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cardio.cardiogenic-shock.post-cardiac-surgery.v1PRODUCTION
cardio.cardiogenic-shock.post-cardiac-surgery.v1

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

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11/12 authored

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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

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CT surgery + anesthesia + TEE team activated

Patient inputs (10)

AKI common post-CPB (especially with long bypass time in valve/transplant cases); eGFR for drug dosing

Chest tube output trend: rising = active bleeding; sudden drop + decline = loculated tamponade

CPB time >180 min strongly predicts pump failure + vasoplegia; transplant + complex valve cases routinely exceed this

CVP elevation differentiates RV failure (post-LVAD, post-MV-repair pulm HTN) and tamponade from vasoplegia

STAT TEE is critical: valve dehiscence, paravalvular leak, prosthetic valve thrombosis, biventricular function, tamponade, RV failure post-LVAD, PGD post-transplant

New ST elevation in coronary button territory (Bentall) or transplant donor coronary anastomosis territory → graft/anastomotic failure

Mixed/central venous O2 saturation marks CO adequacy

Perioperative MI threshold per 4th UDMI: troponin >10x ULN + ECG/imaging changes; identifies coronary button or donor anastomosis ischemia

SBP <90 sustained drives shock-trigger threshold; differentiates pump failure vs vasoplegia by SVR pattern

Lactate trend marks SCAI Stage C+; rising lactate after off-bypass hallmark of low CO syndrome

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningpost_non_cabg_valve_dehiscence
    Post-AVR/MVR/double-valve patient with new severe AR/MR or paravalvular jet on TEE + hemodynamic decline → emergent re-operation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpost_lvad_rv_failure
    Post-LVAD with low LVAD flows + high CVP + low PA pressure + worsening congestion → acute RV failure post-LVAD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpost_mv_repair_pulm_htn_crisis
    Post-MV-repair with pre-op pulm HTN now with acute RV dilation + dysfunction + PA pressure >50 + low CO with high CVP off-bypass → pulm HTN crisis
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpgd_post_heart_transplant_severe
    Post-heart-transplant with severe LV/RV/biventricular dysfunction within 24h not explained by hyperacute rejection or surgical complication → severe PGD per ISHLT 2024
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepost_non_cabg_paravalvular_leak_severe
    Post-AVR/MVR with severe paravalvular leak on post-op TEE → re-operation vs catheter-based closure depending on anatomy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepost_non_cabg_persistent_vasoplegia_despite_methylene_blue
    Post-cardiac-surgery patient with persistent vasoplegia (NE >0.5 + vasopressin maxed + methylene blue ×1-2 doses) and MAP <65 → consider angiotensin II + hydroxocobalamin
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Post non-CABG cardiac surgery CS — etiology-tailored regimen (pump failure / valve mechanical complication / pulm HTN crisis / RV failure post-LVAD / PGD / perioperative MI)
axis: post_non_cabg_cardiac_surgery_cs_phenotype
Selected axis "Post non-CABG cardiac surgery CS — etiology-tailored regimen (pump failure / valve mechanical complication / pulm HTN crisis / RV failure post-LVAD / PGD / perioperative MI)" by default fallback (first axis)
