Patrick Wieruszewski, BCCCP, PharmD
Assistant Professor of Anesthesiology and Pharmacy
Mayo Clinic
Rochester, Minnesota
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Troy Seelhammer, MD
Assistant Professor of Anesthesiology
Mayo Clinic, United States
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Ashish Khanna, MD, FCCP, FASA,FCCM
Anesthesiologist & Intensivist, Associate Professor of Anesthesiology
Wake Forest Baptist Medical Center
Winston Salem, North Carolina
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Bhavita Gaglani, MD
Critical Care Fellow
Wake Forest Baptist Medical Center
Winston-Salem, North Carolina, United States
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Danielle Davison, MD
Associate Professor of Anesthesiology and Critical Care Medicine and of Medicine
George Washington University Medical Center, United States
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Jonathan Chow, MD
Department of Anesthesiology and Critical Care Medicine
George Washington University School of Medicine, United States
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Laurence Busse, MBA, MD, FCCM
Assistant Professor
Emory University School of Medicine, United States
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Caitlin Ten Lohuis, ACNP
Acute Care Nurse Practitioner
Emory University
Atlanta, Georgia
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Erin Barreto, MSc, PharmD, FCCM
Associate Professor of Pharmacy and Medicine
Mayo Clinic
Rochester, Minnesota
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Erica Wittwer, MD, PhD
Associate Professor of Anesthesiology
Mayo Clinic, United States
Disclosure information not submitted.
Title: Angiotensin II for Distributive Shock in Patients with Durable Left Ventricular Assist Devices
Introduction: Implanted durable left ventricular assist devices (LVADs) are increasingly utilized in medically refractory heart failure. Compared to healthy hearts, those with end-stage heart failure after LVAD have complex derangements in the renin-angiotensin system. Due to lack of evidence in these unique patients, the objective of this study was to evaluate safety and effectiveness of angiotensin II, a recently approved vasopressor, in the management of shock in patients with LVADs.
Methods: This is a retrospective study of adults (≥18 years) with an implanted LVAD who received angiotensin II between May 2018 and July 2021 across 4 academic medical centers. Data were summarized with descriptive statistics.
Results: Ten patients with an LVAD received angiotensin II during the study time-period, most (n = 8) of which were in the immediate post-implantation setting. All, but one patient, were male and the median (IQR) age was 48 (45, 64) years. Heart failure was due to ischemic (n = 4) or dilated (n = 4) cardiomyopathy, or unknown (n = 2), and most implanted devices were HeartMate III (n = 7), followed by HeartWare (n = 2), and HeartMate II (n = 1). Two patients also had a temporary right ventricular assist device with oxygenator and intra-aortic counter-pulsation device in place at the time of angiotensin II receipt. Median ejection fraction was 15 (7.5, 25) % and most had moderate (n = 2) or severe (n = 6) right ventricular failure. Nine patients had shock due to post-operative vasoplegia and 1 due to sepsis. At baseline, the mean arterial pressure was 58 (53, 69) mmHg, supported by 3 (3, 3) vasopressors dosed at 0.38 (0.28, 0.57) mcg/kg/min norepinephrine equivalents. Angiotensin II was initiated at a rate of 15 (10, 20) ng/kg/min and continued for 21 (6, 55) hours. Three hours following initiation, the mean arterial pressure changed by +10 (-2, +16) mmHg and vasopressor dose changed by -0.08 (+0.06, -0.15) mcg/kg/min. No ischemic events or stroke were reported. The median ICU and hospital lengths of stay were 22 (11, 34) and 26 (20, 63) days, respectively. Four (40%) patients died in the ICU, a median of 11 days from LVAD insertion.
Conclusions: Angiotensin II rapidly increases blood pressure and reduces concomitant vasopressor needs in patients with LVADs. Further study in this unique population is warranted.