{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T10:32:54Z","timestamp":1786357974936,"version":"build-2736575974"},"reference-count":136,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T00:00:00Z","timestamp":1786320000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Cardiovasc. Dev. Dis.","JCDD"],"abstract":"<jats:p>Vasoplegia remains one of the most challenging and incompletely understood complications across the spectrum of mechanical circulatory support (MCS). Initially described following cardiopulmonary bypass, it is increasingly recognized in patients supported with veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and combined unloading strategies such as ECPELLA (ECMO and Impella support) as well as in patients bridged to heart transplantation with temporary or durable mechanical circulatory support (MCS). Despite occurring in different clinical settings, these syndromes share common pathophysiological features, including systemic inflammation, endothelial dysfunction, glycocalyx degradation, dysregulated nitric oxide signaling, neurohormonal imbalance, microcirculatory impairment and severe vasomotor dysregulation. Although vasoplegia is commonly considered a technology-specific complication, growing evidence suggests that CPB-associated vasoplegia, postcardiotomy vasoplegic syndrome, ECMO-related vasodilatory shock and distributive shock during ECPELLA may represent distinct manifestations of a common pathobiological process driven by blood\u2013artificial surface interactions, ischemia\u2013reperfusion injury, hemolysis and immune activation. This narrative review proposes a unified framework of vasoplegia across the continuum of MCS. Key mechanistic pathways and current therapeutic strategies, including catecholamines, vasopressin, angiotensin II, methylene blue and hydroxocobalamin, are discussed. By integrating evidence from cardiac surgery, critical care and mechanical circulatory support, vasoplegia is presented as a unifying syndrome of extracorporeal circulation. This perspective may support earlier recognition, phenotype-based management and the development of more targeted therapeutic strategies in a clinically significant yet underexplored area of cardiovascular critical care.<\/jats:p>","DOI":"10.3390\/jcdd13080378","type":"journal-article","created":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T09:24:53Z","timestamp":1786353893000},"page":"378","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Vasoplegia in Cardiac Surgery and Mechanical Circulatory Support: From Cardiopulmonary Bypass to Advanced Circulatory Support Devices"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-5046-4275","authenticated-orcid":false,"given":"Debora Emanuela","family":"Torre","sequence":"first","affiliation":[{"name":"Department of Cardiac Anesthesia and Intensive Care Unit, Cardiac Surgery, Ospedale dell\u2019Angelo, 30174 Venice, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0119-6549","authenticated-orcid":false,"given":"Carmelo","family":"Pirri","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, Institute of Human Anatomy, University of Padova, 35121 Padua, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,10]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"174","DOI":"10.1186\/s13054-018-2102-1","article-title":"Definitions and pathophysiology of vasoplegic shock","volume":"22","author":"Lambden","year":"2018","journal-title":"Crit. Care"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"2766","DOI":"10.1053\/j.jvca.2019.12.013","article-title":"Vasoplegia During Cardiopulmonary Bypass: Current Literature and Rescue Therapy Options","volume":"34","author":"Ortoleva","year":"2020","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1186\/s13054-020-2743-8","article-title":"Vasoplegic syndrome following cardiothoracic surgery-review of pathophysiology and update of treatment options","volume":"24","author":"Busse","year":"2020","journal-title":"Crit. Care"},{"key":"ref_4","first-page":"619","article-title":"Vasoplegic syndrome after open heart surgery","volume":"39","author":"Gomes","year":"1998","journal-title":"J. Cardiovasc. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"698","DOI":"10.1016\/j.jacc.2018.11.038","article-title":"Venoarterial ECMO for Adults: JACC Scientific Expert Panel","volume":"73","author":"Guglin","year":"2019","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"387","DOI":"10.1186\/s13054-016-1570-4","article-title":"The inflammatory response to extracorporeal membrane oxygenation (ECMO): A review of the pathophysiology","volume":"20","author":"Millar","year":"2016","journal-title":"Crit. Care"},{"key":"ref_7","first-page":"E166","article-title":"Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology","volume":"7","author":"Makdisi","year":"2015","journal-title":"J. Thorac. Dis."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"100916","DOI":"10.1016\/j.jacadv.2024.100916","article-title":"Predictors and Impact of Prolonged Vasoplegia After Continuous-Flow Left Ventricular Assist Device Implantation","volume":"3","author":"Lamba","year":"2024","journal-title":"JACC Adv."