Table 1
Individualized blood pressure management in the post-cardiac surgery patient. SAM: septal anterior motion; CPB: cardiopulmonary bypass; MAP: mean arterial pressure; HCOM/SAM: hypertrophic obstructive cardiomyopathy/systolic anterior motion; LVOT: left ventricular outflow tract; LVH: left ventricular hypertrophy; SBP: systolic blood pressure; VSD: ventricular septal defect; LVAD: left ventricular assist device; VV vs VA ECMO: venovenous vs venoarterial extracorporeal membrane
| A. Decision points for individualized blood pressure targets for post cardiac surgery patients |
| 1. Age |
| 2. Nature of surgery |
| 3. Intraoperative course and intraoperative data |
| 4. Left ventricular versus right ventricular dysfunction |
| 5. Presence or absence of mechanical circulatory support devices |
| B. Patients who need a higher mean arterial pressure goal to optimize tissue perfusion |
| 1. Right ventricular (RV) failure |
| 2. Post-heart transplant with RV dysfunction |
| 3. Hemodynamic instability on weaning from CPB |
| 4. Air in the coronary arteries post-cardiac surgery needing higher MAP goals during initial few hours postoperatively |
| 5. Patients with long CPB time and cross-clamp time |
| 6. Acute kidney injury identified by low urine output intraoperatively |
| 7. HCOM/SAM needing higher MAP to stent open the LVOT |
| 8. Patient with LVH |
| 9. History of chronic hypertension with shift in cerebral autoregulation |
| C. Patients who need a lower MAP goal to optimize perfusion |
| 1. Patients with LV dysfunction where a reduction in afterload will help increase cardiac output |
| 2. Post aortic surgery, complex congenital repairs, fistula repairs and VSD repairs where a higher-than-normal SBP/MAP can cause increased tension on critical suture sites and lead to catastrophic bleeding |
| 3. Patients with circulatory support devices LVAD, impella, VV vs VA ECMO where increase in systemic arterial blood pressure can compromise flow through these support devices |
Figure 1
Society of Cardiovascular Angiography and Interventions (SCAI) classification of cardiogenic shock. Reprinted with permission.28 ECMO: extracorporeal membrane oxygenation; CPR: cardiopulmonary resuscitation
Figure 2
Effects of cardiac output and afterload and the inter-relationship with end-organ perfusion. CO: cardiac output; SVR: systemic vascular resistance
Figure 3
Cardiogenic shock with hypotension and hypoperfusion and compensated shock with normal or increased afterload. POCUS: point of care ultrasound; CO: cardiac output; MAP: mean arterial pressure; SVR: systemic vascular resistance; PAC: pulmonary artery catheter
Table 2
Clinical, diagnostic, and laboratory markers of tissue hypoperfusion.
| 1. Decreased blood pressure: systolic < 90 mm Hg OR mean pressure < 60 mm Hg OR > 30 mm Hg drop from baseline |
| 2. Tachycardia: heart rate > 100 beats/min |
| 3. Weak or absent peripheral pulses |
| 4. Cool, clammy, or mottled skin |
| 5. Altered mental status |
| 6. Decreased urine output < 30 mL/hr |
| 7. Cardiac index < 2.2 |
| 8. Pulmonary capillary wedge pressure > 15 mm Hg |
| 9. Right atrial pressure ≥ 0.8 mm Hg |
| 10. Pulmonary artery pulsatility index < 1.85 |
| 11. Cardiac power output ≤ 0.6 watts |
| 12. Mixed venous oxygen saturation (SvO2) < 60% |
| 13. Elevated lactate > 2 mmol/L |
| 14. Creatinine doubling |
| 15. 50% drop in glomerular filtration rate |
| 16. Deranged liver function |
| 17. Elevated NT-pro brain natriuretic peptide |
Figure 4
(A) Transgastric transesophageal echocardiography (TEE) short axis view of a failing left ventricle at end systole. (B) TEE short axis view of a failing left ventricle at end diastole. Photo credit Chandrika Garner, MD, Atrium Health Wake Forest University Medical Center
Figure 5
(A) Transgastric short axis transesophageal echocardiography (TEE) view of a hypertrophied, underfilled left ventricle in end systole. (B) Transgastric short axis TEE view of a hypertrophied, underfilled left ventricle in end diastole. Photo credit Chandrika Garner, MD, Atrium Health Wake Forest University Medical Center
Figure 6
(A) Transgastric short axis transesophageal echocardiography (TEE) view of an underfilled left ventricle with normal function at end systole. This patient was hypotensive and responded to volume administration. (B) Transgastric short axis TEE view of an underfilled left ventricle with normal function at end diastole. Photo credit Kyle Buck, MD, Atrium Health Wake Forest Baptist Medical Center