  • norepinephrine
    first line
    alpha_beta_pressor
    0.05-0.5 mcg/kg/min IV titrate to MAP ≥65 • IV • continuous
    triggers: post_cardiac_surgery_hypotension
    SOAP-II PMID 20200382 — first-line vasopressor; lower arrhythmia than dopamine
    rxcui 7512
  • vasopressin
    first line
    v1_agonist
    0.03-0.04 U/min fixed (no titration) • IV • continuous
    triggers: post_cardiac_surgery_vasoplegia, pre_op_acei_or_arb_use, post_mv_repair_pulm_htn
    V1 vasoconstriction; pulmonary-sparing (preferred over NE in pulm HTN crisis); effective post-CPB vasoplegia (Lomivorotov 2017)
    rxcui 11149
  • methylene blue
    second line
    guanylate_cyclase_inhibitor
    1-2 mg/kg IV bolus over 20 min (may repeat once at 4-6h) • IV • bolus
    triggers: refractory_vasoplegia_on_max_ne_and_vasopressin
    Inhibits NO-mediated vasodilation; effective for refractory vasoplegia post-cardiotomy (Lomivorotov 2017); CONTRAINDICATED G6PD deficiency + serotonergic agents
    rxcui 6878
  • epinephrine
    rescue
    alpha_beta_pressor_inotrope
    0.05-0.5 mcg/kg/min IV titrate • IV • continuous
    triggers: refractory_low_co_after_ne_and_dobutamine, pgd_post_transplant
    Dual alpha + beta; reserve for refractory shock per OptimaCC; first-line in PGD per ISHLT
    rxcui 3992
  • dobutamine
    first line
    beta1_inotrope
    2.5-10 mcg/kg/min IV • IV • continuous
    triggers: post_cardiac_surgery_low_ci_lt_2_2
    Inotrope for myocardial stunning post-CPB; titrate to CI ≥2.2; DOREMI PMID 33704937
    rxcui 3616
  • milrinone
    first line
    pde3_inhibitor_inodilator
    0.125-0.5 mcg/kg/min IV (no bolus; renal-dose adjust) • IV • continuous
    triggers: post_mv_repair_pulm_htn, rv_failure_post_lvad, post_cardiac_surgery_with_pre_op_bb
    Inodilator preferred for RV failure + pulm HTN (PDE3 inhibition lowers PVR); non-inferior to dobutamine (DOREMI PMID 33704937)
    rxcui 52769
  • inhaled nitric oxide
    first line
    pulmonary_vasodilator_inhaled
    20-40 ppm via ventilator circuit • inhaled • continuous
    triggers: post_mv_repair_pulm_htn_crisis, rv_failure_post_lvad, pgd_with_pulm_htn
    Selective pulmonary vasodilator without systemic hypotension; first-line for pulm HTN crisis post-MV repair; methemoglobin q4h monitoring; rebound on weaning so taper slowly
    rxcui 7442
  • sildenafil
    first line
    pde5_inhibitor
    20-40 mg q8h NG/PO • NG/PO • q8h
    triggers: post_mv_repair_pulm_htn_crisis, iNO_weaning_bridge
    PDE5 inhibition prolongs cGMP-mediated pulmonary vasodilation; bridges off iNO to prevent rebound; safe with NE/vasopressin
    rxcui 136411
  • epoprostenol
    second line
    prostacyclin_iv
    1-4 ng/kg/min IV continuous, titrate up by 1-2 ng/kg/min q15-30 min • IV • continuous
    triggers: refractory_pulm_htn_crisis_despite_ino_and_sildenafil
    IV prostacyclin for refractory pulm HTN crisis; bridges to RV-assist device; can also be inhaled (avoid systemic hypotension)
    rxcui 8814
  • methylprednisolone
    first line
    corticosteroid_iv
    500-1000 mg IV pulse for PGD; standard transplant induction per ISHLT • IV • pulse + maintenance
    triggers: pgd_post_heart_transplant, transplant_induction_per_ishlt
    Pulse-dose for severe PGD per ISHLT 2024; standard induction immunosuppression per ISHLT
    rxcui 6902

