Journal Information
Vol. 36. Issue 4.
Pages 277-287 (May 2012)
Share
Share
Download PDF
More article options
Visits
1777
Vol. 36. Issue 4.
Pages 277-287 (May 2012)
Consensus statement
Full text access
Summary of the consensus document: “Clinical practice guide for the management of low cardiac output syndrome in the postoperative period of heart surgery”
Resumen del documento de consenso «Guías de práctica clínica para el manejo del síndrome de bajo gasto cardiaco en el postoperatorio de cirugía cardiaca»
Visits
1777
J.L. Pérez Velaa,
Corresponding author
perezvela@yahoo.es

Corresponding author.
, J.C. Martín Benitezb, M. Carrasco Gonzalezc, M.A. de la Cal Lópezd, R. Hinojosa Péreze, V. Sagredo Menesesf, F. del Nogal Saezg, Grupo de Trabajo de Cuidados Intensivos Cardiológicos y RCP de SEMICYUC, «con el aval científico de la SEMICYUC»
a Servicio de Medicina intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
b Servicio de Medicina intensiva, Hospital Clínico Universitario San Carlos, Madrid, Spain
c Unidad Postoperatoria de Cirugía Cardiaca, Hospital Vall d’Hebron, Barcelona, Spain
d Servicio de Medicina intensiva, Hospital Universitario de Getafe, Madrid, Spain
e Servicio de Medicina intensiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain
f Servicio de Medicina intensiva, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
g Servicio de Medicina intensiva, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
This item has received
Article information
Abstract

Low cardiac output syndrome (LCOS) is a potential complication in cardiac surgery patients and is associated with increased morbidity and mortality. This guide provides recommendations for the management of these patients, immediately after surgery and following admission to the Intensive Care Unit (ICU). The recommendations are grouped into different sections, addressing from the most basic concepts such as definition of the disorder to the different sections of basic and advanced monitoring, and culminating with the complex management of this syndrome. We propose an algorithm for initial management, as well as two others for ventricular failure (predominantly left or right). Most of the recommendations are based on expert consensus, due to the lack of randomized trials of adequate design and sample size in patients of this kind. The quality of evidence and strength of the recommendations were based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The guide is presented as a list of recommendations (with the level of evidence for each recommendation) for each question on the selected topic. For each question, justification of the recommendations is then provided.

Keywords:
Low cardiac output syndrome
Ventricular failure
Cardiac surgery
GRADE methodology
Resumen

El síndrome de bajo gasto cardiaco es una potencial complicación de los pacientes intervenidos de cirugía cardiaca y asocia un aumento de la morbimortalidad. La presente guía pretende proporcionar recomendaciones para el manejo de estos pacientes, en el postoperatorio inmediato, ingresados en UCI. Las recomendaciones se han agrupado en diferentes apartados, tratando de dar respuesta desde los conceptos más básicos como es la definición a los diferentes apartados de monitorización básica y avanzada, y terminando con el complejo manejo de este síndrome. Se propone un algoritmo de manejo inicial, así como otros de fracaso ventricular predominantemente izquierdo o derecho. La mayor parte de las recomendaciones están basadas en el consenso de expertos, debido a la falta de estudios clínicos aleatorizados, de adecuado diseño y tamaño muestral en este grupo de pacientes. La calidad de la evidencia y la fuerza de las recomendaciones se realizó siguiendo la metodología GRADE. La guía se presenta como una lista de recomendaciones (y nivel de evidencia de cada recomendación) para cada pregunta del tema seleccionado. A continuación, en cada pregunta, se procede a la justificación de las recomendaciones.

Palabras clave:
Síndrome de bajo gasto cardiaco
Fracaso ventricular
Cirugía cardiaca
Metodología GRADE
Glossary of abbreviations and terms
ACC/AHA

American College of Cardiology/American Heart Association

IABP

intraaortic counterpulsation balloon pump

PAC

pulmonary artery catheter

HS

heart surgery

ECC

extracorporeal circulation

EG

echocardiogram

ESC

European Society of Cardiology

TEE

transesophageal echocardiogram

TTE

transthoracic echocardiogram

LVEF

left ventricle ejection fraction

CO

cardiac output

GRADE

Grading of Recommendations Assessment, Development and Evaluation (working group)

PHT

pulmonary hypertension

CI

cardiac index

AHF

acute heart failure

PCI

percutaneous coronary intervention

CVP

central venous pressure

RIFLE/AKIN

Risk, Injury, Failure, Loss of kidney function, and End-stage renal failure/Acute Kidney Injury Network

LCOS

postoperative low cardiac output syndrome (in heart surgery)

CS

cardiogenic shock

SEMICYUC

Sociedad Española de Medicina Intensiva, Critica y Unidades Coronarias

ALS

advanced life support

ScvO2

central venous oxygen saturation

SvO2

venous oxygen saturation

BP

blood pressure

MBP

mean blood pressure

SBP

systolic blood pressure

LCT

left common trunk

ICU

Intensive Care Unit

Full Text
Concept

Low cardiac output syndrome (LCOS) in the postoperative period of heart surgery (PHS) is a potential complication in heart surgery (HS) patients. Its reported incidence varies between 3 and 45%, depending on the literature source, and the syndrome is associated to an increase in morbidity–mortality, a prolongation of stay in the Intensive Care Unit (ICU), and an increase in resource utilization.1–3 LCOS is a broad concept, and the literature also offers other terms or designations such as postoperative myocardial dysfunction, postoperative cardiocirculatory dysfunction, acute cardiovascular dysfunction, postsurgery heart failure, heart failure or postcardiotomy shock. The origin and form of presentation of LCOS differ from those of medical acute heart failure (AHF). Consequently, the AHF classifications of the European Society of Cardiology (ESC) and of the American College of Cardiology (ACC) are not directly applicable to the postoperative PHS.4

Morbidity–mortality in the postoperative phase of HS has evolved favorably in recent years. This is probably a result of improvements at all implicated healthcare levels, including surgery (surgical technique, myocardial protection, etc.), anesthesia, monitorization, and postoperative management and treatment. The sum of these improvements has encouraged surgeons to operate upon increasingly older patients and with greater comorbidity, i.e., individuals more likely to develop complications, including hemodynamic problems.

Objectives of the guide

The present guide aims to offer recommendations for the management of adult patients with LCOS in the immediate postoperative period of HS, admitted to the ICU. The recommendations are based on consensus among experts in Intensive Care Medicine with special dedication to PHS, as well as an intensivist with expertise in methodological issues. The guide is transparent in reference to the literature supporting the recommendations and the level of evidence, as well as regards the methodology used to develop the guide. This makes it reproducible and applicable in the different ICUs.

