Preoperative Intestinal Preconditioning to Prevent Postoperative Vasoplegia Following Tricuspid Valve Surgery

Background: Intestinal bacterial translocation due to right ventricular dysfunction and subsequent portal venous hypertension is a proposed mechanism for the increased incidence of systemic inflammatory response syndrome and vasoplegia following tricuspid valve (TV) surgery. We hypothesize that using a preoperative intestinal preconditioning protocol composed of an oral antibiotic (Rifaximin) and laxatives 24 hours before surgery can help reduce intestinal bacterial translocation, thus reducing postoperative vasoplegia. This study aims to evaluate the impact of this preoperative intestinal preconditioning protocol on early clinical outcomes following TV surgery.

Methods: Retrospective single-center analysis including patients who underwent TV surgery between 2017 and 2021. The outcomes of patients treated with preoperative intestinal preconditioning were compared with those without preconditioning. Primary study outcomes were in-hospital mortality and the occurrence of postoperative vasoplegia. Secondary outcomes were intensive care unit (ICU) and hospital length of stay (LOS).

Results: Of 142 patients included in the analysis, 44 (30.9%) received preoperative intestinal preconditioning, and 98 (69.0%) did not. Baseline patient characteristics were similar in both groups. Intraoperative details such as cardiopulmonary bypass and cross-clamp times, as well as early postoperative complications such as bleeding, acute kidney injury, and cardiogenic shock, were similar in both groups. In-hospital mortality was 6.8% versus 5.1% (p = 0.682) in patients with and without preconditioning, respectively. Vasoplegia did not occur (0%) in patients with preconditioning but was observed in 9/98 (9.2%) patients without preconditioning. (p = 0.038). The mean ICU LOS was 2 days shorter amongst patients with preconditioning (5 ± 9 vs. 7 ± 12 days, p = 0.451), but the hospital LOS was similar in both groups (22± 1 vs. 23 ± 19 days; p = 0.812, in patients with and without preconditioning, respectively). A subgroup analysis showed lower in-hospital mortality (3.7% vs. 33.3%; p < 0.001), and shorter ICU (6 ± 10 days vs. 15 ± 14;p = 0.020) and hospital LOS (22 ± 17 vs. 27 ± 13 days; p = 0.020) amongst patients who did not develop postoperative vasoplegia, compared with those who did.

Conclusion: Patients with vasoplegia following TV surgery have significantly higher in-hospital mortality rates and longer hospital and ICU stays. Preoperative intestinal preconditioning in patients undergoing TV is safe and significantly reduces the incidence of vasoplegia.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
13 February 2024