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Schmoeckel M, Thielmann M, Hassan K, Geidel S, Schmitto J, Meyer AL, