopic heart transplant (OHT) is contested in the literature. A standardized definition of vasoplegic syndrome (VS) is needed to better recognize and manage vasoplegic shock. RECENT FINDINGS Vasoplegic syndrome occurs after orthotopic heart transplant more frequently than after other surgeries requiring cardiopulmonary bypass. c-LVADs lead to small vessel endothelial dysfunction and desensitized adrenal receptors; however, their contribution to the development of vasoplegia is debated in clinical studies. Pulsatility may mitigate vascular dysfunction resulting from long-term continuous flow, and should be further explored in the clinical setting when considering risk factors for vasoplegic syndrome. The incidence of vasoplegic syndrome after orthotopic heart transplant is rising with the increasing use of c-LVAD bridge to therapy. Robust clinical studies are needed to advance our understanding and approach to mitigating VS after OHT.
Collapse
Affiliation(s)
- Shyama Sathianathan
- School of Medicine, Penn State College of Medicine, 500 University Dr, Hershey, PA, 17033, USA.
| | - Geetha Bhat
- Heart and Vascular Institute, Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Robert Dowling
- Heart and Vascular Institute, Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA, USA
| |
Collapse
|
11
|
Emmanuel S, Pearman M, Jansz P, Hayward CS. Vasoplegia in patients following ventricular assist device explant and heart transplantation. Perfusion 2021; 37:152-161. [PMID: 33482711 DOI: 10.1177/0267659121989229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Vasoplegia has been shown to be associated with increased morbidity and mortality in patients undergoing cardiac surgery. It has been previously stated that low pulsatile states as seen with current left ventricular assist devices (LVADs) may contribute to vasoplegia post LVAD-explant and heart transplant. We sought to examine the literature regarding vasoplegia in the post-operative setting for patients undergoing LVAD explant and heart transplant. METHOD A literature review was conducted to firstly define vasoplegia in the setting of LVAD patients, and secondly to better understand the relationship between vasoplegia and LVAD explantation in the postoperative heart transplant patient cohort. A keyword search of 'vasoplegia' OR 'vasoplegic' AND 'transplant' was used. Search engines used were PubMed, Cochrane Library, ClinicalTrials.gov, Ovid, Scopus and grey literature. RESULTS 17 studies met the selection criteria for review. Three key themes emerged from the literature. Firstly, there is limited consensus regarding the definition of vasoplegia. Secondly, patients with LVADs experienced higher rates of vasoplegia following heart transplant than their counterparts and thirdly, increased cardiopulmonary bypass time was associated with a higher rate of vasoplegia. CONCLUSION Vasoplegia is not clearly defined in the literature as it pertains to the LVAD patient cohort. Patients bridged with LVADs appear to have higher rates of vasoplegia, however the aetiology of this is unclear and may be associated with continuous flow physiology or prolonged cardiopulmonary bypass time. A universal definition will aid in risk stratification, early recognition and management.
Collapse
Affiliation(s)
- Sam Emmanuel
- St Vincent's Hospital, Sydney, NSW, Australia.,School of Medicine, University of New South Wales, Sydney, NSW, Australia.,School of Medicine, University of Notre Dame, Sydney, NSW, Australia.,The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - Madeleine Pearman
- St Vincent's Hospital, Sydney, NSW, Australia.,School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | - Paul Jansz
- St Vincent's Hospital, Sydney, NSW, Australia.,School of Medicine, University of New South Wales, Sydney, NSW, Australia.,School of Medicine, University of Notre Dame, Sydney, NSW, Australia.,The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - Christopher Simon Hayward
- St Vincent's Hospital, Sydney, NSW, Australia.,School of Medicine, University of New South Wales, Sydney, NSW, Australia.,The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| |
Collapse
|
12
|
Neethling E, Moreno Garijo J, Mangalam TK, Badiwala MV, Billia P, Wasowicz M, Van Rensburg A, Slinger P. Intraoperative and Early Postoperative Management of Heart Transplantation: Anesthetic Implications. J Cardiothorac Vasc Anesth 2020; 34:2189-2206. [DOI: 10.1053/j.jvca.2019.09.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 09/07/2019] [Accepted: 09/24/2019] [Indexed: 12/16/2022]
|
13
|
Barnes TJ, Hockstein MA, Jabaley CS. Vasoplegia after cardiopulmonary bypass: A narrative review of pathophysiology and emerging targeted therapies. SAGE Open Med 2020; 8:2050312120935466. [PMID: 32647575 PMCID: PMC7328055 DOI: 10.1177/2050312120935466] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 05/21/2020] [Indexed: 12/29/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Theresa J Barnes
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
| | | | - Craig S Jabaley
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
| |
Collapse
|
14
|
Ali JM, Patel S, Catarino P, Vuylsteke A, Pettit S, Bhagra S, Kydd A, Lewis C, Parameshwar J, Kaul P, Sudarshan C, Tsui S, Jenkins D, Abu-Omar Y, Berman M. Vasoplegia following heart transplantation and left ventricular assist device explant is not associated with inferior outcomes. J Thorac Dis 2020; 12:2426-2434. [PMID: 32642148 PMCID: PMC7330418 DOI: 10.21037/jtd.2020.03.53] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Vasoplegia has been associated with inferior outcomes following heart transplantation (HTx). This observational study was designed to investigate outcomes in recipients with vasoplegia following left ventricular assist device (LVAD) explant HTx. Methods Patients undergoing LVAD explant followed by HTx from 01/2013–12/2018 at our centre were included. Vasoplegia was defined as the requirement for high dose vasopressor [noradrenaline (>0.5 μg/kg/min) and vasopressin (>1 U/h)] over the first 24 hours following HTx. Demographic and outcome data were retrieved from the transplant unit database. Results During the study period 24 patients underwent LVAD explant HTx. Of these, 13 (54.2%) developed vasoplegia. Both groups had similar duration of LVAD support (median 684 vs. 620 days P=0.62). There was a higher incidence of driveline infection in patients developing vasoplegia (69.2% vs. 18.2% P=0.02). HTx following donation after circulatory death (DCD) occurred in 9 (37.5%) patients and was not associated with a higher incidence of vasoplegia (P=0.21). Vasoplegia developed early following reperfusion and intensive care unit admission vasopressor-inotrope scores were significantly higher in patients with vasoplegia (P=0.002). Patients developing vasoplegia had similar ICU (P=0.79) and hospital (P=0.93) lengths of stay. Survival was equivalent both at 30-day (92.3% vs. 100% P=0.99) and 1-year (67.7% vs. 74.7% P=0.70). Our overall HTx 1-year survival was 89.3% over this period. Conclusions Vasoplegia is seen with a high incidence in HTx recipients bridged with an LVAD. This appears to be associated with the presence of driveline infections. Early aggressive management is advocated, resulting in equivalent 1-year survival to those patients not developing vasoplegia.