Scope of the guide

The recommendations have been grouped into different sections, attempting to address aspects ranging from the more basic concepts such as definitions (where homogeneity is lacking in the literature) to the different basic and advanced monitorization areas in these patients, and the complex management of LCOS. Management in turn ranges from drug treatments available in any center to the most complex procedures such as mechanical circulatory assist techniques and heart transplantation. Lastly, the guide offers a series of simple algorithms applicable to the initial patient management and to the treatment of predominantly left or right ventricle failure.

Limitations of the guide

Most of the recommendations are based on expert consensus, due to the lack of randomized clinical studies of adequate design and sample size in patients of this kind. On the other hand, the guide does not address the pediatric population.

Users

This guide has been developed for consultation and use by physicians involved in the perioperative management of HS or, in reference to the more general aspects, by physicians implicated in cardiac critical care. It can also prove useful for teaching activities targeted to intensivists or residents in training.

Methodology for development of the guideConformation of the group

Under the auspices of the Cardiological Intensive Care Working Group of the Sociedad Española de Medicina Intensiva, Critica y Unidades Coronarias (SEMICYUC), a group of experts gathered with especial dedication to PHS and working in different Autonomous Communities all over Spain. In addition, an intensivist with expertise in methodological issues also participated in the project from the start—providing orientation and support in the literature searches, and contributing to the methodology and development of the guide.

The members of the Working Group established the issues of particular interest to be addressed in the context of LCOS. In this sense, systematic literature searches were made, and after due analysis of the data, a series of initial recommendations were discussed and established among the different members of the group. The text and initial recommendations in turn were submitted to a group of intensivists with special experience and dedication to patients in the context of PHS (Appendix 1 can be consulted in the full version, doi:10.1016/j.medin.2012.02.007. Based on the contributions of these intensivists and on common consensus, established on occasion of the meeting of the Cardiological Intensive Care Working Group of the SEMICYUC at the National Congress of the SEMICYUC 2011, the final conclusions to the document were drawn.

Biomedical literature search and development of the guide

Development of the guidelines was based on a MEDLINE search of publications up until December 2010. Since the biomedical literature can cite LCOS in different terms, randomized clinical trials were sought, together with reviews, cohort studies, case–control studies, descriptive observational studies and case series using the following keywords: post/perioperative low cardiac output syndrome, postcardiotomy heart/cardiac failure, postcardiotomy cardiogenic shock (CS), post/perioperative cardiac/heart failure, transient ventricular dysfunction or myocardial stunning, and low post-cardiac surgery cardiac output (CO). These terms in turn were crossed in each of the sections addressed in this guide: monitorization, inotropic drugs, etc. As a starting point, use was made of the only guides available to date on the hemodynamic management and treatment of HS patients, based on the literature review and experts opinion survey recently published by the Association of the Scientific Medical Societies in Germany.5 In addition, secondary literature references were used (identified from the analyzed studies found in the literature search), together with general recommendations and guidelines referred to heart failure, arrhythmias and monitorization.

The quality of the evidence and the strength of the recommendations were defined following the methodology of the GRADE (Grading of Recommendation Assessment, Development and Evaluation) Working Group.6,7 This system is based on the sequential assessment of the quality of the evidence (taking into account the design and quality of the study, consistency, and the direct-indirect evidence) and the possible recommendations. Thus, the quality of the evidence is classified as high (grade A), moderate (grade B), low (grade C) or very low (grade D) (Table 1 can be consulted in the full version, doi:10.1016/j.medin.2012.02.007), and the recommendations are defined as strong (grade 1) or weak (grade 2). Grading of the recommendations as either strong or weak is conditioned more by clinical importance than by the quality of the evidence. A strong recommendation in favor of a given intervention indicates that the desirable effects obtained on applying the recommendation clearly outweigh the undesirable effects, and means “we recommend”. In contrast, a weak recommendation in favor of an intervention indicates that the undesirable effects will probably outweigh the desirable effects, and means “we suggest” (Table 1 can be consulted in the full version, doi:10.1016/j.medin.2012.02.007).

The guide is presented as a list of recommendations (with the level of evidence of each recommendation) for each issue or question in the selected topic. Then, in each concrete question, justification of the recommendations is provided. Given the large dimensions of the full guide, the present text offers an abridged version addressing only the recommendations. The full text, which includes the justifications of the recommendations and the total 483 literature references, can be accessed at: doi:10.1016/j.medin.2012.02.007.

Updating of the guide

Updating of the guide every four years from the date of publication is proposed, in order to adapt the recommendations to the results and findings of the new clinical studies.

Exoneration

The guide is a useful tool for improving medical decisions, but in any case, the recommendations of such documents are not meant to replace the decision making capacity of the clinician in a concrete situation or circumstance and involving specific clinical variables. Application of the recommendations also depends on the availability of means and resources in each center or institution. On the other hand, new clinical research findings may produce new evidence requiring a change in routine clinical practice even before this guide is updated.

How could we define low cardiac output syndrome in the postoperative period of heart surgery?Recommendation

The following definitions are recommended:

  • 1.

    Postoperative LCOS: Measured cardiac index (CI)<2.2l/min/m2, without associated relative hypovolemia. It may be due to left and/or right ventricle failure and can be accompanied or not by pulmonary congestion. Blood pressure may be normal or low.

  • 2.

    Clinical condition consistent with LCOS: This would apply to patients in which CO is not monitored, and is not known, but in whom the clinical manifestations are consistent with low CO, i.e., oliguria (diuresis<0.5ml/kg/h), central venous saturation<60% (with normal arterial saturation) and/or lactate>3mmol/l, without relative hypovolemia. This group should also include those patients coming from the operating room with inotropic medication and/or an intraaortic counterpulsation balloon pump (IABP), and in which these measures must be maintained to secure adequate hemodynamic conditions.

  • 3.

    CS: This is the most serious situation in the context of LCOS, and is defined as CI<2.0l/min/m2, with SBP<90mmHg, without relative hypovolemia, and with oliguria.

Is low cardiac output syndrome acute heart failure?Recommendation

LCOS could be regarded as AHF with differences referred to its etiology, physiopathology and course versus the forms of clinical AHF contemplated in the classifications proposed by the ESC and ACC/AHA.

Can we identify risk factors for the development of low cardiac output syndrome?Recommendation

No known individual risk factor is able to predict the development of LCOS in the PHS (2D).

What are the basic monitorization needs in the postoperative period of heart surgery?Recommendations

  • 1.

