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cardio.cardiogenic-shock.post-cardiac-surgery.v1

Cardiogenic shock — Post non-CABG cardiac surgery (valve / transplant / complex)

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Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to CS after non-CABG cardiac surgery (isolated AVR/MVR, double-/triple-valve, mitral repair, complex congenital adult repair, aortic root/arch / Bentall, heart transplant, LVAD implant). Distinguished from cardio.cardiogenic-shock.post-cabg.v1 by dominant etiology mix: pump failure from prolonged bypass time, valve mechanical complications (dehiscence, paravalvular leak, prosthetic valve thrombosis), pulm HTN crisis post-MV repair, RV failure post-LVAD, PGD post-transplant per ISHLT 2024, perioperative MI from coronary button (Bentall) or donor anastomosis (transplant), hemorrhagic tamponade. Workup centerpiece: STAT TEE for valve + tamponade + biventricular function, daily echo through POD 7. Treatment: NE first-line per SOAP-II + vasopressin + methylene blue if vasoplegia; iNO + sildenafil + epoprostenol for pulm HTN crisis; Impella RP / Protek Duo for RV failure post-LVAD; pulse-dose methylprednisolone for severe PGD; emergent re-operation for valve dehiscence or hemorrhagic tamponade; VA-ECMO for refractory biventricular failure. Manifest pointer reuses cardio.cardiogenic-shock.core.v1 manifest. Design-brief pointer reuses parent (post-cardiac-surgery-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute as Phase E wave 12 variant.

Entry points (6)

  • history
    Hours-to-days post-AVR/MVR/transplant/Bentall/LVAD: SBP <90 + lactate ↑ + low CI on PA cath
    post_non_cabg_cardiac_surgery_low_co
  • imaging
    Post-op TEE: severe paravalvular leak, valve dehiscence, prosthetic valve thrombosis, or new severe regurgitation
    tee_post_op_valve_or_paravalvular_leak
  • imaging
    Post-MV-repair TEE: acute RV dilation + dysfunction + elevated PA pressure → pulmonary HTN crisis
    tee_post_op_pulmonary_htn_crisis
  • imaging
    Post-LVAD TEE: RV dilation + dysfunction + low LVAD flows → acute RV failure unmasked
    tee_post_lvad_rv_failure
  • lab_abnormality
    Rising lactate post-cardiotomy with low SvO2 → low CO syndrome
    rising_lactate_post_cardiotomy
  • symptom
    Primary graft dysfunction post-heart-transplant: severe LV/RV/biventricular dysfunction within 24h per ISHLT 2024
    pgd_after_transplant

Required inputs (10)

  • sbprequired
    vital • used at RED_FLAGS
    SBP <90 sustained drives shock-trigger threshold; differentiates pump failure vs vasoplegia by SVR pattern
  • cvprequired
    vital • used at INITIAL_WORKUP
    CVP elevation differentiates RV failure (post-LVAD, post-MV-repair pulm HTN) and tamponade from vasoplegia
  • tee_post_oprequired
    imaging • used at INITIAL_WORKUP
    STAT TEE is critical: valve dehiscence, paravalvular leak, prosthetic valve thrombosis, biventricular function, tamponade, RV failure post-LVAD, PGD post-transplant
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    New ST elevation in coronary button territory (Bentall) or transplant donor coronary anastomosis territory → graft/anastomotic failure
  • lactaterequired
    lab • used at RED_FLAGS
    Lactate trend marks SCAI Stage C+; rising lactate after off-bypass hallmark of low CO syndrome
  • svo2_or_scvo2required
    lab • used at INITIAL_WORKUP
    Mixed/central venous O2 saturation marks CO adequacy
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Perioperative MI threshold per 4th UDMI: troponin >10x ULN + ECG/imaging changes; identifies coronary button or donor anastomosis ischemia
  • creatininerequired
    lab • used at CONTEXT
    AKI common post-CPB (especially with long bypass time in valve/transplant cases); eGFR for drug dosing
  • chest_tube_outputrequired
    history • used at CONTEXT
    Chest tube output trend: rising = active bleeding; sudden drop + decline = loculated tamponade
  • cpb_timerequired
    history • used at CONTEXT
    CPB time >180 min strongly predicts pump failure + vasoplegia; transplant + complex valve cases routinely exceed this

12-phase flow (11)

