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Table 4 The three clinical heart failure scenarios and the clinical profiles in each scenario

From: Clinical review: Practical recommendations on the management of perioperative heart failure in cardiac surgery

Clinical scenarios Clinical profiles in each scenario
Precardiotomy heart failure  
   Precardiotomy crash and burn Refractory cardiogenic shock requiring emergent salvage operation: CPR en route to the operating theatre or prior to anaesthesia induction
  Refractory cardiogenic shock (STS definition SBP <80 mmHg and/or CI <1.8 L/minute/m2 despite maximal treatment) requiring emergency operation due to ongoing, refractory (difficult, complicated, and/or unmanageable) unrelenting cardiac compromise resulting in life threatening haemodynamic compromise
   Precardiotomy deteriorating fast Deteriorating haemodynamic instability: increasing doses of intravenous inotropes and/or IABP necessary to maintain SBP > 80 mmHg and/or CI >1.8 L/minute/m2. Progressive deterioration. Emergency operation required due to ongoing, refractory (difficult, complicated, and/or unmanageable) unrelenting cardiac compromise, resulting in severe haemodynamic compromise
   Precardiotomy stable on inotropes Inotrope dependency: intravenous inotropes and/or IABP are necessary to maintain SBP >80 mmHg and/or CI >1.8 L/minute/m2 without clinical improvement. Failure to wean from inotropes (decreasing inotropes results in symptomatic hypotension or organ dysfunction). Urgent operation is required
Failure to wean from CPB  
   Failure to wean from CPB Cardiac arrest after prolonged weaning time (>1 hour)
   Deteriorating fast on withdrawal from CPB Deteriorating haemodynamic instability on withdrawal of CBP after prolonged weaning time (>1 hour)
  Increasing doses of intravenous inotropes and/or IABP necessary to maintain SBP >80 mmHg and/or CI >1.8 L/minute/m2
   Stable but inotrope dependent on withdrawal from CPB Inotrope dependency on withdrawal of CBP after weaning time >30 minutes. Intravenous inotropes and/or IABP are necessary to maintain SBP >80 mmHg and/or CI >1.8 L/minute/m2 without clinical improvement
  The high incidence of complications after VAD implantation is directly related to prolonged attempted weaning periods from CPB. Application of IABP within 30 minutes from the first attempt to wean from CPB and mechanical circulatory support within 1 hour from the first attempts to wean from the CPB are suggested [90]
Postcardiotomy cardiogenic shock  
   Postcardiotomy crash and burn Cardiac arrest requiring CPR until intervention
  Refractory cardiogenic shock (SBP <80 mmHg and/or CI <1.8 L/minute/m2, critical organ hypoperfusion with systemic acidosis and/or increasing lactate levels despite maximal treatment, including inotropes and IABP) resulting in life threatening haemodynamic compromise. Emergency salvage intervention required
   Postcardiotomy deteriorating fast Deteriorating haemodynamic instability. Increasing doses of intravenous inotropes and/or IABP necessary to maintain SBP >80 mmHg and/or CI >1.8 L/minute/m2. Progressive deterioration, worsening acidosis and increasing lactate levels. Emergent intervention required due to ongoing, refractory unrelenting cardiac compromise, resulting in severe haemodynamic compromise
   Postcardiotomy stable on inotropes Inotrope dependency: intravenous inotropes and/or IABP necessary to maintain SBP >80 mmHg and/or CI >1.8 L/minute/m2 without clinical improvement. Failure to decrease inotropic support
  1. CI, cardiac index; CPB, cardiopulmonary bypass; CPR, cardiopulmonary resuscitation; IABP, intra-aortic balloon pump; SBP, systolic blood pressure; STS, Society of Thoracic Surgeons; VAD, ventricular assist device.