outpatient playbook — drug actions (3)

  1. 1. continue secondary prevention bundle
    rxcui 243670
    ASA 81 (mech valve add-on) + atorvastatin 80 + GDMT per HF status • PO • as scheduled
    trigger: Post-cardiac-surgery long-term
    AHA 2025
  2. 2. continue lifelong VKA if mech valve
    rxcui 11289
    warfarin INR per 2020 Valvular Guidelines • PO • daily
    trigger: Mech valve
    2020 ACC/AHA Valvular Guidelines
  3. 3. continue ISHLT immunosuppression if transplant
    rxcui 6902
    tacrolimus + mycophenolate + low-dose prednisone per ISHLT • PO • as scheduled
    trigger: Heart transplant recipient
    ISHLT 2024

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Hours-to-days post-AVR/MVR/transplant/Bentall/LVAD: SBP <90 + lactate ↑ + low CI on PA cath; Post-op TEE: severe paravalvular leak, valve dehiscence, prosthetic valve thrombosis, or new severe regurgitation; Post-MV-repair TEE: acute RV dilation + dysfunction + elevated PA pressure → pulmonary HTN crisis.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardiogenic shock — Post non-CABG cardiac surgery (valve / transplant / complex)** (cardio.cardiogenic-shock.post-cardiac-surgery.v1).
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **Post non-CABG cardiac surgery CS — etiology-tailored regimen (pump failure / valve mechanical complication / pulm HTN crisis / RV failure post-LVAD / PGD / perioperative MI)**.
1. norepinephrine 0.05-0.5 mcg/kg/min IV titrate to MAP ≥65 IV continuous (alpha_beta_pressor, first line) — SOAP-II PMID 20200382 — first-line vasopressor; lower arrhythmia than dopamine
2. vasopressin 0.03-0.04 U/min fixed (no titration) IV continuous (v1_agonist, first line) — V1 vasoconstriction; pulmonary-sparing (preferred over NE in pulm HTN crisis); effective post-CPB vasoplegia (Lomivorotov 2017)
3. methylene blue 1-2 mg/kg IV bolus over 20 min (may repeat once at 4-6h) IV bolus (guanylate_cyclase_inhibitor, second line) — Inhibits NO-mediated vasodilation; effective for refractory vasoplegia post-cardiotomy (Lomivorotov 2017); CONTRAINDICATED G6PD deficiency + serotonergic agents
4. epinephrine 0.05-0.5 mcg/kg/min IV titrate IV continuous (alpha_beta_pressor_inotrope, rescue) — Dual alpha + beta; reserve for refractory shock per OptimaCC; first-line in PGD per ISHLT
5. dobutamine 2.5-10 mcg/kg/min IV IV continuous (beta1_inotrope, first line) — Inotrope for myocardial stunning post-CPB; titrate to CI ≥2.2; DOREMI PMID 33704937
6. milrinone 0.125-0.5 mcg/kg/min IV (no bolus; renal-dose adjust) IV continuous (pde3_inhibitor_inodilator, first line) — Inodilator preferred for RV failure + pulm HTN (PDE3 inhibition lowers PVR); non-inferior to dobutamine (DOREMI PMID 33704937)
7. inhaled nitric oxide 20-40 ppm via ventilator circuit inhaled continuous (pulmonary_vasodilator_inhaled, first line) — Selective pulmonary vasodilator without systemic hypotension; first-line for pulm HTN crisis post-MV repair; methemoglobin q4h monitoring; rebound on weaning so taper slowly
8. sildenafil 20-40 mg q8h NG/PO NG/PO q8h (pde5_inhibitor, first line) — PDE5 inhibition prolongs cGMP-mediated pulmonary vasodilation; bridges off iNO to prevent rebound; safe with NE/vasopressin
9. epoprostenol 1-4 ng/kg/min IV continuous, titrate up by 1-2 ng/kg/min q15-30 min IV continuous (prostacyclin_iv, second line) — IV prostacyclin for refractory pulm HTN crisis; bridges to RV-assist device; can also be inhaled (avoid systemic hypotension)
10. methylprednisolone 500-1000 mg IV pulse for PGD; standard transplant induction per ISHLT IV pulse + maintenance (corticosteroid_iv, first line) — Pulse-dose for severe PGD per ISHLT 2024; standard induction immunosuppression per ISHLT

Setting playbook (outpatient) — Long-term post non-CABG cardiac surgery management: secondary prevention, GDMT maintenance, AF surveillance, valve surveillance (annual echo for prosthetic valve), INR for mechanical valve, immunosuppression for transplant, LVAD long-term care
11. continue secondary prevention bundle ASA 81 (mech valve add-on) + atorvastatin 80 + GDMT per HF status PO as scheduled — Post-cardiac-surgery long-term (AHA 2025)
12. continue lifelong VKA if mech valve warfarin INR per 2020 Valvular Guidelines PO daily — Mech valve (2020 ACC/AHA Valvular Guidelines)
13. continue ISHLT immunosuppression if transplant tacrolimus + mycophenolate + low-dose prednisone per ISHLT PO as scheduled — Heart transplant recipient (ISHLT 2024)

Non-pharmacologic actions:
- Cardiac rehab maintenance
- Annual influenza + pneumococcal + COVID
- Smoking cessation maintenance
- Transplant infection prophylaxis (PJP, CMV) per ISHLT
- LVAD driveline care education