Collapse
Affiliation(s)
- Jason M Ali
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - Serena Patel
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - Pedro Catarino
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - Alain Vuylsteke
- Department of Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Stephen Pettit
- Department of Transplantation Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Sai Bhagra
- Department of Transplantation Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Anna Kydd
- Department of Transplantation Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Clive Lewis
- Department of Transplantation Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Jayan Parameshwar
- Department of Transplantation Cardiology, Royal Papworth Hospital, Cambridge, UK
| | - Pradeep Kaul
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - Catherine Sudarshan
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - Steven Tsui
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - David Jenkins
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - Yasir Abu-Omar
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| | - Marius Berman
- Department of Cardiothoracic Transplantation, Royal Papworth Hospital, Cambridge, UK
| |
Collapse
|
15
|
Miranda LE, Mente ED, Fernandes Molina CA, Sumarelli Albuquerque AA, Rubens de Nadai T, Arcêncio L, Basile-Filho A, Barbosa Evora PR. Methylene blue and the NO/cGMP pathway in solid organs transplants. Minerva Anestesiol 2020; 86:423-432. [PMID: 31994368 DOI: 10.23736/s0375-9393.20.13841-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The nitric oxide/cyclic guanosine monophosphate (NO/cGMP) pathway has a significative influence in hemodynamic changes that occur in transplants. Classically, the ischemia-reperfusion syndrome (IRS) is characterized by hypotension and low vascular resistance, when cGMP and nitric oxide (NO) are increased, contributing to oxidative stress, within an inflammatory context. These mechanisms occur in several types of transplants, such as liver, heart, lungs, kidney, which are a therapeutic choice in several clinical conditions when conventional treatments failed. It is well known the significant relation between graft dysfunction or rejection and ischemia-reperfusion injury that is linked to inflammatory response and NO/cGMP pathway activation. This review aims to study the NO/cGMP pathway in solid organ transplants. Finally, we inquire whether physicians do not underestimate the NO/cGMP pathway.
Collapse
Affiliation(s)
- Luiz E Miranda
- Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Enio D Mente
- Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Carlos A Fernandes Molina
- Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Agnes A Sumarelli Albuquerque
- Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Tales Rubens de Nadai
- Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Livia Arcêncio
- Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Anibal Basile-Filho
- Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Paulo R Barbosa Evora
- Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, São Paulo, Brazil -
| |
Collapse
|
16
|
|
17
|
Ortoleva J, Shapeton A, Vanneman M, Dalia AA. Vasoplegia During Cardiopulmonary Bypass: Current Literature and Rescue Therapy Options. J Cardiothorac Vasc Anesth 2019; 34:2766-2775. [PMID: 31917073 DOI: 10.1053/j.jvca.2019.12.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/04/2019] [Accepted: 12/09/2019] [Indexed: 11/11/2022]
Abstract
Vasoplegia syndrome in the cardiac surgical intensive care unit and postoperative period has been an area of interest to clinicians because of its prevalence and effects on morbidity and mortality. However, there is a paucity of evidence regarding the treatment of vasoplegia syndrome during cardiopulmonary bypass (on-CPB VS). This review aims to detail the incidence, outcomes, and possible treatment options for patients who develop vasoplegia during bypass. The pharmacologic rescue agents discussed are used in cases in which vasoplegia during CPB is refractory to standard catecholamine agents, such as norepinephrine, epinephrine, and phenylephrine. Methods to improve vasoplegia during CPB can be both pharmacologic and nonpharmacologic. In particular, optimization of CPB parameters plays an important nonpharmacologic role in vasoplegia during CPB. Pharmacologic agents that have been demonstrated as being effective in vasoplegia include vasopressin, terlipressin, methylene blue, hydroxocobalamin, angiotensin II (Giapreza), vitamin C, flurbiprofen (Ropion), and hydrocortisone. Although these agents have not been specifically evaluated for vasoplegia during CPB, they have shown signs of effectiveness for vasoplegia postoperatively to varying degrees. Understanding the evidence for, dosing, and side effects of these agents is crucial for cardiac anesthesiologists when treating vasoplegia during CPB bypass.
Collapse
Affiliation(s)
- Jamel Ortoleva
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Alexander Shapeton
- Department of Anesthesia, Critical Care and Pain Medicine, Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, MA
| | - Mathew Vanneman
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam A Dalia
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
18
|
Cox J, Noveras J, Harrell T, Nayak KR. When the pressure drops: A case of vasoplegia during a structural heart intervention. Catheter Cardiovasc Interv 2019; 94:280-284. [PMID: 31025531 DOI: 10.1002/ccd.28214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 02/07/2019] [Accepted: 03/16/2019] [Indexed: 01/21/2023]
Abstract
A 67-year-old male underwent general anesthesia for left atrial appendage occlusion. During the procedure, the patient developed catecholamine refractory hypotension requiring the administration of several vasopressin boluses to maintain adequate perfusion pressure. At the conclusion of the procedure, mild venous bleeding necessitated the administration of protamine. This led to a further decrease in the patient's blood pressure. Tamponade and continued volume loss were quickly ruled out leading to a diagnosis of vasoplegia syndrome (VS). The patient was appropriately treated with a vasopressin infusion with normalization of blood pressure and no significant morbidity or adverse outcome. With the use of general anesthesia during structural heart interventions on the rapid rise, we discuss the two common causes for vasoplegia along with evidence-based treatments and possible prevention strategies.
