Management of Vasoplegic Syndrome in Cardiac Patients

Vasoplegic syndrome is characterised by profound vasodilation and low systemic vascular resistance despite preserved or elevated cardiac output, most commonly manifesting after cardiopulmonary bypass, ventricular assist device implantation or other major cardiac procedures. Management hinges on prompt recognition and multimodal haemodynamic support. First-line therapy remains norepinephrine to restore vascular tone, with adjunctive agents such as vasopressin or angiotensin II deployed to limit catecholamine exposure and receptor desensitisation. In refractory cases, methylene blue or selective nitric oxide modulators may be considered to interrupt excessive cyclic GMP signalling. Corticosteroids can address critical-illness-related corticosteroid insufficiency and support vasopressor responsiveness. Individualised strategies informed by advanced monitoring—such as dynamic arterial elastance—enable algorithmic titration and weaning of vasopressors, reducing organ injury. Prophylactic approaches, including low-dose vasopressin during and immediately after bypass, have shown promise in preventing vasoplegia in high-risk populations. Emerging therapies under investigation aim to refine patient stratification and expand the pharmacological armamentarium, advancing personalised care in this high-risk group.

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Management of Vasoplegic Syndrome in Cardiac Patients publication trend

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Technical terms

Vasoplegic syndrome: A postoperative shock state characterised by pathological low systemic vascular resistance with preserved or elevated cardiac output, leading to refractory hypotension.

Dynamic arterial elastance (Eadyn): The ratio of pulse pressure variation to stroke volume variation, used as a real-time indicator of arterial tone during vasopressor weaning.

Vasopressor: A pharmacological agent that increases vascular tone and mean arterial pressure by acting on vascular smooth muscle receptors.

Systemic vascular resistance (SVR): The resistance offered by the systemic vasculature, calculated from arterial pressure and cardiac output, reflecting vascular tone.

Continuous-flow left ventricular assist device (cfLVAD): A mechanical pump implanted to support left ventricular function by delivering constant blood flow.

References

1. A norepinephrine weaning strategy using dynamic arterial elastance is associated with reduction of acute kidney injury in patients with vasoplegia after cardiac surgery: A post-hoc analysis of the randomized SNEAD study.. Journal of Clinical Anesthesia (2023).
2. Perioperative infusion of low- dose of vasopressin for prevention and management of vasodilatory vasoplegic syndrome in patients undergoing coronary artery bypass grafting-A double-blind randomized study. Journal of Cardiothoracic Surgery (2010).
3. Vasoplegia after implantation of a continuous flow left ventricular assist device: incidence, outcomes and predictors. BMC Anesthesiology (2018).
4. Vasoplegic syndrome following cardiothoracic surgery—review of pathophysiology and update of treatment options. Critical Care (2020).