**5.4 Management of Persistent Vasoplegia**

Vasoplegia occurs when systemic vasodilation with consequent hypotension complicates the hemodynamics in the post CPB/post-transplant period. It is at least partially attributable to unregulated release of nitric oxide from reperfusion injury. This syndrome leads to severe hypotension refractory to high doses of vasopressors, despite normal appearing cardiac function. The hypotension and high dose vasopressors have deleterious effect on end organ perfusion. Medical management includes fluid therapy, Vitamin B12, vasopressors including Angiotensin II, and intravenous

methylene blue. VA ECMO support should be instituted in persistent vasoplegia as a rescue therapy when medical management fails to restore adequate perfusion to prevent end organ failure.
