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 phar-macoresistant 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 vaso-pressin or methylene blue. A 44-year-old patient with sec-ondary toxic cardiomyopathy developed severe cardiopul-monary 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 norepine-phrine (up to 0.7 & mu;g/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 af-ter the start of the infusion, blood pressure increased. Va-sopressin infusion was stopped, while the norepinephrine dose was decreased from 0.7 to 0.15 & mu;g/kg/min. Serum lactate, mixed venous saturation, and glomerular filtra-tion 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 postopera-tive 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 short-ening the ICU and hospital stay.