Collapse
Affiliation(s)
- Justin Cox
- Department of Cardiology, Naval Medical Center San Diego, San Diego, California
| | - Janette Noveras
- Department of Medicine, Naval Medical Center San Diego, San Diego, California
| | - Travis Harrell
- Department of Cardiology, Naval Medical Center San Diego, San Diego, California
| | - Keshav R Nayak
- Department of Cardiology, Naval Medical Center San Diego, San Diego, California.,San Diego Heart and Vascular Associates, San Diego, California.,Department of Cardiology, Scripps Mercy Hospital, San Diego, California
| |
Collapse
|
19
|
Feih JT, Rinka JR, Zundel MT. Methylene Blue Monotherapy Compared With Combination Therapy With Hydroxocobalamin for the Treatment of Refractory Vasoplegic Syndrome: ARetrospective Cohort Study. J Cardiothorac Vasc Anesth 2019; 33:1301-1307. [DOI: 10.1053/j.jvca.2018.11.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Indexed: 11/11/2022]
|
20
|
Orozco Vinasco DM, Triana Schoonewolff CA, Orozco Vinasco AC. Vasoplegic syndrome in cardiac surgery: Definitions, pathophysiology, diagnostic approach and management. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2019; 66:277-287. [PMID: 30736984 DOI: 10.1016/j.redar.2018.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/22/2018] [Accepted: 12/24/2018] [Indexed: 06/09/2023]
Abstract
Vasoplegic syndrome is a state of vasopressor resistant systemic vasodilation in the presence of a normal cardiac output. Its definition, pathophysiology, risk factors, diagnosis and therapeutic approach will be reviewed in this paper. It occurs frequently during cardiac surgery and is associated with high morbidity and mortality. A search in the LILACS, MEDLINE, and GOOGLE SCHOLAR databases was conducted to find the most relevant papers during the last 18 years. Prompt identification and diagnosis of patients at risk must be undertaken in order to implement an optimal therapeutic approach. This latter includes early treatment with vasopressors with different mechanisms of action.
Collapse
Affiliation(s)
- D M Orozco Vinasco
- Departamento de Anestesia cardiovascular, Clínica Colsubsidio Calle 100, Instituto del Corazón de Bucaramanga sede Bogotá, Bogotá, Colombia.
| | - C A Triana Schoonewolff
- Departamento de Anestesia cardiovascular, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - A C Orozco Vinasco
- Departamento de Anestesia, Hospital Universitario Severo Ochoa, Leganés Madrid, España
| |
Collapse
|
21
|
|
22
|
Abstract
Management of the cardiac transplant recipient includes careful titration of inotropes and vasopressors. Recipient pulmonary hypertension and ventilatory status must be optimized to prevent allograft right ventricular failure. Vasoplegia, coagulopathy, arrhythmias, and renal dysfunction also require careful management to achieve an optimal outcome. Primary graft dysfunction (PGD) can be an ominous problem after cardiac transplantation. Although mild degrees of PGD may be managed medically, mechanical circulatory support with extracorporeal membrane oxygenation or temporary ventricular assist devices may be required. Retransplantation may be necessary in some cases.
Collapse
Affiliation(s)
- Joseph Rabin
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
| | - David J Kaczorowski
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, 110 South Paca Street, 7th Floor, Baltimore, MD 21201, USA.
| |
Collapse
|
23
|
Shaefi S, Mittel A, Klick J, Evans A, Ivascu NS, Gutsche J, Augoustides JG. Vasoplegia After Cardiovascular Procedures—Pathophysiology and Targeted Therapy. J Cardiothorac Vasc Anesth 2018; 32:1013-1022. [DOI: 10.1053/j.jvca.2017.10.032] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Indexed: 11/11/2022]
|
24
|
Characterizing Predictors and Severity of Vasoplegia Syndrome After Heart Transplantation. Ann Thorac Surg 2018; 105:770-777. [DOI: 10.1016/j.athoracsur.2017.09.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 08/27/2017] [Accepted: 09/22/2017] [Indexed: 01/19/2023]
|
25
|
Chan JL, Kobashigawa JA, Aintablian TL, Li Y, Perry PA, Patel JK, Kittleson MM, Czer LS, Zarrini P, Velleca A, Rush J, Arabia FA, Trento A, Esmailian F. Vasoplegia after heart transplantation: outcomes at 1 year. Interact Cardiovasc Thorac Surg 2017; 25:212-217. [PMID: 28459983 DOI: 10.1093/icvts/ivx081] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 02/15/2017] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Vasoplegia syndrome is a potentially life-threatening condition that can occur following cardiopulmonary bypass. Heart transplantation is a recognized risk factor for developing this vasodilatory state. The objective of this study was to determine the effects of vasoplegia syndrome on 1-year heart transplant outcomes. METHODS A retrospective review of orthotopic heart transplants at a single institution between November 2010 and December 2014 was performed. Of the 347 consecutive adult patients, 107 patients (30.8%) met criteria for vasoplegia syndrome. Preoperative factors and intraoperative variables were collected and compared between vasoplegia and non-vasoplegia cohorts. The incidence of postoperative complications, transplant rejection and patient survival within 1 year were evaluated. RESULTS Demographics and preoperative medication profiles were similar in both groups, while mechanical circulatory support device use was associated with vasoplegia syndrome (30.8% vs 20.0%; P = 0.039). Perioperative characteristics such as longer cardiopulmonary bypass [165.0 (interquartile range [IQR] 74) min vs 140.0 (IQR 42.7) min; P < 0.001] and increased blood product usage (24.7 ± 17.2 units vs 17.7 ± 14.3 units; P < 0.001) were associated with vasoplegia. Non-vasoplegia patients were more likely to be extubated [42.9 (IQR 37.3) h vs 66.8 (IQR 50.2) h; P < 0.001] and discharged earlier [10.0 (IQR 6) days vs 14.0 (IQR 11.5) days; P < 0.001]. One-year patient survival (92.0% vs 88.6%; P = 0.338) and any-treated rejection rates (82.7% vs 84.3%; P = 0.569) were not significantly different between groups. CONCLUSIONS Although vasoplegia syndrome was associated with an increase in perioperative morbidity, including greater mechanical ventilation time and hospital length of stay, no significant differences in survival or allograft rejection at 1 year was demonstrated.
