Vasopressin in Patients with Septic Shock and Dynamic Left Ventricular Outflow Tract Obstruction
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SHORT COMMUNICAITON
Vasopressin in Patients with Septic Shock and Dynamic Left Ventricular Outflow Tract Obstruction Martin Balik 1
&
Adam Novotny 1 & Daniel Suk 1 & Vojtech Matousek 1 & Michal Maly 1 & Tomas Brozek 1 & Guido Tavazzi 2
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose Left ventricular outflow tract obstruction (LVOTO) is a relatively uncommon but severe condition that may lead to hemodynamic impairment. It can be elicited by morphological (left ventricular hypertrophy, sigmoid septum, prominent papillary muscle, prolonged anterior mitral valve leaflet) and functional (hypovolemia, low afterload, hypercontractility, catecholamines) factors. We sought to determine the incidence of the most severe form of LVOTO in septic shock patients and describe the therapeutic effects of vasopressin. Methods Over a period of 29 months, 527 patients in septic shock were screened for LVOTO. All were mechanically ventilated and treated according to sepsis bundles, including pre-load optimization and norepinephrine infusion. Vasopressin was added in addition to norepinephrine to reduce the adrenergic burden and decrease LVOTO. Results Ten patients were diagnosed with the most severe form of LVOTO, including systolic anterior mitral valve motion (SAM) and severe mitral regurgitation (MR) with pulmonary oedema. The median norepinephrine dosage to obtain a mean arterial pressure of ≥70 mmHg was 0.58 mcg/Kg/min (IQR 0.40–0.78). All patients had a hyper-contractile left ventricle, septal hypertrophy, significant LVOTO (peak gradient 78 [56–123] mmHg) associated with SAM and severe MR with pulmonary oedema. Vasopressin (median 4 IU/h) allowed a significant reduction of norepinephrine (0.18 [0.14–0.30] mcg/kg/min; p = 0.01), LVOT gradient (35 [24–60] mmHg; p = 0.01) and MR with a significant paO2/FiO2 increase (174 [125–213] mmHg; p = 0.01). Conclusion Vasopressin allowed a reduction of norepinephrine with subsequent LVOTO reduction and hemodynamic improvement of the most severe form of LVOTO, which represented 1.9% of all septic shock patients. Keywords Septic shock . Left ventricular outflow tract obstruction . Arginine vasopressin . Norepinephrine . Supraventricular arrhythmia . Atrial fibrillation
Abbreviations AVP arginine vasopressin LVOTO left ventricular outflow tract obstruction ClinicalTrials.gov Identifier: NCT03029169, registered on 24 Jan 2017. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s10557-020-06998-8) contains supplementary material, which is available to authorized users. * Martin Balik [email protected] 1
2
Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, U nemocnice 2, Prague 2 128 08, Czechia Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Unit of Anaesthesia and Intensive Care Fondazione Policlinico San Matteo, IRCCS, University of Pavia, Pavia, Italy
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