Vasopressin in Patients with Septic Shock and Dynamic Left Ventricular Outflow Tract Obstruction

Martin Balik, Adam Novotny, Daniel Suk, Vojtech Matousek, Michal Maly, Tomas Brozek, Guido Tavazzi

Research output: Contribution to journalArticle

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.

Original languageEnglish
JournalCardiovascular Drugs and Therapy
DOIs
Publication statusAccepted/In press - Jan 1 2020

Keywords

  • Arginine vasopressin
  • Atrial fibrillation
  • Left ventricular outflow tract obstruction
  • Norepinephrine
  • Septic shock
  • Supraventricular arrhythmia

ASJC Scopus subject areas

  • Pharmacology
  • Cardiology and Cardiovascular Medicine
  • Pharmacology (medical)

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