Collapse
Affiliation(s)
- Joshua L Chan
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | - Yanqing Li
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Paul A Perry
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | | | | | | | | | | | - Jenna Rush
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Francisco A Arabia
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alfredo Trento
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Fardad Esmailian
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
26
|
|
27
|
Methylene Blue for Vasoplegic Syndrome After Cardiac Operation: Early Administration Improves Survival. Ann Thorac Surg 2017; 104:36-41. [PMID: 28551045 DOI: 10.1016/j.athoracsur.2017.02.057] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/15/2017] [Accepted: 02/16/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Vasoplegic syndrome, defined by hypotension despite normal or increased cardiac output, is associated with high mortality rate after cardiopulmonary bypass. Methylene blue (MB) is reported to ameliorate vasoplegic syndrome through the nitric oxide pathway. We hypothesized that early administration of MB would improve outcomes in patients with vasoplegic syndrome after cardiopulmonary bypass. METHODS All patients that underwent cardiopulmonary bypass at our institution (Jan 1, 2011 to Jun 30, 2016) were identified through our Society of Thoracic Surgery database. Pharmacy records identified patients receiving MB within 72 hours of cardiopulmonary bypass. Multivariate logistic regression identified predictors of major adverse events among patients receiving MB. RESULTS A total of 118 cardiopulmonary bypass patients (3.3%) received MB for vasoplegic syndrome. These patients had a higher incidence of comorbidities, and these cases were more commonly reoperative (76.1% versus 41.2%, p < 0.0001) and complex (70.3% versus 31.8%, p < 0.0001). The only difference in preoperative medications was that MB patients had a higher rate of amiodarone use (15.3% versus 2.2%, p < 0.0001). MB patients had significantly higher rates of postoperative complications, except atrial fibrillation. Early (operating room, 40.7%) versus late (intensive care unit, 59.3%) administration of MB was associated with significantly reduced operative mortality rate (10.4% versus 28.6%, p = 0.018) and risk-adjusted major adverse events (odd ratio 0.35, p = 0.037). CONCLUSIONS Operative mortality rate is high in patients receiving MB for the treatment of vasoplegia after cardiopulmonary bypass. Early administration of MB improves survival and reduces the risk-adjusted rate of major adverse events in these patients.
Collapse
|
28
|
Wolvetang T, Janse R, ter Horst M. Serotonin Syndrome After Methylene Blue Administration During Cardiac Surgery: A Case Report and Review. J Cardiothorac Vasc Anesth 2016; 30:1042-5. [DOI: 10.1053/j.jvca.2015.11.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Indexed: 01/07/2023]
|
29
|
Judenherc-Haouzi A, Zhang XQ, Sonobe T, Song J, Rannals MD, Wang J, Tubbs N, Cheung JY, Haouzi P. Methylene blue counteracts H2S toxicity-induced cardiac depression by restoring L-type Ca channel activity. Am J Physiol Regul Integr Comp Physiol 2016; 310:R1030-44. [PMID: 26962024 DOI: 10.1152/ajpregu.00527.2015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 03/08/2016] [Indexed: 11/22/2022]
Abstract
We have previously reported that methylene blue (MB) can counteract hydrogen sulfide (H2S) intoxication-induced circulatory failure. Because of the multifarious effects of high concentrations of H2S on cardiac function, as well as the numerous properties of MB, the nature of this interaction, if any, remains uncertain. The aim of this study was to clarify 1) the effects of MB on H2S-induced cardiac toxicity and 2) whether L-type Ca(2+) channels, one of the targets of H2S, could transduce some of the counteracting effects of MB. In sedated rats, H2S infused at a rate that would be lethal within 5 min (24 μM·kg(-1)·min(-1)), produced a rapid fall in left ventricle ejection fraction, determined by echocardiography, leading to a pulseless electrical activity. Blood concentrations of gaseous H2S reached 7.09 ± 3.53 μM when cardiac contractility started to decrease. Two to three injections of MB (4 mg/kg) transiently restored cardiac contractility, blood pressure, and V̇o2, allowing the animals to stay alive until the end of H2S infusion. MB also delayed PEA by several minutes following H2S-induced coma and shock in unsedated rats. Applying a solution containing lethal levels of H2S (100 μM) on isolated mouse cardiomyocytes significantly reduced cell contractility, intracellular calcium concentration ([Ca(2+)]i) transient amplitudes, and L-type Ca(2+) currents (ICa) within 3 min of exposure. MB (20 mg/l) restored the cardiomyocyte function, ([Ca(2+)]i) transient, and ICa The present results offer a new approach for counteracting H2S toxicity and potentially other conditions associated with acute inhibition of L-type Ca(2+) channels.
