Adjuvant therapy with methylene blue in the treatment of postoperative vasoplegic syndrome caused by carcinoid crisis after tricuspid valve replacement.

N INCREASING BODY of literature continues to show the benefits of methylene blue in cases of refractory hypotension caused by the systemic inflammatory response syndrome (SIRS), septic shock, or vasoplegic syndrome. 1,2 Methylene blue, by its indirect inhibition of bradykinin, may alleviate the hypotension associated with carcinoid crisis. The authors report the successful use of methylene blue to treat refractory hypotension in a patient with carcinoid syndrome who underwent a tricuspid valve replacement. CASE PRESENTATION A 74-year-old man was referred for tricuspid valve surgery after being diagnosed with tricuspid insufficiency as a result of carcinoid syndrome. His past medical history was significant for small intestinal carcinoid tumor resection 5 years prior and radiation for liver metastases secondary to carcinoid. His medications included octreotide (200 g subcutaneously, 3 times a day), tamsulosin, folic acid, furosemide, mometasone, and psyllium. His body mass index was 23 kg/m2. A transthoracic echocardiogram performed before surgery revealed severe tricuspid regurgitation, normal biventricular function, the absence of pulmonary hypertension, and thickening of the tricuspid valve leaflets. Before surgery, the patient had been experiencing New York Heart Association class IV symptoms. In addition, he also had complained of flushing and diarrhea over the past 4 months that were being controlled with octreotide. The patient was admitted to the hospital 2 days before surgery and was placed on 300 g of octreotide subcutaneously 3 times a day. On the day of the surgery, he was given his regular 300-g subcutaneous dose of octreotide followed by a 500-g dose subcutaneously 3 hours later. This was all done in an effort to reduce his risk of perioperative carcinoid crisis. The patient was taken to the operating room where general anesthesia was induced, and he was intubated without difficulty. On induction of anesthesia, an octreotride infusion was begun at 100 g/h. He also was given 11 g of the antifibrinolytic -aminocaproic acid during the case. On insertion of his pulmonary artery catheter, he had a baseline central venous pressure (CVP) of 20 mmHg and pulmonary artery pressures (PAP) of approximately 35/18 mmHg. An intraoperative tranesophageal echocardiogram (TEE) was performed that agreed with his preoperative echocardiographic findings. A median sternotomy was performed, and the patient was anticoagulated with 31,000 U of heparin and placed on cardiopulmonary bypass. A tricuspid valve replacement was performed through a right atriotomy. After bypass, the CVP was noted to be 22 mmHg, with PAPs of approximately 35/15 mmHg and systemic blood pressures of approximately 90/60 mmHg. The patient then was started on 100 ng/kg/min of epinephrine (7.7 g/min) and 150 ng/kg/min of norepinephrine (11.5 g/min), and his octreotide infusion was continued at 100 g/h. This resulted in a successful wean from cardiopulmonary bypass. To reverse his anticoagulation, 200 mg of protamine were given over 30 minutes. In the immediate post-bypass period, his CVP lowered to 18 mmHg, and his systemic mean blood pressure was maintained at 65 mmHg with this