Methylene blue–induced serotonin syndrome after left ventricular assist device implantation: A case report and literature review

Abstract

Video clip is available online. Serotonin syndrome is a life-threatening condition of serotonin excess in the central nervous system. We report the first case to occur after a routine left ventricular assist device (LVAD) implantation. Through a systematic review of the literature, we then describe the characteristics of all previous patients with serotonin syndrome after cardiovascular procedures and identify common threads that elucidate serotonin syndrome's recent emergence. CASE PRESENTATION A 60-year-old Hispanic man with a medical history of coronary artery bypass graft, hypertension, atrial fibrillation, obesity, obstructive sleep apnea, depression, and ischemic cardiomyopathy with ejection fraction 10% to 15% was admitted for heart failure exacerbation. Right and left heart catheterizations showed nonobstructive coronary artery disease and increased right-sided heart pressures. He subsequently developed cardiogenic shock requiring intra-aortic balloon pump and inotropic support with milrinone. Eleven days later, he underwent LVAD implantation. General anesthesia required fentanyl, midazolam, rocuronium, dexmedetomidine, and etomidate. He required vasopressor and inotropic support with norepinephrine, epinephrine, and milrinone. He also received prophylactic antibiotic treatment with vancomycin, cefepime, and fluconazole. The operation was successful with no complications, and the patient recovered appropriately from anesthesia. VIDEO 1. A video describing the unique aspects of this case report followed by the key findings from a review of all serotonin syndrome cases in the cardiology literature.

Postoperative Serotonin Syndrome Following Methylene Blue Administration for Vasoplegia After Cardiac Surgery: A Case Report and Review of the Literature

“…Serotonin syndrome following administration of methylene blue for vasoplegia after cardiac surgery has been described before. 10-12…”

Methylene blue for vasoplegic syndrome in cardiopulmonary bypass surgery: A systematic review and meta-analysis

“…selective serotonin reuptake inhibitors (SSRIs), MB can precipitate serotonergic excess or serotonin syndrome. 37 MB could not be used as a stand-alone remedy. Vasopressor is still mandatory to ensure the patient's survival.…”

Serotonin syndrome following left ventricular assist device implantation: A report and institution-specific strategy for prevention

“…A meta-analysis in 2006 revealed that 38% of patients with New York Heart Association (NYHA) class III heart failure symptoms and 42% of those with class IV symptoms suffer from depression [3]. Recent reports have described cases of serotonin syndrome following perioperative vasoplegia in cardiac surgical patients on antidepressant medications [4][5][6]. Vasoplegia is defined by profound hypotension with normal or increased cardiac output and is a common complication of cardiopulmonary bypass, occurring in an estimated 8-10% of patients [7].…”