Severe Refractory Vasoplegic Shock Syndrome after OPCABG Successfully Treated with Hydroxycobalamin: A Case Report and Review of the Literature

Abstract

Background: Vasoplegic shock syndrome (VSS) after an off-pump coronary artery bypass graft (OPCABG) is an extremely rare condition. Inotropic support is usually the first-line therapy, though it can precipitate several complications or be ineffective. We report the first case of severe refractory VSS after OPCABG successfully treated with hydroxycobalamin.

Methods: A 77-year-old gentleman underwent OPCABG for three vessels coronary artery disease. Preoperative LV ejection fraction was 28%, and the patient before surgery started sacubitril/valsartan titrated, then, at the highest dose. Surgery was uneventful and, by the end of the procedure, TEE showed improved biventricular contractility.

Results: The patient was transferred to the ICU without inotropic support, but soon developed hypotension. TEE ruled out pericardial tamponade and confirmed fair contractility. Norepinephrine was titrated to a medium-high dose, vasopressin was started and a Swan-Ganz catheter was placed. SVR was 480 dyn·s·cm^-5. Despite aggressive pharmacologic treatment (including methylprednisolone and methylene blue), no improvements were noticed. Ten grams of hydroxycobalamin were administered. One hour later, hemodynamic status re-assessment showed SVR > 800 dyn·s·cm^-5. Afterward, vasopressors were gradually reduced.

Conclusions: Our case demonstrated the importance of adequate early treatment in VSS after OPCABG. This case report shows, for the first time, that hydroxycobalamin was effectively used to restore homeostasis.

Keywords: hydroxycobalamin; off-pump CABG; vasoplegic shock syndrome.

Figure 1

Infusion of hydroxycobalamin.

Figure 2

CPB: Cardiopulmonary bypass; OPCABG: off-pump coronary artery bypass grafting; EF: ejection fraction; ACE-I: angiotensin-converting enzyme inhibitors.