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e50","DOI":"10.1161\/CIR.0000000000001076","article-title":"Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association","volume":"146","author":"Geller","year":"2022","journal-title":"Circulation"},{"key":"ref_10","first-page":"249","article-title":"The science and practice of cardiopulmonary bypass: From cross circulation to ECMO and SIRS","volume":"2013","author":"Punjabi","year":"2013","journal-title":"Glob. Cardiol. Sci. Pract."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"38","DOI":"10.14797\/mdcvj.1245","article-title":"Vasoplegia: A Review","volume":"19","author":"Ratnani","year":"2023","journal-title":"Methodist Debakey Cardiovasc. J."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1016\/j.ccc.2023.06.002","article-title":"Management of Vasoplegic Shock in the Cardiovascular Intensive Care Unit after Cardiac Surgery","volume":"40","author":"Suero","year":"2024","journal-title":"Crit. Care Clin."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1097\/MAT.0000000000000623","article-title":"Incidence and Impact of On-Cardiopulmonary Bypass Vasoplegia During Heart Transplantation","volume":"64","author":"Truby","year":"2018","journal-title":"ASAIO J."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/j.ccc.2023.05.001","article-title":"Cardiogenic Shock: Pathogenesis, Classification, and Management","volume":"40","author":"Sarma","year":"2024","journal-title":"Crit. Care Clin."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"897","DOI":"10.1016\/j.jacc.2022.12.018","article-title":"Association Between Shock Etiology and 5-Year Outcomes After Venoarterial Extracorporeal Membrane Oxygenation","volume":"81","author":"Danial","year":"2023","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"S8","DOI":"10.1186\/cc14726","article-title":"Hemodynamic coherence and the rationale for monitoring the microcirculation","volume":"19","author":"Ince","year":"2015","journal-title":"Crit. Care"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"938","DOI":"10.1001\/jama.2020.0930","article-title":"65 trial investigators. Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory Hypotension: A Randomized Clinical Trial","volume":"323","author":"Lamontagne","year":"2020","journal-title":"JAMA"},{"key":"ref_18","first-page":"101012","article-title":"Inotropes and vasopressors are associated with increased short-term mortality but not long-term survival in critically ill patients","volume":"41","author":"Motiejunaite","year":"2022","journal-title":"Anaesth. Crit. Care Pain Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"214","DOI":"10.1053\/j.jvca.2025.09.035","article-title":"Outcomes and Risk Factors in Vasoplegic Patients Following Left Ventricular Assist Device Implantation","volume":"40","author":"Emery","year":"2026","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2694","DOI":"10.1053\/j.jvca.2020.12.042","article-title":"Methylene Blue for Vasoplegia During Extracorporeal Membrane Oxygenation Support","volume":"35","author":"Ortoleva","year":"2021","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1097\/MAJ.0000000000000341","article-title":"Cardiac vasoplegia syndrome: Pathophysiology, risk factors and treatment","volume":"349","author":"Omar","year":"2015","journal-title":"Am. J. Med. Sci."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1664","DOI":"10.1161\/CIRCULATIONAHA.108.814533","article-title":"Early on-cardiopulmonary bypass hypotension and other factors associated with vasoplegic syndrome","volume":"120","author":"Levin","year":"2009","journal-title":"Circulation"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"973","DOI":"10.1016\/S0022-5223(98)70049-2","article-title":"Management of vasodilatory shock after cardiac surgery: Identification of predisposing factors and use of a novel pressor agent","volume":"116","author":"Argenziano","year":"1998","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1378","DOI":"10.1053\/j.jvca.2024.02.028","article-title":"Diagnosis and Management of Vasoplegia in Temporary Mechanical Circulatory Support: A Narrative Review","volume":"38","author":"Ortoleva","year":"2024","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1016\/j.ahj.2025.03.009","article-title":"Association between vasopressin administration and mortality in patients with cardiogenic shock","volume":"286","author":"Sarma","year":"2025","journal-title":"Am. Heart J."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"2899","DOI":"10.1002\/ehf2.13370","article-title":"Epinephrine administration in venoarterial extracorporeal membrane oxygenation patients is associated with mortality: A retrospective cohort study","volume":"8","author":"Massart","year":"2021","journal-title":"ESC Heart Fail"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"3749","DOI":"10.1111\/jocs.15805","article-title":"Vasoplegic syndrome after cardiovascular surgery: A review of pathophysiology and outcome-oriented therapeutic management","volume":"36","author":"Datt","year":"2021","journal-title":"J. Card. Surg."