  1. 1FRAME
    Post non-CABG cardiac surgery CS = differential of pump failure (long bypass), valve mechanical complication (dehiscence, paravalvular leak, prosthetic thrombosis), pulm HTN crisis post-MV repair, RV failure post-LVAD, PGD post-transplant, tamponade, perioperative MI from coronary button or donor anastomosis; CT surgery + CT anesthesia + transplant team (if applicable) at bedside; STAT TEE critical
    inputs: sbp, lactate
    advance: CT surgery + anesthesia + TEE team activated
  2. 2ENTRY
    Identify primary etiology by TEE + ECG + chest tube output: pump failure (inotropes + MCS), valve mechanical complication (re-explore), pulm HTN crisis (iNO + sildenafil + epoprostenol), RV failure post-LVAD (RV-assist device), PGD (VA-ECMO + pulse steroids), tamponade (drain), perioperative MI (re-cath)
    inputs: sbp, cvp
    advance: Etiology hypothesis from TEE + ECG + chest tube output
  3. 3CONTEXT
    Procedure type (AVR, MVR, transplant, Bentall, LVAD, complex congenital), CPB time, cross-clamp time, intraoperative TEE findings, donor info if transplant, pre-op pulmonary pressures (critical for MV repair pulm HTN crisis risk and post-LVAD RV failure prediction)
    inputs: chest_tube_output, creatinine, cpb_time
    advance: OR record + pre-op cath + transplant donor record reviewed
  4. 4RED_FLAGS
    Hemorrhagic tamponade (chest tube cessation + hypotension) → re-explore; valve dehiscence with hemodynamic collapse → emergent OR; pulm HTN crisis with imminent RV arrest → iNO + epoprostenol + RV-assist; PGD post-transplant requiring VA-ECMO
    inputs: sbp, cvp
    actions: cardiac_tamponade
    advance: Etiology-specific emergent intervention triggered
  5. 5INITIAL_WORKUP
    STAT TEE (valve, tamponade, biventricular function); ECG (coronary button territory in Bentall, donor anastomosis in transplant); ABG + lactate + SvO2; chest tube output trend; CXR; BNP for RV strain; procalcitonin if mediastinitis suspected; daily echo through POD 7
    inputs: tee_post_op, ecg, lactate, svo2_or_scvo2, troponin
    actions: cardiogenic_shock, panel.cardiac, panel.coag
    advance: Etiology classified
  6. 6BRANCHING_WORKUP
    Valve dehiscence/paravalvular leak/prosthetic thrombosis → emergent re-operation; pulm HTN crisis post-MV repair → iNO + IV epoprostenol + sildenafil; RV failure post-LVAD → Impella RP or Protek Duo; PGD post-transplant → VA-ECMO + pulse-dose methylprednisolone per ISHLT 2024; coronary button or donor anastomosis ischemia → re-cath
    inputs: tee_post_op
    actions: acs_pathway
    advance: Etiology-specific intervention triggered
  7. 7RISK_STRATIFICATION
    SCAI 2022 staging; STS predicted operative risk vs observed outcome; ISHLT PGD severity grade if transplant; CardShock for perioperative CS
    inputs: lactate
    advance: Risk stratified
  8. 8TREATMENT
    NE first-line per SOAP-II; vasopressin add-on for vasoplegia (esp pre-op ACE-I); methylene blue 1-2 mg/kg IV for refractory vasoplegia; epinephrine + dobutamine + milrinone for low CI; iNO + sildenafil + epoprostenol for pulm HTN crisis; IABP/Impella/RV-assist/VA-ECMO per etiology; pulse-dose methylprednisolone if PGD post-transplant; emergent re-exploration for valve dehiscence or hemorrhagic tamponade
    inputs: sbp, lactate
    actions: cardiogenic_shock
    advance: Pressor + inotrope + MCS + procedure-specific strategy active
  9. 9DISPOSITION
    CT-ICU at operating institution; transplant ICU if heart transplant; advanced HF center transfer if PGD or refractory shock
    advance: Disposition assigned
  10. 10MONITORING
    A-line + central line + PA catheter (typically already in place from OR); chest tube output q1h; lactate + ABG q2h; daily TEE for valve + biventricular recovery; methemoglobin q4h after methylene blue; iNO weaning protocol if pulm HTN crisis; serial endomyocardial biopsy if transplant per ISHLT cadence
    inputs: lactate
    actions: panel.cardiac
    advance: Monitoring cadence established
  11. 11FOLLOWUP
    GDMT initiation if persistent LV dysfunction (PIONEER-HF cadence); cardiac rehab; sternal precautions; INR management if mechanical valve; immunosuppression if transplant; depression screening; LVAD outpatient management if applicable
    advance: GDMT + cardiac rehab + transplant or LVAD outpatient program + follow-up booked