Perioperative management of vasoplegic syndrome in cardiac surgery: a narrative review.

Vasoplegic syndrome (VS) is a frequent and potentially life-threatening complication following cardiac surgery with cardiopulmonary bypass (CPB) and is associated with significant morbidity and mortality. It is characterized by persistent hypotension, low systemic vascular resistance, and preserved or elevated cardiac output despite adequate volume resuscitation. This narrative review provides a comprehensive and clinically focused synthesis of current evidence on the pathophysiology, risk factors, diagnosis, and perioperative management of VS. A structured literature search of the PubMed database was conducted, focusing on studies published from 2020 to 2026 and complemented by key landmark trials. The pathophysiology of VS is multifactorial, involving systemic inflammatory activation, excessive nitric oxide production, vasopressin depletion, dysregulation of the renin-angiotensin-aldosterone system, and impaired vascular responsiveness to catecholamines. Major risk factors include preoperative use of ACE inhibitors or angiotensin receptor blockers, impaired cardiac function, prolonged CPB duration, and complex surgical procedures. Early recognition and differentiation from other causes of perioperative shock are essential for timely management. Current therapeutic strategies emphasize a multimodal, physiology-guided approach combining catecholamines with non-adrenergic agents such as vasopressin, methylene blue, hydroxocobalamin, and angiotensin II, particularly in refractory cases. Emerging evidence supports early combination vasopressor strategies to improve hemodynamic stability and reduce catecholamine exposure. However, optimal treatment sequencing and patient selection remain uncertain. A structured, algorithm-based approach integrating early diagnosis, targeted therapies, and advanced hemodynamic monitoring may improve clinical outcomes. Further research is needed to refine diagnostic criteria, identify reliable biomarkers, and establish evidence-based management algorithms for VS in cardiac surgery.