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Hagiwara, J., DellaVolpe, J.D., and Matsuzaki, Y. (2025). What Are the Best Biocompatible Materials for Extracorporeal Membrane Oxygenation. J. Funct. Biomater., 16.","DOI":"10.3390\/jfb16060226"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"676","DOI":"10.1378\/chest.112.3.676","article-title":"Inflammatory response to cardiopulmonary bypass: Mechanisms involved and possible therapeutic strategies","volume":"112","author":"Wan","year":"1997","journal-title":"Chest"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1097\/MAT.0000000000002451","article-title":"Impact of Hemolysis During Microaxial Flow Pump Support on Early Outcomes After Durable Left Ventricular Assist Device Implantation","volume":"72","author":"Gallone","year":"2026","journal-title":"ASAIO J."},{"key":"ref_31","first-page":"531","article-title":"Indice d\u2019h\u00e9molyse: Qualification et \u00e9valuation de son utilit\u00e9 chez les patients sous ECMO [Hemolysis index: Qualification and evaluation of usefulness in patients on ECMO]","volume":"83","author":"Fettig","year":"2025","journal-title":"Ann. Biol. Clin."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"129","DOI":"10.1016\/j.ijsu.2005.04.002","article-title":"The systemic inflammatory response syndrome and cardiopulmonary bypass","volume":"3","author":"Day","year":"2005","journal-title":"Int. J. Surg."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1016\/j.molimm.2006.06.020","article-title":"The role of complement in biomaterial-induced inflammation","volume":"44","author":"Nilsson","year":"2007","journal-title":"Mol. Immunol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"785","DOI":"10.1038\/ni.1923","article-title":"Complement: A key system for immune surveillance and homeostasis","volume":"11","author":"Ricklin","year":"2010","journal-title":"Nat. Immunol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"353","DOI":"10.1177\/026765910101600505","article-title":"Systemic inflammation and cardiac surgery: An update","volume":"16","author":"Asimakopoulos","year":"2001","journal-title":"Perfusion"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Szyma\u0144ska, Z., Staniewski, A., Karpi\u0144ski, M., Zalewska, K., Kalus, O., Gramala, Z., Ma\u0107kowiak, J., Mertowski, S., Filipiak, K.J., and Rahnama-Hezavah, M. (2025). The Role of Neutrophil Extracellular Networks in Cardiovascular Pathology. Cells, 14.","DOI":"10.3390\/cells14191562"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"2768","DOI":"10.1182\/blood-2013-10-463646","article-title":"Thrombosis: Tangled up in NETs","volume":"123","author":"Martinod","year":"2014","journal-title":"Blood"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"ezae364","DOI":"10.1093\/ejcts\/ezae364","article-title":"Colchicine prevents perioperative myocardial injury in cardiac surgery by inhibiting the formation of neutrophil extracellular traps: Evidence from rat models","volume":"66","author":"Pan","year":"2024","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"374","DOI":"10.1007\/s10047-024-01486-4","article-title":"Incidence of neutrophil extracellular traps (NETs) in different membrane oxygenators: Pilot in vitro experiments in commercially available coated membranes","volume":"28","author":"Foltan","year":"2025","journal-title":"J. Artif. Organs"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"844","DOI":"10.2174\/1566524023666230619102723","article-title":"Inflammatory Progression in Patients Undergoing Extracorporeal Membrane Oxygenation","volume":"24","author":"Yao","year":"2024","journal-title":"Curr. Mol. Med."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"11","DOI":"10.5482\/HAMO-14-11-0075","article-title":"Endothelium and haemostasis","volume":"35","author":"Aird","year":"2015","journal-title":"Hamostaseologie"},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Naderi-Meshkin, H., and Setyaningsih, W.A.W. (2024). Endothelial Cell Dysfunction: Onset, Progression, and Consequences. Front. Biosci. (Landmark Ed.), 29.","DOI":"10.31083\/j.fbl2906223"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.vph.2017.05.005","article-title":"Oxidative stress and reactive oxygen species in endothelial dysfunction associated with cardiovascular and metabolic diseases","volume":"100","author":"Incalza","year":"2018","journal-title":"Vasc. Pharmacol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1186\/s40635-023-00582-8","article-title":"Capillary leak and endothelial permeability in critically ill patients: A current overview","volume":"11","author":"Saravi","year":"2023","journal-title":"Intensive Care Med. Exp."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"900","DOI":"10.1053\/j.jvca.2019.09.004","article-title":"Vasoplegia After Cardiac Surgery Is Associated With Endothelial Glycocalyx Alterations","volume":"34","author":"Kamel","year":"2020","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"e70109","DOI":"10.1111\/aas.70109","article-title":"Methylprednisolone and Endothelial Dysfunction in Cardiac Surgery: A Pilot Randomized Trial","volume":"69","author":"Halenarova","year":"2025","journal-title":"Acta Anaesthesiol. Scand."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"174","DOI":"10.1051\/ject\/201749174","article-title":"Endothelial Glycocalyx and Cardiopulmonary Bypass","volume":"49","author":"Myers","year":"2017","journal-title":"J. Extra Corpor. Technol."