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Impact of surgical technique on the development of post-operative vasoplegia

Introduction Vasoplegia after cardiothoracic surgery is associated with severe post-operative complications and worse outcomes. Despite recent innovations, lung transplantation (LTx) remains one of the highest risk surgeries. We hypothesise that the avoidance of cardiopulmonary bypass (CPB) and the use of lesser invasive surgical approaches, namely the “minimally invasive” thoracotomy approach (MI) compared to the traditional Clam shell technique (CS), may reduce the incidence of vasoplegia post-operatively. Furthermore, we explore the association of vasoplegia and endothelial dysfunction by analysing the plasma release of endocan. Methods 90 patients received a LTx between October 2013 and June 2015 at Harefield Hospital. 40 were recruited in our prospective study. Clinical data, including surgical approach, use of CPB and OCS were recorded. Vasoplegia in the first 48 hours was defined according to Tsiouris et al (1). Plasma levels of endocan were then measured by ELISA at baseline and at 0, 6, 12, 24, 48 after Ltx. Data were analysed and reported as appropriate. Results 7 patients (44%) in the CPB group developed vasoplegia vs. 6 (46%) in the off-group (p 0.305), 3 after unexpected conversion to CPB (30% of the unexpected CPB group, p 0.302). Within the surgical approach groups, 8 patients (32%) of the CS group developed vasoplegia compared to 5 patients (33%) of the MILT-group (p 1.000). Patients in the vasoplegic group showed a tendency for longer CPB time (146 [81, 230] min vs. 110 [44, 184] min, p 0.470) and surgery duration (335 [290, 425] min vs. 310 [270, 435] min, p 0.690). Only 1 patient developed vasoplegia after OCS-LTx (20%, p 1.000). 2 patients in the vasoplegia group (15%) required re-exploration for bleeding vs. 2 (7%) in the no-vasoplegia group (7%, p 0.584). One patient required ECMO during the ITU stay and he was vasoplegic. Endocan levels were similar during the first 48 hours after LTx and between groups. Discussion Here, we demonstrate a high incidence of vasoplegia after LTx. The development of vasoplegia was not affected by either the surgical approach or the use of CPB. In addition, we found no evidence for association between vasoplegia and endothelial dysfunction. However, vasoplegia may be related to longer duration of CPB and surgery. Further studies are needed to identify mechanisms of vasoplegia following LTx.