B52-24 Navigating Severe Vasoplegic Shock and Right Ventricular Failure After Cardiac Surgery: The Impact of Comprehensive Hemodynamic Support

Abstract Introduction The management of severe vasoplegia and right ventricular failure following cardiac surgery is complex and requires a multifaceted approach. We present a case highlighting the challenges associated with rapidly evolving post-cardiotomy shock. Case Presentation We present the case of a 76-year-old male with no known past medical history presented to an outside hospital after a syncopal episode. Evaluation revealed elevated cardiac biomarkers concerning for acute coronary syndrome, and left heart catheterization demonstrated multivessel coronary artery disease. He was transferred to our institution for cardiothoracic surgery evaluation and subsequently underwent coronary artery bypass grafting. Intraoperatively, he developed significant hemodynamic instability with a cardiac index of 1.1. Attempts at intra-aortic balloon pump placement were unsuccessful due to severe femoral arterial calcification. A left ventricular assist device was then attempted but resulted in left ventricular perforation, necessitating emergent reoperation and LV repair. Due to recurrent hemodynamic instability during chest closure attempts, the chest was left open and the patient was transferred to the cardiothoracic intensive care unit. Initial postoperative transesophageal echocardiography showed preserved biventricular systolic function with evidence of left ventricular diastolic dysfunction. Despite this, the patient experienced progressive shock requiring escalating vasoactive support, including norepinephrine, vasopressin, epinephrine, milrinone, dobutamine, angiotensin II, and methylene blue. Six hours after ICU arrival, repeat echocardiography revealed new moderate-to-severe RV dysfunction. A percutaneous right ventricular assist device was placed; however, this required removal of the Swan-Ganz catheter due to limited vascular access. The patient subsequently developed renal failure requiring continuous renal replacement therapy and progressive hypoxemia despite maximal ventilator support and inhaled epoprostenol. Due to profound instability, he was not a candidate for transfer to an extracorporeal membrane oxygenation-capable facility. Despite maximal medical and mechanical support, the patient ultimately succumbed to multi-organ failure. Discussion This case illustrates the complex management challenges posed by severe vasoplegia with evolving right ventricular failure in the post-cardiac surgery setting. Despite early multimodal pharmacologic therapy and attempts at mechanical support, hemodynamic instability progressed, reflecting the severity of physiologic derangement. Current literature highlights the importance of early incorporation of non-catecholamine agents and timely consideration of advanced mechanical circulatory support, including ECMO, when RV dysfunction emerges. This case underscores the value of anticipating support needs, establishing structured escalation pathways, and coordinating multidisciplinary teams early in rapidly evolving post-cardiotomy shock to optimize outcomes in future cases. This abstract is funded by: None