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"679","DOI":"10.1093\/bja\/aer269","article-title":"Shedding of the coronary endothelial glycocalyx: Effects of hypoxia\/reoxygenation vs ischaemia\/reperfusion","volume":"107","author":"Annecke","year":"2011","journal-title":"Br. J. Anaesth."},{"key":"ref_49","doi-asserted-by":"crossref","unstructured":"Passov, A., Schramko, A., Salminen, U.S., Aittom\u00e4ki, J., Andersson, S., and Pesonen, E. (2021). Endothelial glycocalyx during early reperfusion in patients undergoing cardiac surgery. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0251747"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1111\/joim.12465","article-title":"The glycocalyx and its significance in human medicine","volume":"280","author":"Tarbell","year":"2016","journal-title":"J. Intern. Med."},{"key":"ref_51","doi-asserted-by":"crossref","unstructured":"Venkatesan, S., Smirne, C., Aquino, C.I., Surico, D., Remorgida, V., Ola Pour, M.M., Pirisi, M., and Grossini, E. (2026). Nitric Oxide Signaling in Cardiovascular Physiology and Pathology: Mechanisms, Dysregulation, and Therapeutic Frontiers. Int. J. Mol. Sci., 27.","DOI":"10.3390\/ijms27020629"},{"key":"ref_52","doi-asserted-by":"crossref","unstructured":"Kim, M.E., and Lee, J.S. (2025). Advances in the Regulation of Inflammatory Mediators in Nitric Oxide Synthase: Implications for Disease Modulation and Therapeutic Approaches. Int. J. Mol. Sci., 26.","DOI":"10.3390\/ijms26031204"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"829","DOI":"10.1093\/eurheartj\/ehr304","article-title":"Nitric oxide synthases: Regulation and function","volume":"33","author":"Sessa","year":"2012","journal-title":"Eur. Heart J."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"533","DOI":"10.1146\/annurev-biochem-050410-100030","article-title":"Structure and regulation of soluble guanylate cyclase","volume":"81","author":"Derbyshire","year":"2012","journal-title":"Annu. Rev. Biochem."},{"key":"ref_55","unstructured":"Gamcrlidze, M.M., Intskirveli, N.A., Vardosanidze, K.D., Chikhladze, K., Goliadze, L., and Ratiani, L.R. (2015). Vasoplegia in septic shock (review). Georgian Med. News, 56\u201362."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"1881","DOI":"10.1152\/physrev.00005.2022","article-title":"The superoxide radical switch in the biology of nitric oxide and peroxynitrite","volume":"102","author":"Piacenza","year":"2022","journal-title":"Physiol. Rev."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"532","DOI":"10.1038\/sj.bjp.0705080","article-title":"Nitric oxide, superoxide, and peroxynitrite in myocardial ischaemia-reperfusion injury and preconditioning","volume":"138","author":"Ferdinandy","year":"2003","journal-title":"Br. J. Pharmacol."},{"key":"ref_58","first-page":"455","article-title":"Methylene Blue as an Adjunct to Treat Vasoplegia in Patients Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass: A Literature Review","volume":"86","author":"Arevalo","year":"2018","journal-title":"AANA J."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"1757","DOI":"10.1053\/j.jvca.2023.04.006","article-title":"Hydroxocobalamin for Vasodilatory Hypotension in Shock: A Systematic Review With Meta-Analysis for Comparison to Methylene Blue","volume":"37","author":"Brokmeier","year":"2023","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"3188","DOI":"10.1053\/j.jvca.2024.09.135","article-title":"Hydroxocobalamin Versus Methylene Blue for Treatment of Vasoplegic Shock Following Cardiopulmonary Bypass: A Systematic Review and Meta-analysis","volume":"38","author":"Cadd","year":"2024","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_61","doi-asserted-by":"crossref","unstructured":"Glava\u0161, M., Gitlin-Domagalska, A., D\u0119bowski, D., Ptaszy\u0144ska, N., \u0141\u0119gowska, A., and Rolka, K. (2022). Vasopressin and Its Analogues: From Natural Hormones to Multitasking Peptides. Int. J. Mol. Sci., 23.","DOI":"10.3390\/ijms23063068"},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1016\/j.ccc.2018.11.004","article-title":"Vasopressin in Vasodilatory Shock","volume":"35","author":"Ukor","year":"2019","journal-title":"Crit. Care Clin."},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"1533","DOI":"10.1007\/s40618-020-01465-5","article-title":"Neuroendocrine predictors of vasoplegia after cardiopulmonary bypass","volume":"44","author":"Pasero","year":"2021","journal-title":"J. Endocrinol. Invest."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1186\/s13054-025-05540-2","article-title":"Vasopressin and its analogues in patients with septic shock: Holy Grail or unfulfilled promise?","volume":"29","author":"Lajoye","year":"2025","journal-title":"Crit. Care"},{"key":"ref_65","doi-asserted-by":"crossref","unstructured":"Ltaief, Z., Ben-Hamouda, N., Rancati, V., Gunga, Z., Marcucci, C., Kirsch, M., and Liaudet, L. (2022). Vasoplegic Syndrome after Cardiopulmonary Bypass in Cardiovascular Surgery: Pathophysiology and Management in Critical Care. J. Clin. Med., 11.","DOI":"10.3390\/jcm11216407"},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1097\/ALN.0000000000001434","article-title":"Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock after Cardiac Surgery: The VANCS Randomized Controlled Trial","volume":"126","author":"Hajjar","year":"2017","journal-title":"Anesthesiology"},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"705","DOI":"10.1007\/s00424-024-02908-1","article-title":"The renin angiotensin aldosterone system","volume":"476","author":"Triebel","year":"2024","journal-title":"Pflug. Arch."