Intravenous infusion of angiotensin II for treatment of cardiopulmonary bypass-induced vasoplegic shock after implantation of left ventricular assist device: a case report

We report on the first successful treatment of severe pharmacoresistant vasoplegic syndrome with angiotensin II acetate (ATII) in Croatia. ATII is a novel drug used to treat severe vasoplegic shock resistant to the administration of catecholamines or alternative vasopressors such as vasopressin or methylene blue. A 44-year-old patient with secondary toxic cardiomyopathy developed severe cardiopulmonary bypass-induced vasoplegic shock after scheduled implantation of a left-ventricular assist device. The cardiac output was maintained, but systemic vascular resistance (SVR) was extremely low. The patient had an inadequate reaction to the administration of high doses of norepinephrine (up to 0.7 µg/kg/min) and vasopressin (0.03 IU/min). At postoperative intensive care unit (ICU) admission, serum renin levels were unmeasurably high (>330 ng/L), and infusion of ATII 20 ng/kg/min was initiated. Soon after the start of the infusion, blood pressure increased. Vasopressin infusion was stopped, while the norepinephrine dose was decreased from 0.7 to 0.15 µg/kg/min. Serum lactate, mixed venous saturation, and glomerular filtration rate markedly improved. The patient was extubated 16 h after the ICU admission. Twenty-four hours after the start of the ATII infusion, serum renin dropped to 255 ng/L, and laboratory findings further improved. On postoperative day 3, the norepinephrine infusion was stopped. On day 6, renin further dropped to 136 ng/L, and the patient was hemodynamically stable and discharged from the ICU. In conclusion, ATII favorably affected the patient’s vascular tone, enabling rapid hemodynamic stabilization and shortening the ICU and hospital stay.