    Monitorization in the PHS should be adapted to the clinical situation of the patient (1C).

  • 2.

    The recommended basic monitorization measures for clinically stable patients comprise continuous electrocardiographic monitoring, systemic arterial oxygen saturation, invasive arterial pressure recording, fluid balance (diuresis, drains), and the measurement of central venous pressure (CVP) (1D).

  • 3.

    In low risk patients, monitorization with CVP is considered sufficient, with no need for pulmonary artery catheterization (PAC) or other systems for the measurement of CO or venous oxygen saturation (SvO2) on a continuous basis (1B).

  • 4.

    The use of other devices or techniques will depend on the surgical complexity, the clinical situation and the postoperative course with patient instability (1D).

In which patients should advanced hemodynamic monitorization be considered?Recommendation

Advanced hemodynamic monitorization is advised in postoperative patients showing hemodynamic instability or suspected LCOS, and who fail to respond to the initial management measures (1C) (Fig. 1 can be consulted in the full version, doi:10.1016/j.medin.2012.02.007).

How can we estimate preload?Recommendations

  • 1.

    The evaluation of preload must be made with integration of the clinical data, the information obtained from the different monitorization techniques, and the dynamic response to the adopted treatment measures. A dynamic response on the part of preload as determined after volume expansion is considered fundamental (1D).

  • 2.

    It is not advisable to adopt preload modifying measures on the basis of isolated data obtained by a given technique or procedure (1D).

  • 3.

    The extreme values of CVP offer us information on the situation of preload, though as occurs with the data obtained by other methods, this information must be integrated with the clinical situation of the patient and the data drawn from other explorations (1D).

  • 4.

    In situations of suspected LCOS, it is advisable to assess the information provided by other methods, which moreover afford additional hemodynamic information—particularly echocardiography (EG) and CO measurement systems (1D).

In which patients should we know cardiac output in the postoperative period of heart surgery?Recommendations

  • 1.

    Routine CO monitoring is not advised in patients with an uncomplicated PHS (1C).

  • 2.

    Ventricle function should be assessed in the PHS in situations of clinical instability and/or suspected LCOS (1C).

  • 3.

    There are no recommendations for the choice of a specific method. The decision should depend on the conditions of the patient, availability, and the experience of the attending medical team (1D).

  • 4.

    In patients with prior moderate to severe pulmonary hypertension (PHT), the recommendation is to use PAC (1D).

What role does the echocardiogram play in the postoperative period of heart surgery?Recommendations

EG offers relevant information in postoperative patients with clinical stability, and in cases of suspected LCOS. Therefore:

  • 1.

    EG is recommended in the PHS in patients with persistent hypotension or hypoxemia who fail to respond to the initial therapeutic measures, and in which no apparent cause is identified (1C) (Fig. 1 can be consulted in the full version, doi:10.1016/j.medine.xxxx.xx.xxx).

  • 2.

    Echocardiography is recommended in patients with suspected LCOS (1C).

  • 3.

    TEE is advised when the information cannot be obtained by TTE or other means (1C).

  • 4.

    It is advisable to have TEE available in the PHS in all centers where heart surgery is carried out (2D).

  • 5.

    Continuous transesophageal Doppler is not advised for monitorization in the PHS (2C).

Should venous oxygen saturation be determined?Recommendation

  • 1.

    Its routine use cannot be recommended, though the measurement of venous oxygen saturation (SvO2 or central venous oxygen saturation [ScvO2]) is useful for the identification and management of patients with suspected or established LCOS (2C).

  • 2.

    The serial determination of SvO2 or ScvO2 may be useful for assessing the efficacy of the adopted measures, though it has limitations (2D).

Should we determine lactate in the postoperative period of heart surgery?Recommendations

  • 1.

    Initial lactate measurement in the PHS is advised (2C).

  • 2.

    In the same way as in other critical patients, lactate clearance in the PHS informs us of a favorable/unfavorable trend in the clinical course, and as such may be useful for assessing the patient condition (2C).

What are the general hemodynamic objectives in the management of a patient with low cardiac output syndrome?Recommendation

  • 1.

    Table 3 describes the general hemodynamic objectives in LCOS (1D) (Table 3 can be consulted in the full version, doi:10.1016/j.medin.2012.02.007).

  • 2.

    Fig. 1 shows the recommended algorithm for the initial management of LCOS (1D) (Fig. 1 can be consulted in the full version, doi:10.1016/j.medin.2012.02.007).

Is it important to control heart rate and cardiac rhythm? How should arrhythmias be dealt with?Recommendation

  • 1.

    In bradyarrhythmias with hemodynamic repercussions, epicardial pacing is to be maintained in order to secure adequate hemodynamic conditions (1D).

  • 2.

    Tachyarrhythmias with hemodynamic repercussions require urgent treatment (1B).

  • 3.

    Synchronized electric cardioversion is advised in atrial fibrillation/flutter, in order to restore sinus node rhythm in patients with severe hemodynamic alterations or myocardial ischemia (1B).

  • 4.

    In patients with atrial fibrillation/flutter and less serious hemodynamic alterations, the recommendation is to administer intravenous amiodarone (1B). When the arrhythmia is not accompanied by hemodynamic instability, ventricle frequency should be controlled (1B).

Fig. 2 shows a simplified form of the arrhythmia management algorithm (Fig. 2 can be consulted in the full version, doi:10.1016/j.medin.2012.02.007).

From what hemoglobin levels do these patients require transfusion?Recommendation

There is no defined hemoglobin concentration threshold below which transfusion is indicated in patients without hemorrhagic shock or without acute bleeding, in the presence of hemodynamic instability. Transfusion is reasonable in most patients in the PHS when hemoglobin <7g/dl (1D).

What inotropic drugs and vasopressors may be useful in the management of low cardiac output syndrome? Is there any “best” option?Recommendations

  • 1.

    It is not advisable to administer inotropic drugs based only on the measurement of CO as an isolated parameter. Such medication is recommended in the presence of some accompanying clinical manifestation of LCOS (1D).

  • 2.

    It is not advisable to attempt to normalize or optimize a single hemodynamic parameter with inotropic drugs or vasopressors without taking the global clinical context into account. The previously mentioned hemodynamic objectives must be kept in mind (1D) (Table 3 can be consulted in the full version, doi:10.1016/j.medin.2012.02.007).

  • 3.

    Inotropic drugs and vasopressors are recommended in the circumstances contemplated in the algorithms (1C) (Figs. 3 and 4 can be consulted in the full version, doi:10.1016/j.medin.2012.02.007).

  • 4.