},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"1832","DOI":"10.1016\/j.bja.2025.08.028","article-title":"Attenuated renin response and reduced angiotensin II concentrations: Association with cardiopulmonary bypass-induced vasoplegia","volume":"135","author":"Imielski","year":"2025","journal-title":"Br. J. Anaesth."},{"key":"ref_69","first-page":"392","article-title":"Factors associated with vasoplegic shock in the postoperative period of cardiac surgery and influence on morbidity and mortality of the use of arginine vasopressin as rescue therapy","volume":"48","year":"2024","journal-title":"Med. Intensiv. (Engl. Ed.)"},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"1253","DOI":"10.1164\/rccm.201911-2172OC","article-title":"Renin and Survival in Patients Given Angiotensin II for Catecholamine-Resistant Vasodilatory Shock. A Clinical Trial","volume":"202","author":"Bellomo","year":"2020","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1186\/s13054-018-2225-4","article-title":"Angiotensin in ECMO patients with refractory shock","volume":"22","author":"Ostermann","year":"2018","journal-title":"Crit. Care"},{"key":"ref_72","doi-asserted-by":"crossref","unstructured":"Koumallos, N., Sigala, E., Milas, T., Baikoussis, N.G., Aragiannis, D., Sideris, S., and Tsioufis, K. (2023). Angiotensin Regulation of Vascular Homeostasis: Exploring the Role of ROS and RAS Blockers. Int. J. Mol. Sci., 24.","DOI":"10.3390\/ijms241512111"},{"key":"ref_73","doi-asserted-by":"crossref","unstructured":"Raia, L., and Zafrani, L. (2022). Endothelial Activation and Microcirculatory Disorders in Sepsis. Front. Med., 9.","DOI":"10.3389\/fmed.2022.907992"},{"key":"ref_74","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1186\/s13054-018-2292-6","article-title":"The glycocalyx: A novel diagnostic and therapeutic target in sepsis","volume":"23","author":"Uchimido","year":"2019","journal-title":"Crit. Care"},{"key":"ref_75","doi-asserted-by":"crossref","unstructured":"Torre, D.E., and Pirri, C. (2025). Beyond Standard Parameters: Precision Hemodynamic Monitoring in Patients on Veno-Arterial ECMO. J. Pers. Med., 15.","DOI":"10.3390\/jpm15110541"},{"key":"ref_76","doi-asserted-by":"crossref","first-page":"e12891","DOI":"10.1111\/micc.12891","article-title":"Microcirculatory Perfusion Disturbances During Veno-Arterial Extracorporeal Membrane Oxygenation: A Systematic Review","volume":"31","author":"Volleman","year":"2024","journal-title":"Microcirculation"},{"key":"ref_77","doi-asserted-by":"crossref","first-page":"3992","DOI":"10.21037\/jtd-22-1159","article-title":"Characteristics of sublingual microcirculatory changes during the early postoperative period following cardiopulmonary bypass-assisted cardiac surgery-a prospective cohort study","volume":"14","author":"Li","year":"2022","journal-title":"J. Thorac. Dis."},{"key":"ref_78","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/j.mvr.2019.02.004","article-title":"Correlation between acute degradation of the endothelial glycocalyx and microcirculation dysfunction during cardiopulmonary bypass in cardiac surgery","volume":"124","author":"Wu","year":"2019","journal-title":"Microvasc. Res."},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"20343","DOI":"10.1038\/s41598-019-56831-y","article-title":"Levosimendan and systemic vascular resistance in cardiac surgery patients: A systematic review and meta-analysis","volume":"9","author":"Terbeck","year":"2019","journal-title":"Sci. Rep."},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"2050312120935466","DOI":"10.1177\/2050312120935466","article-title":"Vasoplegia after cardiopulmonary bypass: A narrative review of pathophysiology and emerging targeted therapies","volume":"8","author":"Barnes","year":"2020","journal-title":"SAGE Open Med."},{"key":"ref_81","doi-asserted-by":"crossref","first-page":"92","DOI":"10.5152\/eurasianjmed.2022.20394","article-title":"Vasoplegia: Mechanism and Management Following Cardiopulmonary Bypass","volume":"54","author":"Muhammad","year":"2022","journal-title":"Eurasian J. Med."},{"key":"ref_82","doi-asserted-by":"crossref","first-page":"2729","DOI":"10.1111\/jocs.15663","article-title":"Risk factors for vasoplegia after coronary artery bypass and valve surgery","volume":"36","author":"Bastopcu","year":"2021","journal-title":"J. Card. Surg."},{"key":"ref_83","doi-asserted-by":"crossref","first-page":"812","DOI":"10.1016\/j.athoracsur.2011.04.020","article-title":"Transfusion increases the risk for vasoplegia after cardiac operations","volume":"92","author":"Alfirevic","year":"2011","journal-title":"Ann. Thorac. Surg."