A Global Survey of Post-Cardiac Surgery Shock for the European Association of Cardiothoracic Anaesthesiology & Intensive Care

Abstract

Objective: Mortality after cardiac surgery is declining globally, but is disproportionately represented in patients developing vasoplegic syndrome (VPS), or cardiogenic shock (CS) severe enough to require temporary mechanical circulatory support (tMCS). A global observational study is required to better understand the incidence, aetiology and outcomes of these shock states. We conducted an international survey to examine the current management of post-cardiac surgery shock. Design and method: A 25 question survey was devised for EACTAIC members, endorsed by the EACTAIC Scientific Committee & distributed via the Association from April - June 2025. Respondents were asked to use their most current (or estimated, if not available) incidence data. Result(s) and Conclusion(s): Sixty-three centres in 31 countries responded (76% Europe, 11% Asia, 8% South America, 2% North America, 2% Australia/Oceania & 2% Africa). The response rate was 11%, which should not confer bias given the sampling frame of 670 (Fosnacht et al. RHE. 2017). Median reported incidence of post-cardiac surgery CS was 5% IQR: 3-10%]. Diagnosis and management is primarily informed by transoesophageal echocardiography (TOE) in 98% of centres in the Operating Room (OR), and in 87% by TOE and 75% by transthoracic echocardiogram (TTE) in the Cardiac ICU (CICU). Pulmonary artery catheters (PAC) are used in 70% 79% (OR CICU, respectively) and clinical signs in 70% 73%. Most institutions, 62%, do not have a protocol for CS management. For CS management, intra-aortic balloon pump (IABP) (94%) and VA-ECMO (92%) were available in nearly all centres, with median usage of 3% IQR: 2-10%] and 2% IQR: 1-5%], respectively. Provision of microaxial flow pumps, such as Impella devices, was 57%, with usage of 1% IQR: 0.5-2.5%]), and ventricular assist devices (VAD) was 41%, with 1% usage IQR: 0.5-2%]). In tMCS cases, median mortality was lowest in those receiving IABP (20% IQR: 10-35%]) and VAD (19% IQR: 10-40%]), and highest with use of Impella devices (40% IQR: 30-70%]) and VA-ECMO (42% 20-50%]) support. Most institutions (56%) did not have a standardised definition for VPS. Most (68%) agreed with a pragmatic definition (based on ATHOS-3; Khanna et al. NEJM. 2017), which would result in a median incidence of 9% IQR: 5-20%]. Diagnosis & management of VPS is driven by TOE in the OR in 94% of centres, and by TTE in 83% & TOE in 79% in CICU. Clinical signs support diagnosis and management in 73% 81% (in the OR CICU) of centres, as does PAC monitoring (70% 78%). Noradrenaline is used in all centres in the OR and CICU for VPS, with high availability of of vasopressin (89% 92% OR CICU, respectively), 'shock dose' hydrocortisone (84% 86%), adrenaline (79% 91%) and methylene blue (71% 76.2%). There is more variable use of cytokine absorbers, hydroxocobalamin, vitamin C (all available in 30-50% of centres), and terlipressin, angiotensin II and vitamin B/C (Pabrinex) (in <30% of centres). These therapies were guided by a protocol in only 33% of centres. These results confirm the requirement for a large international observational study of post-cardiac surgery shock to guide future RCTs, refine therapeutic indications & understand the health economics of managing this high-risk cohort. Copyright © 2025