    Inotropic drugs and vasopressors are recommended to increase CO and vascular tone, both of which are altered in LCOS during the PHS, until the patient has clinically recovered from the syndrome (2D).

  • 5.

    No specific inotropic drug or vasopressor can be recommended. It is advisable to use the management algorithms in Figs. 3 and 4 as a general reference, and also to consider the clinical experience and drug availabilities in each particular center (1D) (Figs. 3 and 4 can be consulted in the full version, doi:10.1016/j.medin.2012.02.007).

The clinical indications for the intravenous administration of inotropic drugs in heart surgery patients comprise supportive treatment in weaning from extracorporeal circulation (ECC), LCOS in the PHS, and CS. However, it has not been clearly defined when the patient requires medication or of what kind (purely vasopressors or inotropic agents), or which drug is best - since there are no adequately designed randomized clinical trials offering sufficiently solid evidence, despite the large number of patients subjected to heart surgery. Appendixes 2 and 3 (can be consulted in the full version, doi:10.1016/j.medin.2012.02.007) summarize the most important clinical studies with inotropic drugs in adult patients subjected to heart surgery, and in patients with low CO–CS.8–80

At general level, the ESC guides 200581 and 200882 on the diagnosis and treatment of AHF advise (strong recommendation, with low level of evidence) the use of inotropic agents in the presence of peripheral hypoperfusion, with or without congestion or lung edema, refractory to diuretics and vasodilators at optimum doses. In turn, the AHA/ACC83 guides (with weak recommendation and low level of evidence) consider that dopamine, dobutamine and milrinone can reduce the congestive symptoms and should be reserved for carefully selected patients with low blood pressure, severe systolic dysfunction and evidence of lowered CO, with a view to maintaining systemic perfusion.

Algorithm for the management of predominant left ventricle failureRecommendation

Fig. 3 shows the algorithm for the recommended management of predominant left ventricle failure in LCOS during the PHS (1D) (Fig. 3 can be consulted in the full version, doi:10.1016/j.medin.2012.02.007).

Algorithm for the management of predominant right ventricle failureRecommendation

Fig. 4 shows the algorithm for the recommended management of predominant right ventricle failure in LCOS during the PHS (1D) (Fig. 4 can be consulted in the full version, doi:10.1016/j.medin.2012.02.007).

In what high-risk surgical patients should we consider the preoperative use of an intraaortic counterpulsation balloon pump?Recommendation

An IABP is advised in the preoperative phase of HS when the patient presents the following clinical and/or anatomical criteria (2C).

When meeting at least two of the following criteria

  • Left ventricle ejection fraction (LVEF)<0.40–0.35

  • Lesion of the left common trunk (LCT)>70%

  • Unstable angina

  • Coronary reintervention

Other criteria to be considered

  • High risk patients (EUROSCORE6)

  • Hemodynamic instability

  • Emergent surgery after failed percutaneous coronary intervention (PCI) (<6h)

  • Myocardial revascularization in the presence of ventricular aneurysms or combined with ventricular reconstruction surgery (aneurysmectomy, aneurysmoplasty)

When is an intraaortic counterpulsation balloon pump indicated in the intra- or postoperative phase?Recommendation

An IABP is recommended in patients who cannot be weaned from ECC after one or several attempts, or in the patients who develop LCOS or CS in the immediate PHS, refractory to adequate conventional management (1C).

There are many circumstances in which an adequate level of recommendation cannot be established due to a lack of evidence. However, it may be interesting from the practical perspective to evaluate some recommendations made by experts:

In the case of predominant right ventricle failure: Is an intraaortic counterpulsation balloon pump indicated?

The indication in this case is subject to important controversy,84,85 though there are experiences that report an increase in CI and mean blood pressure (MBP) within one hour after insertion, and with a high disconnection (75%) and hospital survival rate (69%). This benefit has been related to the diastolic increase in blood flow to the right coronary artery, which may improve ventricle function, and to the reduction in systemic vascular resistance which can indirectly increase the contractile capacity of the right ventricle.86

When should we switch to another type of ventricular assist device? or When should we no longer continue with the therapeutic effort?

There are a series of useful prognostic scales or clinical and biochemical markers allowing us to predict the success or failure of IABP on an early basis. In this sense, Boeken et al.84 described different factors indicative of a poor course, while according to the prognostic scale developed by Haussmann,87 patients with higher scores should be regarded as candidates for early ventricular assist measures.

When is an intraaortic counterpulsation balloon pump contraindicated in the heart surgery patient?Recommendation

The following are regarded as absolute contraindications (1D):

  • -

    Moderate to severe aortic valve insufficiency

  • -

    Aortic dissection

  • -

    Bilateral femoropopliteal or iliofemoral bypass (percutaneous IABP)

It use and potential benefits should be carefully evaluated in patients at risk of suffering complications:

  • -

    Abdominal aortic aneurysm

  • -

    Severe aortoiliac or femoral disease

  • -

    Previous aortofemoral bypass

  • -

    Severe coagulation disorders

  • -

    Absence of definitive treatment for underlying diseases

  • -

    Multiorgan failure associated to CS and/or sepsis.88

Which patients could be candidates for mechanical circulatory assist measures in the postoperative period of heart surgery?Recommendation

Mechanical circulatory assist devices are recommended in heart surgery patients in which:

  • In the operating room: weaning from ECC is not possible, despite adequate surgical correction.

  • In the PHS: the patient develops criteria of CS in the immediate postoperative period.

In any of the situations: patients refractory to maximum pharmacological circulatory support (with at least 2 vasoactive drugs) and/or IABP, and who present no contraindications to implantation (1C).

Which patients with postcardiotomy shock should not receive circulatory assist devices?Recommendation

A circulatory assist device should not be implanted in the absence or lack of indication criteria. In many cases the contraindication is not absolute; as a result, evaluation is required of the possible general and relative contraindications in each concrete case—with individualized assessment of the possible benefits as weighed against the potential complications (1D).

Which patients could be candidates for heart transplantation in LCOS in the postoperative period of heart surgery?Recommendation

Possible candidates for heart transplantation are patients who after heart surgery:

  • -

    Suffer CS refractory to treatment, including mechanical support (IABP and/or ventricular assist), or have confirmed dependency upon intravenous inotropic support in order to maintain adequate organ perfusion.

  • -

    Present irreversible hemodynamic conditions.

  • -

    Present no contraindication, with non-reversible multiple organ involvement (2D).