},{"key":"ref_84","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1016\/j.mvr.2017.04.001","article-title":"Blood transfusions may impair endothelium-dependent vasodilatation during coronary artery bypass surgery","volume":"112","author":"Rungatscher","year":"2017","journal-title":"Microvasc. Res."},{"key":"ref_85","doi-asserted-by":"crossref","unstructured":"Lim, P., Le Maistre, M., Campanini, L.B., De Roux, Q., Mongardon, N., Landon, V., Bouguerra, H., Aouate, D., Woerther, P.L., and Vincent, F. (2022). Vasoplegic Syndrome after Cardiac Surgery for Infective Endocarditis. J. Clin. Med., 11.","DOI":"10.3390\/jcm11195523"},{"key":"ref_86","first-page":"532","article-title":"Incidence and predictors of vasoplegia after heart failure surgery","volume":"51","author":"Palmen","year":"2017","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"705","DOI":"10.1016\/j.athoracsur.2025.02.022","article-title":"A Novel Clinical Risk Score to Predict Vasoplegia After Adult Cardiac Surgery","volume":"120","author":"Miles","year":"2025","journal-title":"Ann. Thorac. Surg."},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"e008377","DOI":"10.1161\/JAHA.117.008377","article-title":"Determinants and Outcomes of Vasoplegia Following Left Ventricular Assist Device Implantation","volume":"7","author":"Tecson","year":"2018","journal-title":"J. Am. Heart Assoc."},{"key":"ref_89","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1186\/s40635-019-0249-y","article-title":"Extracorporeal life support and systemic inflammation","volume":"7","author":"Pettenuzzo","year":"2019","journal-title":"Intensive Care Med. Exp."},{"key":"ref_90","doi-asserted-by":"crossref","first-page":"931","DOI":"10.1016\/j.healun.2024.02.1458","article-title":"Vasoplegic syndrome during heart transplantation: A systematic review and meta-analysis","volume":"43","author":"Kumar","year":"2024","journal-title":"J. Heart Lung Transplant."},{"key":"ref_91","doi-asserted-by":"crossref","first-page":"1902","DOI":"10.1016\/j.amjcard.2018.08.035","article-title":"Relation of Vasoplegia in the Absence of Primary Graft Dysfunction to Mortality Following Cardiac Transplantation","volume":"122","author":"Raza","year":"2018","journal-title":"Am. J. Cardiol."},{"key":"ref_92","doi-asserted-by":"crossref","first-page":"e149","DOI":"10.1016\/j.healun.2025.12.029","article-title":"Summary of the International Society for Heart and Lung Transplantation (ISHLT) Consensus Conference on Graft Dysfunction within the First 72 hours after Heart Transplantation: A 10-year Update","volume":"45","author":"Kobashigawa","year":"2026","journal-title":"J. Heart Lung Transplant."},{"key":"ref_93","doi-asserted-by":"crossref","first-page":"250","DOI":"10.4330\/wjc.v14.i4.250","article-title":"Effect of preoperative renin-angiotensin system blockade on vasoplegia after cardiac surgery: A systematic review with meta-analysis","volume":"14","author":"Noubiap","year":"2022","journal-title":"World J. Cardiol."},{"key":"ref_94","doi-asserted-by":"crossref","first-page":"e013108","DOI":"10.1161\/JAHA.119.013108","article-title":"Predictors and Clinical Outcomes of Vasoplegia in Patients Bridged to Heart Transplantation With Continuous-Flow Left Ventricular Assist Devices","volume":"8","author":"Asleh","year":"2019","journal-title":"J. Am. Heart Assoc."},{"key":"ref_95","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1016\/j.healun.2022.10.015","article-title":"The International Society for Heart and Lung Transplantation (ISHLT) guidelines for the care of heart transplant recipients","volume":"42","author":"Velleca","year":"2023","journal-title":"J. Heart Lung Transplant."},{"key":"ref_96","doi-asserted-by":"crossref","unstructured":"de Waal, E.E.C., van Zaane, B., van der Schoot, M.M., Huisman, A., Ramjankhan, F., van Klei, W.A., and Marczin, N. (2018). Vasoplegia after implantation of a continuous flow left ventricular assist device: Incidence, outcomes and predictors. BMC Anesthesiol., 18.","DOI":"10.1186\/s12871-018-0645-y"},{"key":"ref_97","doi-asserted-by":"crossref","first-page":"101","DOI":"10.1007\/s11886-021-01534-y","article-title":"Vasoplegia from Continuous Flow Left Ventricular Assist Devices","volume":"23","author":"Sathianathan","year":"2021","journal-title":"Curr. Cardiol. Rep."},{"key":"ref_98","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1177\/0003319720946977","article-title":"Endothelial Function in Patients With Continuous-Flow Left Ventricular Assist Devices","volume":"72","author":"Poredos","year":"2021","journal-title":"Angiology"},{"key":"ref_99","doi-asserted-by":"crossref","first-page":"519","DOI":"10.1152\/physrev.1995.75.3.519","article-title":"Flow-mediated endothelial mechanotransduction","volume":"75","author":"Davies","year":"1995","journal-title":"Physiol. Rev."},{"key":"ref_100","doi-asserted-by":"crossref","unstructured":"Zhou, H.L., Jiang, X.Z., and Ventikos, Y. (2023). Role of blood flow in endothelial functionality: A review. Front. Cell Dev. Biol., 11.","DOI":"10.3389\/fcell.2023.1259280"},{"key":"ref_101","doi-asserted-by":"crossref","unstructured":"Khalil, F., Asleh, R., Perue, R.K., Weinstein, J.M., Solomon, A., Betesh-Abay, B., Briasoulis, A., and Alnsasra, H. (2023). Vascular Function in Continuous Flow LVADs: Implications for Clinical Practice. Biomedicines, 11.","DOI":"10.3390\/biomedicines11030757"},{"key":"ref_102","doi-asserted-by":"crossref","first-page":"609","DOI":"10.3325\/cmj.2014.55.609","article-title":"Why pulsatility still matters: A review of current knowledge","volume":"55","year":"2014","journal-title":"Croat. Med. J."