Collapse
Affiliation(s)
- Annick Judenherc-Haouzi
- Heart and Vascular Institute, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania;
| | - Xue-Qian Zhang
- Center of Translational Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania; and
| | - Takashi Sonobe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Jianliang Song
- Center of Translational Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania; and
| | - Matthew D Rannals
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - JuFang Wang
- Center of Translational Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania; and
| | - Nicole Tubbs
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Joseph Y Cheung
- Center of Translational Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania; and Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Philippe Haouzi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| |
Collapse
|
30
|
Haouzi P, Sonobe T, Judenherc-Haouzi A. Developing effective countermeasures against acute hydrogen sulfide intoxication: challenges and limitations. Ann N Y Acad Sci 2016; 1374:29-40. [PMID: 26945701 DOI: 10.1111/nyas.13015] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 12/25/2015] [Accepted: 01/11/2016] [Indexed: 12/20/2022]
Abstract
Hydrogen sulfide (H2 S) is a chemical hazard in the gas and farming industry. As it is easy to manufacture from common chemicals, it has also become a method of suicide. H2 S exerts its toxicity through its high affinity with metalloproteins, such as cytochrome c oxidase and possibly via its interactions with cysteine residues of various proteins. The latter was recently proposed to acutely alter ion channels with critical implications for cardiac and brain functions. Indeed, during severe H2 S intoxication, a coma, associated with a reduction in cardiac contractility, develops within minutes or even seconds leading to death by complete electromechanical dissociation of the heart. In addition, long-term neurological deficits can develop owing to the direct toxicity of H2 S on neurons combined with the consequences of a prolonged apnea and circulatory failure. Here, we review the challenges impeding efforts to offer an effective treatment against H2 S intoxication using agents that trap free H2 S, and present novel pharmacological approaches aimed at correcting some of the most harmful consequences of H2 S intoxication.
Collapse
Affiliation(s)
- Philippe Haouzi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Takashi Sonobe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Annick Judenherc-Haouzi
- Heart and Vascular Institute, Department of Medicine, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| |
Collapse
|
31
|
Evora PRB, Alves Junior L, Ferreira CA, Menardi AC, Bassetto S, Rodrigues AJ, Scorzoni Filho A, Vicente WVDA. Twenty years of vasoplegic syndrome treatment in heart surgery. Methylene blue revised. Braz J Cardiovasc Surg 2015; 30:84-92. [PMID: 25859872 PMCID: PMC4389523 DOI: 10.5935/1678-9741.20140115] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 10/12/2014] [Indexed: 11/20/2022] Open
Abstract
Objective This study was conducted to reassess the concepts established over the past 20
years, in particular in the last 5 years, about the use of methylene blue in the
treatment of vasoplegic syndrome in cardiac surgery. Methods A wide literature review was carried out using the data extracted from: MEDLINE,
SCOPUS and ISI WEB OF SCIENCE. Results The reassessed and reaffirmed concepts were 1) MB is safe in the recommended doses
(the lethal dose is 40 mg/kg); 2) MB does not cause endothelial dysfunction; 3)
The MB effect appears in cases of NO up-regulation; 4) MB is not a
vasoconstrictor, by blocking the cGMP pathway it releases the cAMP pathway,
facilitating the norepinephrine vasoconstrictor effect; 5) The most used dosage is
2 mg/kg as IV bolus, followed by the same continuous infusion because plasma
concentrations sharply decrease in the first 40 minutes; and 6) There is a
possible "window of opportunity" for MB's effectiveness. In the last five years,
major challenges were: 1) Observations about side effects; 2) The need for
prophylactic and therapeutic guidelines, and; 3) The need for the establishment of
the MB therapeutic window in humans. Conclusion MB action to treat vasoplegic syndrome is time-dependent. Therefore, the great
challenge is the need, for the establishment the MB therapeutic window in humans.
This would be the first step towards a systematic guideline to be followed by
possible multicenter studies.
Collapse
Affiliation(s)
- Paulo Roberto Barbosa Evora
- Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Lafaiete Alves Junior
- Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Cesar Augusto Ferreira
- Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Antônio Carlos Menardi
- Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Solange Bassetto
- Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Alfredo José Rodrigues
- Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Adilson Scorzoni Filho
- Department of Surgery and Anatomy, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | | |
Collapse
|
32
|
Sonobe T, Chenuel B, Cooper TK, Haouzi P. Immediate and Long-Term Outcome of Acute H2S Intoxication Induced Coma in Unanesthetized Rats: Effects of Methylene Blue. PLoS One 2015; 10:e0131340. [PMID: 26115032 PMCID: PMC4482667 DOI: 10.1371/journal.pone.0131340] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 06/01/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Acute hydrogen sulfide (H2S) poisoning produces a coma, the outcome of which ranges from full recovery to severe neurological deficits. The aim of our study was to 1--describe the immediate and long-term neurological effects following H2S-induced coma in un-anesthetized rats, and 2--determine the potential benefit of methylene blue (MB), a compound we previously found to counteract acute sulfide cardiac toxicity. METHODS NaHS was administered IP in un-sedated rats to produce a coma (n = 34). One minute into coma, the rats received MB (4 mg/kg i.v.) or saline. The surviving rats were followed clinically and assigned to Morris water maze (MWM) and open field testing then sacrificed at day 7. RESULTS Sixty percent of the non-treated comatose rats died by pulseless electrical activity. Nine percent recovered with neurological deficits requiring euthanasia, their brain examination revealed major neuronal necrosis of the superficial and middle layers of the cerebral cortex and the posterior thalamus, with variable necrosis of the caudate putamen, but no lesions of the hippocampus or the cerebellum, in contrast to the typical distribution of post-ischemic lesions. The remaining animals displayed, on average, a significantly less effective search strategy than the control rats (n = 21) during MWM testing. Meanwhile, 75% of rats that received MB survived and could perform the MWM test (P<0.05 vs non-treated animals). The treated animals displayed a significantly higher occurrence of spatial search than the non-treated animals. However, a similar proportion of cortical necrosis was observed in both groups, with a milder clinical presentation following MB. CONCLUSION In conclusion, in rats surviving H2S induced coma, spatial search patterns were used less frequently than in control animals. A small percentage of rats presented necrotic neuronal lesions, which distribution differed from post-ischemic lesions. MB dramatically improved the immediate survival and spatial search strategy in the surviving rats.
