Loay Kontar, William Beaubien-Souligny, Etienne J. Couture, Matthias Jacquet-Lagrèze, Yoan Lamarche, Sylvie Levesque, Denis Babin, André Y. Denault
Abstract
To identify potentially modifiable risk factors related to prolonged cardiovascular pharmacological support after weaning from cardiopulmonary bypass (CPB).
Introduction
Hemodynamic instability is a frequent complication after cardiopulmonary bypass (CPB) separation and can lead to significant morbidity and mortality that worsen postoperative clinical outcomes [1, 2]. Vasoplegia syndrome (VS) [3] and low cardiac output syndrome (LCOS) [4] are the most common causes of prolonged cardiovascular pharmacological support after weaning from CPB. The incidence of VS vary from 5% to 45% of patients [5] while LCOS is around 3.9% to 14.7% [4, 6–8]. This wide variation is due to some extent to the absence of consensual definitions in terms of threshold or duration. Even in the absence of LCOS, VS can lead to prolonged use of vasoconstrictor agents with increased mortality [9, 10].
Only limited evidence is available regarding risk factors of prolonged cardiovascular pharmacological support following cardiac surgery [11]. Several risk factors have been identified such as CPB duration [9, 11], platelet transfusion [12], lower temperature during CPB [13], an elevated interleukin-6 level 4 hours after CPB [11] and reduced left ventricular ejection fraction (LVEF) [11]. A reduced hematocrit, which may be mediated by fluid overload, has not been reported as a risk factor [9].
Materials and method
This is a secondary analysis of two prospective cohort study in a specialized cardiac surgery institution in adult patients undergoing cardiac surgery with the use of CPB between August 2016 and July 2017. Prolonged cardiovascular pharmacological support was defined by the need for at least one vasopressor or one inotropic agent 24 hours after separation from CPB. Risk factors were identified among baseline characteristics and peri-operative events through multivariable logistic regression
Results
A total of 247 patients were included and 98 (39.7%) developed prolonged pharmacological support. In multivariable analysis, left ventricular ejection fraction ≤ 30% (OR 9.52, 95% confidence interval (CI) 1.14; 79.25), elevated systolic pulmonary artery pressure (sPAP) > 30 and ≤ 55 mmHg (moderate) (OR 2.52, CI 1.15; 5.52) and sPAP > 55 mmHg (severe) (OR 8.12, CI 2.54; 26.03), as well as cumulative fluid balance in the first 24 hours after surgery (OR 1.76, CI 1.32; 2.33) were independently associated with the development of prolonged pharmacological support.
Discussion
In this cohort of cardiac surgical patients, we found that preexisting severe LV systolic dysfunction, preoperative PH and postoperative fluid overload were independently associated with prolonged cardiovascular pharmacological support after cardiac surgery with CPB. The resulting model reliably identified patients who had prolonged cardiovascular pharmacological support within the studied sample. Similar to Weis et al. in their cohort of 1558 patients [11], we found that prolonged cardiovascular pharmacological support remains a frequent complication, with a prevalence of 40%, and is associated with adverse clinical outcomes as reported by others [3, 10, 24] such as AKI, prolonged mechanical ventilation, delirium and prolonged length of ICU and hospital stay.
Pre-operative PH and low LVEF are severity markers of the underlying severity of heart disease which may convey a higher risk of needing prolonged cardiovascular pharmacological support. As reported by Weiss [11] and Sun [2] reduced LVEF is an independent risk factor for prolonged vasoactive support. In addition, patients with preoperative LV dysfunction are known to have decreased myogenic reactivity to circulating catecholamines, thereby leading to a resistance to vasopressors [25]. PH is new and has not been previously reported as a risk factor associated with prolonged cardiovascular pharmacological support.
Conclusion
Prolonged cardiovascular pharmacological support after cardiac surgery remains a common problem associated with significant complications. Reduced LVEF, PH and a positive fluid balance were found to be independent risk factors in the context of cardiac surgery.
Citation: Kontar L, Beaubien-Souligny W, Couture EJ, Jacquet-Lagrèze M, Lamarche Y, Levesque S, et al. (2023) Prolonged cardiovascular pharmacological support and fluid management after cardiac surgery. PLoS ONE 18(5): e0285526. https://doi.org/10.1371/journal.pone.0285526
Editor: Redoy Ranjan, BSMMU: Bangabandhu Sheikh Mujib Medical University, BANGLADESH
Received: October 3, 2022; Accepted: April 25, 2023; Published: May 11, 2023
Copyright: © 2023 Kontar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Patient data contain potentially identifying and/or confidential sensitive patient information, therefore, are not publicly available but can be accessed by researchers who meet criteria for accesses to sensitive data under the Montreal Heart Institute Research Ethics terms. For further information, contact: [email protected].
Funding: This work was supported by the Montreal Heart Institute Foundation and the Richard I. Kaufman Endowment Fund in Anesthesia and Critical Care, Montreal. All the funding sources had no involvement in this study. There was no additional external funding received for this study. This confirms that the funders provided support in the form of salaries, equipment, drugs and/or supplies for the author (AYD), but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific role of this author is articulated in the ‘author contributions’ section.
Competing interests: Dr. Denault is on the Speakers Bureau for CAE Healthcare (2010), Masimo (2017) and Edwards (2019). No other conflict of interest. This does not alter our adherence to PLOS ONE policies on sharing data and materials.
Abbreviations: AKI, acute kidney injury; CFB, cumulative fluid balance; CPB, cardiopulmonary bypass; ICU, intensive care unit; IQR, interquartile range; LCOS, low
cardiac output syndrome; LOESS, locally estimated scatterplot smoothing; LV, left ventricular; LVEF, left ventricular ejection fraction; PAP, pulmonary artery pressure; pEEG, processed electroencephalogram; PH, pulmonary hypertension; RV, right ventricular; SD, standard deviation; TEE, transesophageal echocardiography; VS, vasoplegic syndrome
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0285526#sec020