In which patients are renal replacement therapy recommended, and which modality should be used in postcardiotomy low cardiac output syndrome?Recommendation

  • In patients who develop acute renal failure according to the Risk, Injury, Failure, Loss of kidney function, and End-stage renal failure/Acute Kidney Injury Network (RIFLE/AKIN) criteria, with due clinical evaluation of the patient (1C).

  • These techniques are advised in patients with fluid overload and for correcting hyponatremia, in patients refractory to diuretics (1C).

What is the correct moment for starting such therapy in patients with low cardiac output syndrome?Recommendation

No universal recommendation can be made regarding the promptness of use in LCOS during the PHS. The decision depends on clinical and logistic criteria (2D).

Conflicts of interest

The authors declare no conflicts of interest.

References
[1]
V. Rao, J. Ivanov, R.D. Weisel, J.S. Ikonomidis, G.T. Christakis, T.E. David.
Predictors of low cardiac output syndrome after coronary artery bypass.
J Thorac Cardiovasc Surg, 112 (1996), pp. 38-51
[2]
J. Álvarez Escudero, M. Taboada Muñiz, M.J. Rodríguez Forja, M. Rey Jorge, B. Ulloa Iglesias, V. Ginesta Galán.
Complicaciones hemodinámicas de la cirugía cardiaca.
Riesgo y complicaciones en Cirugía Cardiaca, pp. 205-219
[3]
A. Rudiger, F. Businger, M. Streit, E.R. Schmid, M. Maggiorini, F. Follath.
Presentation and outcome of critically ill medical and cardiac-surgery patients with acute heart failure.
Swiss Med Wkly, 139 (2009), pp. 110-116
[4]
A. Mebazaa, A.A. Pitsis, A. Rudiger, W. Toller, D. Longrois, S.E. Ricksten, et al.
Practical recommendations on the management of perioperative heart failure in cardiac surgery.
Crit Care, 14 (2010), pp. 201-214
[5]
M. Carl, A. Alms, J. Braun, A. Dongas, J. Erb, A. Goetz, et al.
S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system.
Ger Med Sci, 8 (2010),
[6]
D. Atkins, D. Best, P.A. Briss, M. Eccles, Y. Falck-Ytter, S. Flottorp, GRADE Working Group, et al.
Grading quality of evidence and strength of recommendations.
BMJ, 328 (2004), pp. 1490-1498
[8]
T. Sakamoto, T. Yamada.
Hemodynamic effects of dobutamine in patients following open heart surgery.
Circulation, 55 (1977), pp. 525-533
[9]
P. Van Trigt, T.L. Spray, M.K. Pasque, R.B. Peyton, G.L. Pellom, A.S. Wechsler.
The comparative effects of dopamine and dobutamine on ventricular mechanics after coronary artery bypass grafting: a pressure-dimension analysis.
Circulation, 70 (1984), pp. 1112-1117
[10]
M.B. Fowler, E.L. Alderman, S.N. Oesterle, G. Derby, G.T. Daughters, E.B. Stinson, et al.
Dobutamine and dopamine after cardiac surgery: greater augmentation of myocardial blood flow with dobutamine.
Circulation, 70 (1984), pp. 1103-1111
[11]
P. Costa, G.M. Ottino, A. Matani, S. Pansini, C. Canavese, G. Passerini, et al.
Low-dose dopamine during cardiopulmonary bypass in patients with renal dysfunction.
J Cardiothorac Anesth, 4 (1990), pp. 469-473
[12]
J. Boldt, D. Kling, B. Zickmann, F. Dapper, G. Hempelmann.
Efficacy of the phosphodiesterase inhibitor enoximone in complicated cardiac surgery.
Chest, 98 (1990), pp. 53-58
[13]
K.J. Schwenzer, R.F. Kopel.
Hemodynamic and metabolic effects of dobutamine in 18 patients after open heart surgery.
Crit Care Med, 18 (1990), pp. 1107-1110
[14]
R.L. Royster, J.F. Butterworth, R.C. Prielipp, P.G. Robertie, N.D. Kon, W.Y. Tucker, et al.
A randomized, blinded, placebo-controlled evaluation of calcium chloride and epinephrine for inotropic support after emergence from cardiopulmonary bypass.
Anesth Analg, 74 (1992), pp. 3-13
[15]
J.Y. Dupuis, R. Bondy, C. Cattran, H.J. Nathan, J.E. Wynands.
Amrinone and dobutamine as primary treatment of low cardiac output syndrome following coronary artery surgery: a comparison of their effects on hemodynamics and outcome.
J Cardiothorac Vasc Anesth, 6 (1992), pp. 542-553
[16]
J.F. Butterworth, G.P. Zaloga, R.C. Prielipp, W.Y. Tucker, R.L. Royster.
Calcium inhibits the cardiac stimulating properties of dobutamine but not of amrinone.
Chest, 101 (1992), pp. 174-180
[17]
E. Ruokonen, J. Takala, A. Kari.
Regional blood flow and oxygen transport in patients with the low cardiac output syndrome after cardiac surgery.
Crit Care Med, 21 (1993), pp. 1304-1311
[18]
T.J. Tarr, N.A. Moore, R.S. Frazer, E.S. Shearer, M.J. Desmond.
Haemodynamic effects and comparison of enoximone, dobutamine and dopamine following mitral valve surgery.
Eur J Anaesthesiol Suppl, 8 (1993), pp. 15-24
[19]
R.L. Royster, J.F. Butterworth, R.C. Prielipp, G.P. Zaloga, S.G. Lawless, B.J. Spray, et al.
Combined inotropic effects of amrinone and epinephrine after cardiopulmonary bypass in humans.
Anesth Analg, 77 (1993), pp. 662-672
[20]
J.F. Butterworth, R.L. Royster, R.C. Prielipp, S.T. Lawless, S.L. Wallenhaupt.
Amrinone in cardiac surgical patients with left-ventricular dysfunction.
Chest, 104 (1993), pp. 1660-1667
[21]
M. Günnicker, M. Brinkmann, T.J. Donovan, U. Freund, M. Schieffer, J.C. Reidemeister.
The efficacy of amrinone or adrenaline on low cardiac output following cardiopulmonary bypass in patients with coronary artery disease undergoing preoperative beta-blockade.
Thorac Cardiovasc Surg, 43 (1995), pp. 153-160
[22]
J.F. Butterworth, R.L. Hines, R.L. Royster, R.L. James.
A pharmacokinetic and pharmacodynamic evaluation of milrinone in adults undergoing cardiac surgery.