Collapse
Affiliation(s)
- Takashi Sonobe
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Pennsylvania State University, College of Medicine, Hershey, PA, United States of America
| | - Bruno Chenuel
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Pennsylvania State University, College of Medicine, Hershey, PA, United States of America
| | - Timothy K. Cooper
- Department of Comparative Medicine, Pennsylvania State University, College of Medicine, Hershey, PA, United States of America
- Department of Pathology, Pennsylvania State University, College of Medicine, Hershey, PA, United States of America
| | - Philippe Haouzi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Pennsylvania State University, College of Medicine, Hershey, PA, United States of America
- * E-mail:
| |
Collapse
|
33
|
Sonobe T, Haouzi P. H2S induced coma and cardiogenic shock in the rat: Effects of phenothiazinium chromophores. Clin Toxicol (Phila) 2015; 53:525-39. [PMID: 25965774 DOI: 10.3109/15563650.2015.1043440] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
CONTEXT Hydrogen sulfide (H2S) intoxication produces an acute depression in cardiac contractility-induced circulatory failure, which has been shown to be one of the major contributors to the lethality of H2S intoxication or to the neurological sequelae in surviving animals. Methylene blue (MB), a phenothiazinium dye, can antagonize the effects of the inhibition of mitochondrial electron transport chain, a major effect of H2S toxicity. OBJECTIVES We investigated whether MB could affect the immediate outcome of H2S-induced coma in un-anesthetized animals. Second, we sought to characterize the acute cardiovascular effects of MB and two of its demethylated metabolites-azure B and thionine-in anesthetized rats during lethal infusion of H2S. MATERIALS AND METHODS First, MB (4 mg/kg, intravenous [IV]) was administered in non-sedated rats during the phase of agonal breathing, following NaHS (20 mg/kg, IP)-induced coma. Second, in 4 groups of urethane-anesthetized rats, NaHS was infused at a rate lethal within 10 min (0.8 mg/min, IV). Whenever cardiac output (CO) reached 40% of its baseline volume, MB, azure B, thionine, or saline were injected, while sulfide infusion was maintained until cardiac arrest occurred. RESULTS Seventy-five percent of the comatose rats that received saline (n = 8) died within 7 min, while all the 7 rats that were given MB survived (p = 0.007). In the anesthetized rats, arterial, left ventricular pressures and CO decreased during NaHS infusion, leading to a pulseless electrical activity within 530 s. MB produced a significant increase in CO and dP/dtmax for about 2 min. A similar effect was produced when MB was also injected in the pre-mortem phase of sulfide exposure, significantly increasing survival time. Azure B produced an even larger increase in blood pressure than MB, while thionine had no effect. CONCLUSION MB can counteract NaHS-induced acute cardiogenic shock; this effect is also produced by azure B, but not by thionine, suggesting that the presence of methyl groups is a prerequisite for producing this protective effect.
Collapse
Affiliation(s)
- Takashi Sonobe
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Pennsylvania State University, College of Medicine , Hershey, PA , USA
| | | |
Collapse
|
34
|
Hall R. Identification of Inflammatory Mediators and Their Modulation by Strategies for the Management of the Systemic Inflammatory Response During Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:983-1033. [DOI: 10.1053/j.jvca.2012.09.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Indexed: 12/21/2022]
|
35
|
Evora PRB. Methylene blue, serotonergic syndrome, and heart transplant. J Thorac Cardiovasc Surg 2013; 145:897. [PMID: 23415006 DOI: 10.1016/j.jtcvs.2012.11.090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Accepted: 11/06/2012] [Indexed: 10/27/2022]
|
36
|
Evora PRB. Methylene blue for the treatment of refractory anaphylaxis without hypotension. Am J Emerg Med 2013; 31:753. [DOI: 10.1016/j.ajem.2013.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 01/25/2013] [Accepted: 01/28/2013] [Indexed: 10/27/2022] Open
|
37
|
Lenglet S, Mach F, Montecucco F. Methylene blue: potential use of an antique molecule in vasoplegic syndrome during cardiac surgery. Expert Rev Cardiovasc Ther 2012; 9:1519-25. [PMID: 22103871 DOI: 10.1586/erc.11.160] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Vasoplegic syndrome is a common complication of cardiopulmonary bypass, appearing with an incidence ranging between 5 and 25%. It is characterized by significant hypotension, high or normal cardiac output and low systemic vascular resistance. This syndrome is hypothesized to be caused by the inflammation-mediated dysregulation of endothelial homeostasis and subsequent endothelial dysfunction. In vasoplegic syndrome, the inhibition of the nitric oxide/cyclic guanosine monophosphate pathway with concomitant administration with traditional ionotropes may represent a promising therapeutic option. Methylene blue, an inhibitor of nitric oxide synthase and guanylate cyclase, may contribute to the improvement of refractory hypotension associated with endothelial dysfunction in vasoplegia. In this article, we will update evidence on the potential therapeutic use of methylene blue in vasoplegic syndrome.
Collapse
Affiliation(s)
- Sébastien Lenglet
- Division of Cardiology, Faculty of Medicine, Foundation for Medical Research, Geneva University Hospitals, Avenue de la Roseraie 64, 1211 Geneva 4, Switzerland
| | | | | |
Collapse
|
38
|
Vasopressortherapie des postoperativen vasoplegischen Syndroms. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2011. [DOI: 10.1007/s00398-011-0881-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
|
39
|
Bhalla T, Sawardekar A, Russell H, Tobias JD. The Role of Methylene Blue in the Pediatric Patient With Vasoplegic Syndrome. World J Pediatr Congenit Heart Surg 2011; 2:652-5. [DOI: 10.1177/2150135111410992] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Patients with vasoplegic syndrome (VPS) in the post-cardiopulmonary bypass setting usually require escalating vasopressor support. The utilization of methylene blue (MB) in the treatment of VPS in the adult population has been well described. We present a 5-year-old girl who developed vasodilatory shock due to VPS that was resistant to escalating doses of adrenergic agonists following cardiac transplantation. After receiving 1 mg/kg of MB, there was a significant improvement in the patient’s mean arterial pressure which allowed for progressive weaning of the vasopressor support. To date, there are limited data regarding the use of MB in pediatric patients with VPS following cardiothoracic surgery. The cellular mechanisms of MB in VPS are discussed and reports of its use in the adult and pediatric population are reviewed. Dosing regimens and potential adverse effects of MB are presented.
