Use of Oral Droxidopa to Improve Arterial Pressure and Reduce Vasoactive Drug Requirements During Persistent Vasoplegic Syndrome After Cardiac Transplantation.

Abstract

VASOPLEGIC SYNDROME IS a common complication of cardiopulmonary bypass that occurs in as many as 25% of patients undergoing cardiac surgery. 1 Gomes W.J. Carvalho A.C. Palma J.H. et al. Vasoplegic syndrome after open heart surgery. J Cardiovasc Surg (Torino). 1998; 39: 619-623 PubMed Google Scholar , 2 Fischer G.W. Levin M.A. Vasoplegia during cardiac surgery: Current concepts and management. Semin Thorac Cardiovasc Surg. 2010; 22: 140-144 Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar The mechanisms responsible for vasoplegia are incompletely understood. Proinflammatory cytokine release (eg, interleukins 6 and 8, tumor necrosis factor) 3 Wan S. Marchant A. DeSmet J.M. et al. Human cytokine responses to cardiac transplantation and coronary artery bypass grafting. J Thorac Cardiovasc Surg. 1996; 111: 469-477 Abstract Full Text Full Text PDF PubMed Scopus (168) Google Scholar and complement activation 4 Kirklin J.K. Prospects for understanding and eliminating the deleterious effects of cardiopulmonary bypass. J Thorac Cardiovasc Surg. 1991; 51: 529-531 Scopus (210) Google Scholar contribute to endothelial dysfunction, characterized by disinhibited cyclic guanosine monophosphate-mediated nitric oxide production. 5 Lenglet S. Mach F. Montecucco F. Methylene blue: Potential use of an antique molecule in vasoplegic syndrome during cardiac surgery. Expert Rev Cardiovasc Ther. 2011; 9: 1519-1525 Crossref PubMed Scopus (30) Google Scholar When combined with a relative absence of endogenous vasoconstrictors, 6 Argenziano M. Chen J.M. Choudhri A.F. et al. Management of vasodilatory shock after cardiac surgery: Identification of predisposing factors and use of a novel pressor agent. J Thorac Cardiovasc Surg. 1998; 116: 973-980 Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar this endothelial dysfunction causes profound arterial and venous vasodilation, reduces left ventricular preload and afterload, and results in precipitous declines in mean arterial pressure. 5 Lenglet S. Mach F. Montecucco F. Methylene blue: Potential use of an antique molecule in vasoplegic syndrome during cardiac surgery. Expert Rev Cardiovasc Ther. 2011; 9: 1519-1525 Crossref PubMed Scopus (30) Google Scholar The resulting hypotension may be refractory to volume administration and intravenous vasoactive medications. 2 Fischer G.W. Levin M.A. Vasoplegia during cardiac surgery: Current concepts and management. Semin Thorac Cardiovasc Surg. 2010; 22: 140-144 Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar Vasoplegic syndrome that does not respond to treatment with norepinephrine 7 Mekontso-Dessap A. Houel R. Soustelle C. et al. Risk factors for post-cardiopulmonary bypass vasoplegia in patients with preserved left ventricular function. Ann Thorac Surg. 2001; 71: 1428-1432 Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar and vasoplegia that persists for more than 48 hours after cardiac surgery are associated with poor prognosis. 8 Leyh R.G. Kofidis T. Struber M. et al. Methylene blue: The drug of choice for catecholamine-refractory vasoplegia after cardiopulmonary bypass?. J Thorac Cardiovasc Surg. 2003; 125: 1426-1431 Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar , 9 Levin M.A. Lin H.M. Castillo J.G. et al. Early on-cardiopulmonary bypass hypotension and other factors associated with vasoplegic syndrome. Circulation. 2009; 120: 1664-1671 Crossref PubMed Scopus (156) Google Scholar