Anesth Analg, 81 (1995), pp. 783-792
[23]
M. Kikura, M.K. Lee, R.A. Safon, J.M. Bailey, J.H. Levy.
The effects of milrinone on platelets in patients undergoing cardiac surgery.
Anesth Analg, 81 (1995), pp. 44-48
[24]
M. Kikura, J.H. Levy, L.G. Michelsen, J.S. Shanewise, J.M. Bailey, S.M. Sadel, et al.
The effect of milrinone on hemodynamics and left ventricular function after emergence from cardiopulmonary bypass.
Anesth Analg, 85 (1997), pp. 16-22
[25]
P.M.J. Rosseell, F.W. Santman, H. Bouter, C.S. Dott.
Postcardiac surgery low cardiac output syndrome: dopexamine or dopamine?.
Intensive Care Med, 23 (1997), pp. 962-968
[26]
E. Berendes, T. Möllhoff, H. Van Aken, C. Schmidt, M. Erren, M.C. Deng, et al.
Effects of dopexamine on creatinine clearance, systemic inflammation, and splanchnic oxygenation in patients undergoing coronary artery bypass grafting.
Anesth Analg, 84 (1997), pp. 950-957
[27]
T. Hachenberg, T. Möllhoff, D. Holst, T. Brüssel.
Cardiopulmonary effects of enoximone or dobutamine and nitroglycerin on mitral valve regurgitation and pulmonary venous hypertension.
J Cardiothorac Vasc Anesth, 11 (1997), pp. 453-457
[28]
R.J. Totaro, R.F. Raper.
Epinephrine-induced lactic acidosis following cardiopulmonary bypass.
Crit Care Med, 25 (1997), pp. 1693-1699
[29]
I.R. Jenkins, J. Dolman, J.P. O’Connor, D.M. Ansley.
Amrinone versus dobutamine in cardiac surgical patients with severe pulmonary hypertension after cardiopulmonary bypass: a prospective, randomized double-blinded trial.
Anaesth Intensive care, 25 (1997), pp. 245-249
[30]
L.A. Doolan, E.F. Jones, J. Kalman, B.F. Buxton, A.M. Tonkin.
A placebo-controlled trial verifying the efficacy of milrinone in weaning high-risk patients from cardiopulmonary bypass.
J Cardiothorac Vasc Anesth, 11 (1997), pp. 37-41
[31]
E.B. Lobato, O. Florete Jr., H.L. Bingham.
A single dose of milrinone facilitates separation from cardiopulmonary bypass in patients with pre-existing left ventricular dysfunction.
Br J Anaesth, 81 (1998), pp. 782-784
[32]
M. Kikura, J.H. Levy, Bailey, J.S. Shanewise, L.G. Michelsen, M. Sadel.
A bolus dose of 1.5mg/kg amrinone effectively improves low cardiac output state following separation from cardiopulmonary bypass in cardiac surgical patients.
Acta Anesth Scand, 42 (1998), pp. 825-833
[33]
J.F. Butterworth 4th, C. Legault, R.L. Royster, J.W. Hammon Jr..
Factors that predict the use of positive inotropic drug support after cardiac valve surgery.
Anesth Analg, 86 (1998), pp. 461-467
[34]
J.P. Rathmell, R.C. Prielipp, J.F. Butterworth, E. Williams, F. Villamaria, L. Testa, et al.
A multicenter, randomized, blind comparison of amrinone with milrinone after elective cardiac surgery.
Anesth Analg, 86 (1998), pp. 683-690
[35]
J. Lilleberg, M.S. Nieminem, J. Akkila, L. Heikkila, A. Kuitunen, L. Lehtonen, et al.
Effects of a new calcium sensitizer, levosimendan, on hemodynamics, coronary blood flow and myocardial substrate utilization early after CABG.
Eur Heart J, 19 (1998), pp. 660-668
[36]
J.L. Romson, J.M. Leung, W.H. Bellows, M. Bronstein, F. Keith, W. Moores, et al.
Effects of dobutamine on hemodynamics and left ventricular performance after cardiopulmonary bypass in cardiac surgical patients.
Anesthesiology, 91 (1999), pp. 1318-1328
[37]
A. Thorén, M. Elam, S.E. Ricksten.
Differential effects of dopamine, dopexamine, and dobutamine on jejunal mucosal perfusion early after cardiac surgery.
Crit Care Med, 28 (2000), pp. 2338-2343
[38]
T. Yamada, J. Takeda, N. Katori, K. Tsuzaki, R. Ochiai.
Hemodynamic effects of milrinone during weaning from cardiopulmonary bypass: comparison of patients with a low and high prebypass cardiac index.
J Cardiothorac Vasc Anesth, 14 (2000), pp. 367-373
[39]
R.O. Feneck, K.M. Sherry, P.S. Withington, A. Oduro-Dominah, European Milrinone Multicenter Trial Group.
Comparison of the hemodynamic effects of milrinone with dobutamine in patients after cardiac surgery.
J Cardiothorac Vasc Anesth, 15 (2001), pp. 306-315
[40]
M. Kikura, S. Sato.
The efficacy of preemptive milrinone or amrinone therapy in patients undergoing coronary artery bypass grafting.
Anesth Analg, 94 (2002), pp. 22-30
[41]
M. Kivikko, L. Lehtonen, W.S. Colucci.
Sustained hemodynamic effects of intravenous levosimendan.
Circulation, 107 (2003), pp. 81-86
[42]
J. Dernellis, M. Panaretou.
Effects of levosimendan on restrictive left ventricular filling in severe heart failure: a combined hemodynamic and Doppler echocardiographic study.
Chest, 128 (2005), pp. 2633-2639
[43]
J. Álvarez, M. Bouzada, A.L. Fernández, V. Caruezo, M. Taboada, J. Rodríguez, et al.
Comparación de los efectos hemodinámicos del levosimendán con la dobutamina en los pacientes con bajo gasto cardiaco después de cirugía cardiaca.
Rev Esp cardiol, 59 (2006), pp. 338-345
[44]
L. Tritapepe, V. De Santis, D. Vitale, M. Santulli, A. Morelli, I. Nofroni, et al.
Preconditioning effects of levosimendan in coronary artery bypass grafting—a pilot study.
Br J Anaesth, 96 (2006), pp. 694-700
[45]
E. Al-Shawaf, A. Ayed, I. Vislocky, B. Radomir, N. Dehrab, R. Tarazi.
Levosimendan or milrinone in the type 2 diabetic patient with low ejection fraction undergoing elective coronary artery surgery.
J Cardiothorac Vasc Anesth, 20 (2006), pp. 353-357
[46]
A. Tasouli, K. Papadopoulos, T. Antoniou, I. Kriaras, G. Stavridis, D. Degiannis, et al.