Collapse
Affiliation(s)
- Tarun Bhalla
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Amod Sawardekar
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Hyde Russell
- Department of Congenital Cardiothoracic Surgery, Northwestern University’s Children’s Memorial Hospital, Chicago, IL, USA
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| |
Collapse
|
40
|
Raikhelkar JK, Milla F, Darrow B, Scurlock C. Adjuvant Therapy with Methylene Blue in the Treatment of Right Ventricular Failure after Pulmonary Embolectomy. Heart Lung Circ 2011; 20:234-6. [DOI: 10.1016/j.hlc.2010.08.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Revised: 07/17/2010] [Accepted: 08/30/2010] [Indexed: 11/16/2022]
|
41
|
Fischer GW, Levin MA. Vasoplegia during cardiac surgery: current concepts and management. Semin Thorac Cardiovasc Surg 2011; 22:140-4. [PMID: 21092891 DOI: 10.1053/j.semtcvs.2010.09.007] [Citation(s) in RCA: 156] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2010] [Indexed: 12/11/2022]
Abstract
Vasoplegic syndrome (VS) is a recognized and relatively common complication of cardiopulmonary bypass (CPB), appearing with an incidence ranging between 5% and 25%. It is characterized by significant hypotension, high or normal cardiac outputs and low systemic vascular resistance (SVR), and increased requirements for fluids and vasopressors during or after CPB. Patients developing VS are at increased risk for death and other major complications following cardiac surgery. This review will focus on the pathophysiology and contemporary strategies of treating VS encountered after CPB.
Collapse
Affiliation(s)
- Gregory W Fischer
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York 10029, USA.
| | | |
Collapse
|
42
|
Fischer GW, Bengtsson Y, Scarola S, Cohen E. Methylene Blue for Vasopressor-Resistant Vasoplegia Syndrome During Liver Transplantation. J Cardiothorac Vasc Anesth 2010; 24:463-6. [DOI: 10.1053/j.jvca.2008.07.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Indexed: 11/11/2022]
|
43
|
Levin MA, Lin HM, Castillo JG, Adams DH, Reich DL, Fischer GW. Early on-cardiopulmonary bypass hypotension and other factors associated with vasoplegic syndrome. Circulation 2009; 120:1664-71. [PMID: 19822810 DOI: 10.1161/circulationaha.108.814533] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Vasoplegic syndrome is a form of vasodilatory shock that can occur after cardiopulmonary bypass (CPB). We hypothesized that the severity and duration of the decline in mean arterial pressure immediately after CPB is begun can be used as a predictor of patients will develop vasoplegia in the immediate post-CPB period and of poor clinical outcome. We quantified the decline in mean arterial pressure by calculating an area above the mean arterial blood pressure curve. METHODS AND RESULTS We retrospectively analyzed 2823 adult cardiac surgery cases performed between July 2002 and December 2006. Of these 2823, 577 (20.4%) were vasoplegic after separation from CPB. We found that 1645 patients (58.3%) had a clinically significant decline in mean arterial pressure after starting CPB (area above the mean arterial blood pressure curve >0) and were significantly more likely to become vasoplegic (23.0% versus 16.9%; odds ratio, 1.26; 95% confidence interval, 1.12 to 1.43; P<0.001). These patients were also far more likely either to die in hospital or to have a length of stay >10 days (odds ratio, 3.30; 95% confidence interval, 1.44 to 7.57; P=0.005). Additional risk factors for developing vasoplegia that were identified included the additive euroSCORE, procedure type, prebypass mean arterial pressure, length of bypass, administration of pre-CPB vasopressors, core temperature on CPB, pre- and post-CPB hematocrit, the preoperative use of beta-blockers or angiotensin-converting enzyme inhibitors, and the intraoperative use of aprotinin. CONCLUSIONS The results of this investigation suggest that it is possible to predict vasoplegia intraoperatively before separation from CPB and that the presence of a clinically significant area above the mean arterial blood pressure curve serves as a predictor of poor clinical outcome.
Collapse
Affiliation(s)
- Matthew A Levin
- Departments of Anesthesiology, Mount Sinai Medical Center, New York, NY 10029, USA
| | | | | | | | | | | |
Collapse
|
44
|
Bozzetti G, Ranucci M, Grillone G. Concomitant Pulmonary Hypertension and Vasoplegia Syndrome After Heart Transplant: A Challenging Picture. J Cardiothorac Vasc Anesth 2008; 22:868-71. [DOI: 10.1053/j.jvca.2007.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Indexed: 11/11/2022]
|
45
|
Abstract
Vasoplegia resulting from severe burns may persist despite adequate fluid resuscitation and treatment with norepinephrine (NE), vasopressin (VP), and steroids. The adenylate cyclase inhibitor methylene blue (MB), currently used in the burn patient to treat methemoglobinemia, has been used to treat vasoplegia after cardiopulmonary bypass. We report the case of MB infusion in two burn patients refractory to NE. The patients had severe burns, 95 and 80% TBSA not responding to conventional treatment. Fluid requirements were estimated according to Parkland formula and then to maintain a urinary output of 30-50 ml/hr. Patient #1, 95% TBSA, was adrenally insufficient and was receiving steroids according to the Annane protocol, as well as VP at 0.2 U/min. His NE requirements were 55 mcg/kg/min. Patient #2, 80% TBSA, was receiving 20 mcg/kg/min of NE. Circulatory failure was defined as inability to maintain mean arterial pressure >70 mm Hg. Hemodynamic and physiologic parameters were measured before and after infusion of a single dose of 2 mg/kg of MB. Both patients showed dramatic improvements in their shock after MB. Patient #1 had an initial reaction within 30 minutes and reached peak effect at 1 hour. His NE requirements decreased to 0.2 mcg/kg/min and VP decreased to 0.04 U/min. Patient #2 showed effects within 15 minutes of the infusion and by 2 hours the NE was stopped. No adverse side effects were noted in either of the two patients. The fact that MB successfully reversed refractory vasoplegia after severe burns suggests a new tool for treating a small subgroup of patients who exhibit persistent vasoplegia from their burn injury. A controlled randomized trial is needed to test its effects on a large number of patients and graft survival.
