Vasopressin in Patients with Septic Shock and Dynamic Left Ventricular Outflow Tract Obstruction



Left ventricular outflow tract obstruction (LVOTO) is a relatively uncommon but severe condition that may lead to hemodynamic impairment. It can be elicited by morphological (left ventricular hypertrophy, sigmoid septum, prominent papillary muscle, prolonged anterior mitral valve leaflet) and functional (hypovolemia, low afterload, hypercontractility, catecholamines) factors. We sought to determine the incidence of the most severe form of LVOTO in septic shock patients and describe the therapeutic effects of vasopressin.


Over a period of 29 months, 527 patients in septic shock were screened for LVOTO. All were mechanically ventilated and treated according to sepsis bundles, including pre-load optimization and norepinephrine infusion. Vasopressin was added in addition to norepinephrine to reduce the adrenergic burden and decrease LVOTO.


Ten patients were diagnosed with the most severe form of LVOTO, including systolic anterior mitral valve motion (SAM) and severe mitral regurgitation (MR) with pulmonary oedema. The median norepinephrine dosage to obtain a mean arterial pressure of ≥70 mmHg was 0.58 mcg/Kg/min (IQR 0.40–0.78). All patients had a hyper-contractile left ventricle, septal hypertrophy, significant LVOTO (peak gradient 78 [56–123] mmHg) associated with SAM and severe MR with pulmonary oedema. Vasopressin (median 4 IU/h) allowed a significant reduction of norepinephrine (0.18 [0.14–0.30] mcg/kg/min; p = 0.01), LVOT gradient (35 [24–60] mmHg; p = 0.01) and MR with a significant paO2/FiO2 increase (174 [125–213] mmHg; p = 0.01).


Vasopressin allowed a reduction of norepinephrine with subsequent LVOTO reduction and hemodynamic improvement of the most severe form of LVOTO, which represented 1.9% of all septic shock patients.

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Fig. 1



arginine vasopressin


left ventricular outflow tract obstruction


continuous wave Doppler




mitral regurgitation


systolic anterior mitral valve motion


ejection fraction of left ventricle


heart rate


velocity-time integral


body mass index


  1. 1.

    Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving Sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med. 2017;45(3):486–552.

    Article  PubMed  Google Scholar 

  2. 2.

    Hamzaoui O, Jozwiak M, Geffriaud T, Sztrymf B, Prat D, Jacobs F, et al. Norepinephrine exerts an inotropic effect during the early phase of human septic shock. Br J Anaesth. 2018;120(3):517–24.

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Guarracino F, Bertini P, Pinsky MR. Cardiovascular determinants of resuscitation from sepsis and septic shock. Crit Care. 2019;23(1):118.

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Evans JS, Huang SJ, McLean AS, Nalos M. Left ventricular outflow tract obstruction-be prepared! Anaesth Intensive Care. 2017;45(1):12–20.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Chauvet JL, El-Dash S, Delastre O, Bouffandeau B, Jusserand D, Michot JB, et al. Early dynamic left intraventricular obstruction is associated with hypovolemia and high mortality in septic shock patients. Crit Care. 2015;19:262.

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Giraldeau G, Duchateau N, Bijnens B, Gabrielli L, Penela D, Evertz R, et al. Dyssynchronization reduces dynamic obstruction without affecting systolic function in patients with hypertrophic obstructive cardiomyopathy: a pilot study. Int J Cardiovascular Imag. 2016;32(8):1179–88.

    Article  Google Scholar 

  7. 7.

    Nagendran M, Russell JA, Walley KR, Brett SJ, Perkins GD, Hajjar L, et al. Vasopressin in septic shock: an individual patient data meta-analysis of randomised controlled trials. Intensive Care Med. 2019;45(6):844–55.

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Young PJ, Delaney A, Venkatesh B. Vasopressin in septic shock: what we know and where to next? Intensive Care Med. 2019;45(6):902–3.

    Article  PubMed  Google Scholar 

  9. 9.

    Balik M, Waldauf P, Maly M, Matousek V, Brozek T, Rulisek J, et al. Efficacy and safety of 1C class antiarrhythmic agent (propafenone) for supraventricular arrhythmias in septic shock compared to amiodarone: protocol of a prospective randomised double-blind study. BMJ Open. 2019;9(9):e031678.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Vincent JL. The coming era of precision medicine for intensive care. Crit Care. 2017;21(Suppl 3):314.

    Article  PubMed  PubMed Central  Google Scholar 

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Support was provided through the grant project NV 18–06-00417 of the Czech Ministry of Health.

Author information




MB designed the study and performed the echocardiography. AN, DS, VM, MM and TB collected and analysed the clinical data. GT supervised the study and together with all authors contributed to the development of the manuscript.

Corresponding author

Correspondence to Martin Balik.

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University Hospital Ethical Board on 6 October 2017 (No. 1691/16S-IV).

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Balik, M., Novotny, A., Suk, D. et al. Vasopressin in Patients with Septic Shock and Dynamic Left Ventricular Outflow Tract Obstruction. Cardiovasc Drugs Ther (2020).

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  • Septic shock
  • Left ventricular outflow tract obstruction
  • Arginine vasopressin
  • Norepinephrine
  • Supraventricular arrhythmia
  • Atrial fibrillation