Efficacy and safety of perioperative infusion of levosimendan in patients with compromised cardiac function undergoing open-heart surgery: importance of early use.
Eur J Cardiothorac Surg, 32 (2007), pp. 629-633
[47]
S.G. De Hert, S. Lorsomradee, S. Cromheecke, P.J. Van der Linden.
The effects of levosimendan in cardiac surgery patients with poor left ventricular function.
Anesth Analg, 104 (2007), pp. 766-773
[48]
M. Heringlake, M. Wernerus, J. Grünefeld, S. Klaus, H. Heinze, M. Bechtel, et al.
The metabolic and renal effects of adrenaline and milrinone in patients with myocardial dysfunction after coronary artery bypass grafting.
Crit Care, 11 (2007), pp. R51
[49]
S.G. De Hert, S. Lorsomradee, H. vanden Eede, S. Cromheecke, P.J. Van der Linden.
A randomized trial evaluating different modalities of levosimendan administration in cardiac surgery patients with myocardial dysfunction.
J Cardiothorac Vasc Anesth, 22 (2008), pp. 699-705
[50]
N.E. El Mokhtari, A. Arlt, A. Meissner, M. Lins.
Inotropic therapy for cardiac low output syndrome: comparison of hemodynamic effects of dopamine/dobutamine versus dopamine/dopexamine.
Eur J Med Res, 13 (2008), pp. 459-463
[51]
K. Järvelä, P. Maaranen, T. Sisto, E. Ruokonen.
Levosimendan in aortic valve surgery: cardiac performance and recovery.
J Cardiothorac Vasc Anesth, 22 (2008), pp. 693-698
[52]
R.L. Levin, M.A. Degrange, R. Porcile, F. Salvagio, N. Blanco, A.L. Botbol, et al.
Superioridad del sensibilizante al calcio levosimendan comparado con dobutamina en el síndrome de bajo gasto cardiaco postoperatorio.
Rev Esp Cardiol, 61 (2008), pp. 471-479
[53]
L. Tritapepe, V. De Santis, D. Vitale, F. Guarracino, F. Pellegrini, P. Pietropaoli, et al.
Levosimendan pre-treatment improves outcomes in patients undergoing coronary artery bypass graft surgery.
Br J Anaesth, 102 (2009), pp. 198-204
[54]
A. Zangrillo, G. Biondi-Zoccai, A. Mizzi, G. Bruno, E. Bignami, C. Gerli, et al.
Levosimendan reduces cardiac troponin release after cardiac surgery: a meta-analysis of randomized controlled studies.
J Cardiothorac Vasc Anesth, 23 (2009), pp. 474-478
[55]
H.I. Eriksson, J.R. Jalonen, L.O. Heikkinen, M. Kivikko, M. Laine, K.A. Leino, et al.
Levosimendan facilitates weaning from cardiopulmonary bypass in patients undergoing coronary artery bypass grafting with impaired left ventricular function.
Ann Thorac Surg, 87 (2009), pp. 448-454
[56]
A. Noto, S. Lentini, A. Versaci, M. Giardina, D.C. Risitano, R. Messina, et al.
A retrospective analysis of terlipressin in bolus for the management of refractory vasoplegic hypotension after cardiac surgery.
Interact Cardiovasc Thorac Surg, 9 (2009), pp. 588-592
[57]
G. Landoni, A. Mizzi, G. Biondi-Zoccai, G. Bruno, E. Bignami, L. Corno, et al.
Reducing mortality in cardiac surgery with levosimendan: a meta-analysis of randomized controlled trials.
J Cardiothorac Vasc Anesth, 24 (2010), pp. 51-57
[58]
M. Ranucci, D. De Benedetti, C. Bianchini, S. Castelvecchio, A. Ballotta, A. Frigiola, et al.
Effects of fenoldopam infusion in complex cardiac surgical operations: a prospective, randomized, double-blind, placebo-controlled study.
Minerva Anestesiol, 76 (2010), pp. 249-259
[59]
H.S. Loeb, E.B.J. Winslow, S.H. Rahimtoola, K.M. Rosen, R.M. Gunnar.
Acute hemodynamic effects of dopamine in patients with shock.
Circulation, 44 (1971), pp. 163-173
[60]
C.V. Leier, J. Webel, C.A. Bush.
The cardiovascular effects of the continuous infusion of dobutamine in patients with severe cardiac failure.
Circulation, 56 (1977), pp. 468-472
[61]
H.S. Loeb, J. Bredakis, R.M. Gunnar.
Superiority of dobutamine over dopamine for augmentation of cardiac output in patients with chronic low output cardiac failure.
Circulation, 55 (1977), pp. 375-381
[62]
D.S. Baim, A.V. McDowell, J. Cherniles, E.S. Monrad, J.A. Parker, J. Edelson, et al.
Evaluation of a new bipyridine inotropic agent-milrinone-in patients with severe congestive heart failure.
N Engl J Med, 309 (1983), pp. 748-756
[63]
M. Packer, N. Medina, M. Yushak.
Hemodynamic and clinical limitations of long-term inotropic therapy with amrinone in patients with severe chronic heart failure.
Circulation, 70 (1984), pp. 1038-1047
[64]
J.L. Anderson, D.S. Baim, S.A. Fein, R.A. Goldstein, T.H. Lejemtel, M.J. Likoff.
Efficacy and safety of sustained (48 hour) intravenous infusions of milrinone in patients with severe congestive heart failure: a multicenter study.
JACC, 9 (1987), pp. 711-722
[65]
C.V. Leier, J.J. Lima, S.E. Meiler, D.V. Unverferth.
Central and regional hemodynamic effects of oral enoximone in congestive heart failure: a double-blind, placebo-controlled study.
Am Heart J, 115 (1988), pp. 1051-1059
[66]
R. DiBianco, R. Shabetai, W. Kostuk, J. Moran, R.C. Schlant, R. Wright.
A comparison of oral milrinone digoxin, and their combination in the treatment of patients with chronic heart failure.
N Engl J Med, 320 (1989), pp. 677-683
[67]
B.F. Urestky, M. Jessup, M.A. Konstam, G.W. Dec, C.V. Leier, J. Benotti, et al.
Multicenter trial of oral enoximone in patients with moderate to moderately severe congestive heart failure.
Circulation, 82 (1990), pp. 774-780
[68]
M. Packer, J.R. Carver, R.J. Rodeheffer, R.J. Ivanhoe, R. DiBianco, S.M. Zeldis, for the PROMISE Study Research Group, et al.
Effect of oral milrinone on mortality in severe chronic heart failure.
N Engl J Med, 325 (1991), pp. 1468-1475
[69]
