Abstract
BackgroundVasoplegia is a severe complication which may occur after cardiac surgery, particularly in patients with heart failure. It is a result of activation of vasodilator pathways, inactivation of vasoconstrictor pathways and the resistance to vasopressors. However, the precise etiology remains unclear. The aim of the Vasoresponsiveness in patients with heart failure (VASOR) study is to objectify and characterize the altered vasoresponsiveness in patients with heart failure, before, during and after heart failure surgery and to identify the etiological factors involved.MethodsThis is a prospective, observational study conducted at Leiden University Medical Center. Patients with and patients without heart failure undergoing cardiac surgery on cardiopulmonary bypass are enrolled. The study is divided in two inclusion phases. During phase 1, 18 patients with and 18 patients without heart failure are enrolled. The vascular reactivity in response to a vasoconstrictor (phenylephrine) and a vasodilator (nitroglycerin) is assessed in vivo on different timepoints. The response to phenylephrine is assessed on t1 (before induction), t2 (before induction, after start of cardiotropic drugs and/or vasopressors), t3 (after induction), t4 (15 min after cessation of cardiopulmonary bypass) and t5 (1 day post-operatively). The response to nitroglycerin is assessed on t1 and t5. Furthermore, a sample of pre-pericardial fat tissue, containing resistance arteries, is collected intraoperatively. The ex vivo vascular reactivity is assessed by constructing concentrations response curves to various vasoactive substances using isolated resistance arteries. Next, expression of signaling proteins and receptors is assessed using immunohistochemistry and mRNA analysis. Furthermore, the groups are compared with respect to levels of organic compounds that can influence the cardiovascular system (e.g. copeptin, (nor)epinephrine, ANP, BNP, NTproBNP, angiotensin II, cortisol, aldosterone, renin and VMA levels). During inclusion phase 2, only the ex vivo vascular reactivity test is performed in patients with (N = 12) and without heart failure (N = 12).DiscussionUnderstanding the difference in vascular responsiveness between patients with and without heart failure in detail, might yield therapeutic options or development of preventive strategies for vasoplegia, leading to safer surgical interventions and improvement in outcome.Trial registrationThe Netherlands Trial Register (NTR), NTR5647. Registered 26 January 2016.
Highlights
Vasoplegia is a severe complication which may occur after cardiac surgery, in patients with heart failure
Surgical treatment of end-stage chronic heart failure encompasses different treatment modalities like surgical revascularization of ischemic territories using coronary artery bypass grafting (CABG), alleviating functional mitral valve insufficiency and reconstructing left ventricular geometry and thereby improving contractility in patients that suffered from a large myocardial infarction resulting in a scarred and dilated left ventricle
Left ventricular function can be replaced by performing orthotopic heart transplantation or by implantation of a left ventricular assist device (LVAD)
Summary
Vasoplegia is a severe complication which may occur after cardiac surgery, in patients with heart failure. Left ventricular function can be replaced by performing orthotopic heart transplantation or by implantation of a left ventricular assist device (LVAD). These surgical options have improved clinical outcome [2,3,4]. Heart failure surgery is associated with an increased risk on vasoplegia, named vasodilatory shock [5]. This syndrome is characterized by hypotension and the continuous need of vasopressors, despite a normal or high cardiac index. An earlier study showed that the 90-day survival rate after heart failure surgery is decreased in vasoplegic patients compared with nonvasoplegic patients (71% vs 91%, P < 0.001) [8]
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