Collapse
|
46
|
Faber P, Ronald A, Millar BW. Methylthioninium chloride: pharmacology and clinical applications with special emphasis on nitric oxide mediated vasodilatory shock during cardiopulmonary bypass. Anaesthesia 2005; 60:575-87. [PMID: 15918829 DOI: 10.1111/j.1365-2044.2005.04185.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Vasodilatory shock after cardiopulmonary bypass is a common complication requiring treatment with high doses of inotropes and prolonged stays in the intensive care unit. The vasodilatory shock is initiated by an inflammatory response to the extracorporeal circuit. The inflammatory response results in endothelial synthesis and release of nitric oxide resembling the clinical features observed in vasodilatory shock caused by septicaemia. During vasodilatory shock, the inhibition of nitric oxide synthase and the nitric oxide/cyclic guanylyl monophosphate pathway is an attractive adjunct to therapy with traditional inotropes. Methylthioninium chloride inhibits nitric oxide/cyclic guanylyl monophosphate mediated vasodilation and can successfully be used as a supplement in the treatment of vasodilatory shock associated with cardiopulmonary bypass. The application of methylthioninium chloride in septicaemia has not produced comparable positive clinical results.
Collapse
Affiliation(s)
- P Faber
- Department of Cardiac Anaesthesia, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, Scotland, UK.
| | | | | |
Collapse
|
47
|
Levin RL, Degrange MA, Bruno GF, Del Mazo CD, Taborda DJ, Griotti JJ, Boullon FJ. Methylene blue reduces mortality and morbidity in vasoplegic patients after cardiac surgery. Ann Thorac Surg 2004; 77:496-9. [PMID: 14759425 DOI: 10.1016/s0003-4975(03)01510-8] [Citation(s) in RCA: 176] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2003] [Indexed: 11/23/2022]
Abstract
BACKGROUND The discovery of nitric oxide as mediator in cardiac postoperative vasoplegia encourages the use of inhibitory drugs such as methylene blue. This drug has been used with favorable results in isolated cases. The purpose of this article is to analyze the incidence of the postoperative vasoplegic syndrome, to consider its prognosis, and to evaluate the effect of intravenous methylene blue on mortality. METHODS Cardiac surgery patients were consecutively included. Vasoplegic syndrome was defined by the presence of the following five criteria: (1) hypotension, (2) low filling pressures, (3) high or normal cardiac index, (4) low peripheral resistance, and (5) vasopressor requirements. Those with vasoplegia were randomized to receive 1.5 mg/Kg of methylene blue or a placebo. A p value less than 0.05 was considered significant. RESULTS Six hundred thirty eight cardiac surgery patients were consecutively included in this study. Fifty-six of these patients fulfilled vasoplegia criteria (8.8%) resulting in higher mortality (10.7% or 6 of 56 patients vs 3.6% or 21 of 582 patients; p value = 0.02). Those treated with methylene blue showed morbidity and mortality reductions (0% versus 21.4% or 6 of 28 patients; p value = 0.01). The duration of the vasoplegic syndrome was shorter in those patients treated with the drug, lasting less than 6 hours in all patients. Patients in the control group showed a slower recovery, lasting more than 48 hours in 8 patients (p value = 0.0007). CONCLUSIONS Vasoplegic postoperative syndrome was seen in 8.8% of all patients. Outcome in patients with vasoplegia was worse with increased morbidity and mortality. The use of methylene blue reduced the high mortality in this population.
Collapse
Affiliation(s)
- Ricardo L Levin
- Division of Cardiovascular Surgery, Navy Hospital, French Hospital, Swiss-Argentine Clinic, Argentine Institute of Diagnosis and Saint Elizabeth Clinic, Buenos Aires, Argentina.
| | | | | | | | | | | | | |
Collapse
|
48
|
Leyh RG, Kofidis T, Strüber M, Fischer S, Knobloch K, Wachsmann B, Hagl C, Simon AR, Haverich A. Methylene blue: the drug of choice for catecholamine-refractory vasoplegia after cardiopulmonary bypass? J Thorac Cardiovasc Surg 2003; 125:1426-31. [PMID: 12830064 DOI: 10.1016/s0022-5223(02)73284-4] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Vasoplegia is a frequent complication after cardiopulmonary bypass that often requires the application of norepinephrine. In a number of cases, however, vasoplegia is refractory to norepinephrine. The guanylate cyclase inhibitor methylene blue could be an attractive treatment alternative in such cases. This study examines the results of methylene blue therapy for norepinephrine-refractory vasoplegia after cardiopulmonary bypass. METHODS A total of 54 patients with norepinephrine-refractory vasoplegia after cardiopulmonary bypass were treated with methylene blue (2 mg/kg) administered intravenously through a period of 20 minutes. The effects on hemodynamics, norepinephrine dosage, and clinical outcome were evaluated. RESULTS Three patients (5.6%) died during the hospital stay. A clinically relevant increase in systemic vascular resistance and a decrease in norepinephrine dosage were observed in 51 patients within 1 hour after methylene blue infusion. Four patients (7.4%) had no response to methylene blue. No adverse effects related to methylene blue were observed. CONCLUSIONS A single dose of methylene blue seems to be a potent approach to norepinephrine-refractory vasoplegia after cardiopulmonary bypass for most patients, with no obvious side effects. Guanylate cyclase inhibitors could be a novel class of agents for the treatment of norepinephrine-refractory vasoplegia after cardiopulmonary bypass. A controlled clinical trial is now needed to evaluate the role of methylene blue in this situation.
Collapse
Affiliation(s)
- Rainer G Leyh
- Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|