M.S. Nieminen, J. Akkila, G. Hasenfuss, F.X. Kleber, L.A. Lehtonen, V. Mitrovic, et al.
Hemodynamic and neurohumoral effects of continuous infusion of levosimendan in patients with congestive heart failure.
J Am Coll Cardiol, 36 (2000), pp. 1903-1912
[70]
M.T. Slawsky, W.S. Colucci, S.S. Gottlieb, B.H. Greenberg, E. Haeusslein, J. Hare, et al.
Acute hemodynamic and clinical effects of levosimendan in patients with severe heart failure.
Circulation, 102 (2000), pp. 2222-2227
[71]
M.H. Yamani, S.A. Haji, R.C. Starling, L. Kelly, N. Albert, D.L. Knack, et al.
Comparison of dobutamine-based and milrinone-based therapy for advanced decompensated congestive heart failure: hemodynamic efficacy, clinical outcome, and economic impact.
Am Heart J, 142 (2001), pp. 998-1002
[72]
S. Thackray, J. Easthaugh, N. Freemantle, J.G. Cleland.
The effectiveness and relative effectiveness of intravenous inotropic drugs acting through the adrenergic pathway in patients with heart failure—a meta-regression analysis.
Eur J Heart Fail, 4 (2002), pp. 515-529
[73]
F. Follath, J.F.G. Cleland, H. Just, J.G.Y. Papp, K. Peuhkurinen, V.P. Harjola, et al.
Efficacy and safety of intravenous levosimendan compared with dobutamina in severe low-output heart failure (the LIDO study): a randomized double blind trial.
Lancet, 360 (2002), pp. 196-202
[74]
M.S. Cuffe, R.M. Califf, K.F. Adams, R. Benza, R. Bourge, W.S. Colucci, Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) Investigators, et al.
Short-term intravenous milrinone for acute exacerbation of chronic heart failure. A randomized controlled trial.
JAMA, 287 (2002), pp. 1541-1547
[75]
V.S. Moiseyev, P. Pöder, N. Andrejevs, M.Y. Ruda, A.P. Golikov, L.B. Lazebnik, on behalf of RUSSLAN Study Investigators, et al.
Eur Heart J, 23 (2002), pp. 1422-1432
[76]
A. Mebazaa, M.S. Nieminen, M. Packer, A. Cohen-Solal, F.X. Kleber, S.J. Pocock, et al.
Levosimendan vs dobutamine for patients with acute decompensated heart failure. The SURVIVE randomized trial.
JAMA, 297 (2007), pp. 1883-1891
[77]
J.T. Fuhrmann, A. Schmeisser, M.R. Schulze, C. Wunderlich, S.P. Schoen, T. Rauwolf, et al.
Levosimendan is superior to enoximone in refractory cardiogenic shock complicating acute myocardial infarction.
Crit Care Med, 36 (2008), pp. 2257-2266
[78]
A. Mebazaa, M. Nieminen, G.S. Filippatos, J.G. Cleland, J.E. Salon, R. Yhakkar, et al.
Levosimendan vs dobutamine: outcomes for acute heart failure patients on beta-blockers in SURVIVE.
Eur J Heart fail, 11 (2009), pp. 304-311
[79]
M.A. Russ, R. Prondzinsky, J.M. Carter, A. Schlitt, H. Ebelt, H. Schmidt, et al.
Right ventricular function in myocardial infarction complicated by cardiogenic shock: Improvement with levosimendan.
Crit Care Med, 37 (2009), pp. 3017-3023
[80]
D. De Backer, P. Biston, J. Devriendt, C. Madl, D. Chochrad, C. Aldecoa, SOAP II investigators, et al.
Comparison of dopamine and norepinephrine in the treatment of shock.
N Engl J Med, 362 (2010), pp. 779-789
[81]
M.S. Nieminen, M. Böhm, M.R. Cowie, H. Drexler, G.S. Filippatos, G. Jondeau, ESC Committee for Practice Guideline, et al.
Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology.
Eur Heart J, 26 (2005), pp. 384-416
[82]
K. Dickstein, A. Cohen-Solal, G. Filippatos, J.J. McMurray, P. Ponikowski, P.A. Poole-Wilson, ESC Committee for Practice Guidelines (CPG), et al.
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM).
Eur Heart J, 29 (2008), pp. 2388-2442
[83]
S.A. Hunt, W.T. Abraham, M.H. Chin, A.M. Feldman, G.S. Francis, T.G. Ganiats, et al.
2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation.
Circulation, 119 (2009), pp. e391-e479
[84]
U. Boeken, P. Feindt, J. Litmathe, M. Kart, E. Gams.
Intraaortic Balloon Pumping in patients with right ventricular insufficiency after cardiac surgery: parameters to predict failure of IABP support.
Thorac Cardiovasc Surg, 57 (2009), pp. 324-328
[85]
O.j. Liakopoulos, J.K. Ho, A.B. Yezbick, E. Sanchez, V. Singh, A. Mahajan.
Right ventricular failure resulting from pressure overload: Role of intra-aortic balloon counterpulsation and vasopressor therapy.
[86]
F.W. Lombard, K.P. Grichnik.
Update on management strategies for separation from cardiopulmonary bypass.
Curr Opin Anaesthesiol, 24 (2011), pp. 49-57
[87]
H. Haussmann, E.V. Potapov, A. Koster, T. Krabatsch, J. Stein, R. Meter, et al.
Prognosis alter the implantation of a Intra-Aortic Balloon Pump in cardiac surgery calculated with a new score.
Circulation, 106 (2002), pp. I203-I206
[88]
R. Prondzinsky, H. Lemm, M. Swyter, N. Wegener, S. Unverzagt, M. Justin, et al.
Intra-aortic balloon counterpulsation in patients with acute myocardial infarction complicated by cardiogenic shock: the prospective, randomized IABP SHOCK Trial for attenuation of multiorgan dysfunction syndrome.
Crit Care Med, (2010), pp. 38

Please cite this article as: Pérez Vela E, et al. Resumen del documento de consenso «Guías de práctica clínica para el manejo del síndrome de bajo gasto cardiaco en el postoperatorio de cirugía cardiaca». Med Intensiva. 2012;36:277–87.

The full version of this consensus document is published in Medicina Intensiva 2012. doi:10.1016/j.medin.2012.02.007. Available from: www.elsevier.es/medicina-intensiva.

Copyright © 2011. Elsevier España, S.L. and SEMICYUC
Idiomas
Medicina Intensiva (English Edition)
Article options
Tools
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?