AVOID / contraindication checks:
- Methylene_blue_contraindicated_g6pd_deficiency (hemolysis risk)
- Methylene_blue_avoid_with_ssris_serotonergic (serotonin syndrome)
- Vasopressin_avoid_in_severe_pulmonary_htn_when_alone (must be with iNO + epoprostenol; isolated vasopressin can worsen PVR if myocardial reserve poor)
- Do_not_delay_re_exploration_for_hemorrhagic_tamponade (mortality scales with delay)
- Do_not_delay_re_operation_for_valve_dehiscence (mortality scales with delay)
- Milrinone_renal_dose_required_egfr_lt_60
- Avoid_routine_iabp_no_mortality_benefit (IABP SHOCK II PMID 22920912; selective use only)
- Avoid_isolated_lv_mcs_if_rv_failure_dominant (use Impella RP or VA ECMO)
- Taper_iNO_slowly_to_prevent_rebound_pulm_htn (bridge with sildenafil)
- Transplant_immunosuppression_per_ishlt_specific_protocol_only

Monitoring

Regimen monitoring:
- continuous arterial line BP + pa catheter for co pcwp svo2
- lactate + abg q2h until clearing
- chest tube output q1h (re-exploration threshold >200ml/h x 4h or sudden drop)
- daily tee for valve + biventricular recovery
- methemoglobin q4h post iNO or methylene blue
- serotonin syndrome screen if methylene blue + ssri
- cbc + coag q4h post op until stable
- BNP trend for RV strain post LVAD or post MV repair
- serial endomyocardial biopsy per ishlt cadence if transplant

Setting (outpatient) monitoring:
- Annual lipid + LVEF + valve function
- INR cadence if mech valve
- Tacrolimus trough + biopsy per ISHLT if transplant

Follow-up plan: 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
- Close-out criterion: GDMT + cardiac rehab + transplant or LVAD outpatient program + follow-up booked

Monitoring phase: 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

Disposition

Current setting: outpatient — Long-term post non-CABG cardiac surgery management: secondary prevention, GDMT maintenance, AF surveillance, valve surveillance (annual echo for prosthetic valve), INR for mechanical valve, immunosuppression for transplant, LVAD long-term care

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 if HFrEF + cardio.afib.core.v1 if AF; transplant + LVAD chronic engines for long-term programs

Escalation triggers (move to higher acuity):
- Recurrent angina or syncope → urgent cath
- New HFrEF symptoms → expedite cardiology + GDMT
- Suspected rejection (LVEF drop, dyspnea) → urgent biopsy
- LVAD malfunction → urgent LVAD team

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Post-AVR/MVR/double-valve patient with new severe AR/MR or paravalvular jet on TEE + hemodynamic decline → emergent re-operation
- [LIFE_THREATENING] Post-LVAD with low LVAD flows + high CVP + low PA pressure + worsening congestion → acute RV failure post-LVAD
- [LIFE_THREATENING] Post-MV-repair with pre-op pulm HTN now with acute RV dilation + dysfunction + PA pressure >50 + low CO with high CVP off-bypass → pulm HTN crisis

Citations

- 2020 ACC/AHA Valvular Heart Disease Guideline (Otto JACC 2021, PMID 33342586) + ISHLT 2024 Heart Transplant Guidelines + 2023 ISHLT MCS / LVAD Guideline + SCAI 2022 CS staging (Naidu PMID 35718438) + ELSO Red Book (post-cardiotomy ECMO) [PMID:33342586](https://pubmed.ncbi.nlm.nih.gov/33342586/)
- Cited evidence (PMID 35718438) [PMID:35718438](https://pubmed.ncbi.nlm.nih.gov/35718438/)
- Cited evidence (PMID 35363499) [PMID:35363499](https://pubmed.ncbi.nlm.nih.gov/35363499/)
- Cited evidence (PMID 20200382) [PMID:20200382](https://pubmed.ncbi.nlm.nih.gov/20200382/)
- Cited evidence (PMID 29449068) [PMID:29449068](https://pubmed.ncbi.nlm.nih.gov/29449068/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 2020 ACC/AHA Valvular Heart Disease Guideline (Otto JACC 2021, PMID 33342586) + ISHLT 2024 Heart Transplant Guidelines + 2023 ISHLT MCS / LVAD Guideline + SCAI 2022 CS staging (Naidu PMID 35718438) + ELSO Red Book (post-cardiotomy ECMO) — PMID:33342586
  • Cited evidence (PMID 35718438) — PMID:35718438
  • Cited evidence (PMID 35363499) — PMID:35363499
  • Cited evidence (PMID 20200382) — PMID:20200382
  • Cited evidence (PMID 29449068) — PMID:29449068