},{"key":"ref_103","doi-asserted-by":"crossref","first-page":"329","DOI":"10.1097\/HCO.0000000000000283","article-title":"Creating adequate pulsatility with a continuous flow left ventricular assist device: Just do it!","volume":"31","author":"Patel","year":"2016","journal-title":"Curr. Opin. Cardiol."},{"key":"ref_104","doi-asserted-by":"crossref","first-page":"999","DOI":"10.1016\/j.healun.2014.09.012","article-title":"Does pulsatility matter in the era of continuous-flow blood pumps?","volume":"34","author":"Moazami","year":"2015","journal-title":"J. Heart Lung Transpl."},{"key":"ref_105","doi-asserted-by":"crossref","first-page":"e004670","DOI":"10.1161\/CIRCHEARTFAILURE.117.004670","article-title":"Living Without a Pulse: The Vascular Implications of Continuous-Flow Left Ventricular Assist Devices","volume":"11","author":"Purohit","year":"2018","journal-title":"Circ. Heart Fail"},{"key":"ref_106","first-page":"551","article-title":"Impact of Mechanical Circulatory Support on Posttransplant Outcomes","volume":"36","author":"Dardas","year":"2018","journal-title":"Cardiol. Clin."},{"key":"ref_107","doi-asserted-by":"crossref","first-page":"100272","DOI":"10.1016\/j.jhlto.2025.100272","article-title":"Prognostic value of the vasoactive-inotropic score in predicting outcomes following LVAD implantation","volume":"9","author":"Pickering","year":"2025","journal-title":"JHLT Open"},{"key":"ref_108","first-page":"110","article-title":"Shock circolatorio: Diagnosi e terapia precoce [Circulatory shock: Early diagnosis and therapy]","volume":"24","author":"Valente","year":"2023","journal-title":"G. Ital. Cardiol."},{"key":"ref_109","first-page":"219","article-title":"Right Ventricular Failure After Left Ventricular Assist Device","volume":"38","author":"Cogswell","year":"2020","journal-title":"Cardiol. Clin."},{"key":"ref_110","doi-asserted-by":"crossref","unstructured":"Torre, D.E., and Pirri, C. (2025). Right Heart Failure in Critical and Chronic Care: Current Concepts, Challenges and Mechanical Support Strategies. Med. Sci., 13.","DOI":"10.3390\/medsci13040210"},{"key":"ref_111","doi-asserted-by":"crossref","unstructured":"Torre, D.E., and Pirri, C. (2025). Point-of-Care Transesophageal Echocardiography in Emergency and Intensive Care: An Evolving Imaging Modality. Biomedicines, 13.","DOI":"10.3390\/biomedicines13112680"},{"key":"ref_112","doi-asserted-by":"crossref","first-page":"2608318","DOI":"10.1155\/2020\/2608318","article-title":"Quantitative Assessment of Blood Lactate in Shock: Measure of Hypoxia or Beneficial Energy Source","volume":"2020","author":"Levitt","year":"2020","journal-title":"BioMed Res. Int."},{"key":"ref_113","doi-asserted-by":"crossref","first-page":"1971","DOI":"10.1007\/s00134-025-08137-z","article-title":"ESICM guidelines on circulatory shock and hemodynamic monitoring 2025","volume":"51","author":"Monnet","year":"2025","journal-title":"Intensive Care Med."},{"key":"ref_114","doi-asserted-by":"crossref","first-page":"169","DOI":"10.1016\/j.ajem.2025.01.055","article-title":"Emergency medicine updates: Evaluation and diagnosis of sepsis and septic shock","volume":"90","author":"Long","year":"2025","journal-title":"Am. J. Emerg. Med."},{"key":"ref_115","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1186\/s13741-015-0014-z","article-title":"Perioperative fluid therapy: A statement from the international Fluid Optimization Group","volume":"4","author":"Navarro","year":"2015","journal-title":"Perioper. Med."},{"key":"ref_116","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1016\/j.bja.2023.11.009","article-title":"International Collaboration for Transfusion Medicine Guidelines. Intravenous albumin in cardiac and vascular surgery: A systematic review and meta-analysis","volume":"132","author":"Skubas","year":"2024","journal-title":"Br. J. Anaesth."},{"key":"ref_117","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1186\/s13741-024-00445-0","article-title":"Use of colloids and crystalloids for perioperative clinical infusion management in cardiac surgery patients and postoperative outcomes: A meta-analysis","volume":"13","author":"Chen","year":"2024","journal-title":"Perioper. Med."},{"key":"ref_118","doi-asserted-by":"crossref","first-page":"e042711","DOI":"10.1161\/JAHA.125.042711","article-title":"Deleterious Effects of Liberal Fluid Therapy During Extracorporeal Cardiopulmonary Resuscitation in a Porcine Model of Prolonged Cardiac Arrest","volume":"15","author":"Jendoubi","year":"2026","journal-title":"J. Am. Heart Assoc."},{"key":"ref_119","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1186\/s44158-026-00346-2","article-title":"Perioperative fluid accumulation and clinical outcomes after cardiac surgery: A systematic review and Bayesian meta-analysis","volume":"6","author":"Melo","year":"2026","journal-title":"J. Anesth. Analg. Crit. Care"},{"key":"ref_120","doi-asserted-by":"crossref","first-page":"843","DOI":"10.1177\/0885066620917630","article-title":"Vasopressor and Inotrope Therapy in Cardiac Critical Care","volume":"36","author":"Jentzer","year":"2021","journal-title":"J. Intensive Care Med."