Cardiology resident IMSS Hidalgo del parral, Chihuahua, Mexico
Disclosure(s):
Fernanda S. Soria: No financial relationships to disclose
Background: Vasoplegic syndrome is a recognized complication after cardiac surgery with, reported in up to 25% of postoperative patients. It is characterized by refractory hypotension, low systemic vascular resistance, and normal or increased cardiac output despite catecholamine therapy. Risk factors include ventricular dysfunction, prolonged bypass time, diabetes, and RAS inhibitor use.
Methods: We describe the clinical management of a case of vasoplegic syndrome in the immediate postoperative period, with successful resolution following vasopressor therapy and management in the coronary care unit. Information was obtained from the medical record, with prior patient authorization.
Outcome: A 56-year-old man with a history of arterial hypertension and diabetes mellitus presented with angina of one-year duration. Transthoracic echocardiography showed global hypokinesia with a left ventricular ejection fraction of 35%, and an exercise stress test was positive for ischemia. Coronary angiography revealed three-vessel disease with left main coronary artery involvement. After multidisciplinary discussion, the patient was referred for coronary artery bypass grafting. Three grafts were placed, with a cardiopulmonary bypass time of 88 minutes and an aortic cross-clamp time of 44 minutes. At the end of the procedure, the patient developed shock with signs of low cardiac output. Cardiogenic shock was initially suspected, and an intra-aortic balloon pump (1:1) was placed in the operating room. The patient was admitted to the coronary care unit in critical condition, requiring high-dose vasopressor and inotropic support, with blood pressure outside target ranges. Hemodynamic assessment revealed systemic vascular resistance of 319 dyn·s·cm⁻⁵ and a cardiac output of 25. Vasoplegic syndrome was suspected, and vasopressin therapy was initiated. Hemodynamic improvement was observed within a few hours, and the patient was successfully extubated 24 hours after the procedure with favorable clinical evolution.
Conclusion: The main challenge is differentiating vasoplegic syndrome from other causes of postoperative shock, particularly cardiogenic shock. In this case, persistent hypotension with high cardiac output and low systemic vascular resistance enabled timely diagnosis. it´s essential to consider diagnosis even under optimal conditions, as early recognition and treatment may impact prognosis.