},{"key":"ref_121","doi-asserted-by":"crossref","first-page":"1815","DOI":"10.1053\/j.jvca.2025.02.047","article-title":"Vasoplegic Syndrome in Cardiac Surgery: A Narrative Review of Etiologic Mechanisms and Therapeutic Options","volume":"39","author":"Polyak","year":"2025","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_122","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1056\/NEJMra2312086","article-title":"Cardiogenic Shock","volume":"394","author":"Thiele","year":"2026","journal-title":"N. Engl. J. Med."},{"key":"ref_123","doi-asserted-by":"crossref","first-page":"102482","DOI":"10.1016\/j.jchf.2025.02.028","article-title":"Vasoplegia Syndrome After Cardiac Surgery: Insights Into Mechanisms and Treatment","volume":"13","author":"Castagna","year":"2025","journal-title":"JACC Heart Fail"},{"key":"ref_124","doi-asserted-by":"crossref","unstructured":"Garc\u00eda-\u00c1lvarez, R., and Arboleda-Salazar, R. (2023). Vasopressin in Sepsis and Other Shock States: State of the Art. J. Pers. Med., 13.","DOI":"10.3390\/jpm13111548"},{"key":"ref_125","doi-asserted-by":"crossref","first-page":"2225","DOI":"10.1053\/j.jvca.2018.04.006","article-title":"Vasopressin in Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials","volume":"32","author":"Bouvet","year":"2018","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_126","doi-asserted-by":"crossref","first-page":"2015","DOI":"10.1111\/j.1476-5381.2011.01588.x","article-title":"Use of inotropes and vasopressor agents in critically ill patients","volume":"165","author":"Bangash","year":"2012","journal-title":"Br. J. Pharmacol."},{"key":"ref_127","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1056\/NEJMoa1704154","article-title":"ATHOS-3 Investigators. Angiotensin II for the Treatment of Vasodilatory Shock","volume":"377","author":"Khanna","year":"2017","journal-title":"N. Engl. J. Med."},{"key":"ref_128","doi-asserted-by":"crossref","first-page":"1676","DOI":"10.1177\/02676591231215920","article-title":"Angiotensin-II for vasoplegia following cardiac surgery","volume":"39","author":"Johnson","year":"2024","journal-title":"Perfusion"},{"key":"ref_129","doi-asserted-by":"crossref","unstructured":"Kofler, O., Simbeck, M., Tomasi, R., Hinske, L.C., Klotz, L.V., Uhle, F., Born, F., Pichlmaier, M., Hagl, C., and Weigand, M.A. (2022). Early Use of Methylene Blue in Vasoplegic Syndrome: A 10-Year Propensity Score-Matched Cohort Study. J. Clin. Med., 11.","DOI":"10.3390\/jcm11041121"},{"key":"ref_130","doi-asserted-by":"crossref","first-page":"E234","DOI":"10.1532\/hsf.1806","article-title":"Methylene Blue for Vasoplegic Syndrome","volume":"20","author":"Booth","year":"2017","journal-title":"Heart Surg. Forum"},{"key":"ref_131","first-page":"e28267","article-title":"High-Dose Hydroxocobalamin for Refractory Vasoplegia Post Cardiac Surgery","volume":"14","author":"Bak","year":"2022","journal-title":"Cureus"},{"key":"ref_132","doi-asserted-by":"crossref","first-page":"1013","DOI":"10.1053\/j.jvca.2017.10.032","article-title":"Vasoplegia After Cardiovascular Procedures-Pathophysiology and Targeted Therapy","volume":"32","author":"Shaefi","year":"2018","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_133","doi-asserted-by":"crossref","first-page":"1071","DOI":"10.1213\/ANE.0000000000001629","article-title":"New Innovations in Circulatory Support With Ventricular Assist Device and Extracorporeal Membrane Oxygenation Therapy","volume":"124","author":"Sladen","year":"2017","journal-title":"Anesth. Analg."},{"key":"ref_134","doi-asserted-by":"crossref","unstructured":"Torre, D.E., and Pirri, C. (2025). ECMO in Refractory Septic Shock: Patient Selection, Timing and Hemodynamic Targets. J. Clin. Med., 14.","DOI":"10.3390\/jcm14227904"},{"key":"ref_135","doi-asserted-by":"crossref","first-page":"101432","DOI":"10.1016\/j.jacadv.2024.101432","article-title":"Mixed Cardiogenic-Vasodilatory Shock: Current Insights and Future Directions","volume":"4","author":"Jentzer","year":"2024","journal-title":"JACC Adv."},{"key":"ref_136","doi-asserted-by":"crossref","first-page":"e007679","DOI":"10.1161\/CIRCHEARTFAILURE.120.007679","article-title":"Liberation From Venoarterial Extracorporeal Membrane Oxygenation: A Review","volume":"14","author":"Brahmbhatt","year":"2021","journal-title":"Circ. Heart Fail"}],"container-title":["Journal of Cardiovascular Development and Disease"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2308-3425\/13\/8\/378\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T10:03:35Z","timestamp":1786356215000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2308-3425\/13\/8\/378"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,10]]},"references-count":136,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["jcdd13080378"],"URL":"https:\/\/doi.org\/10.3390\/jcdd13080378","relation":{},"ISSN":["2308-3425"],"issn-type":[{"value":"2308-3425","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,10]]}}}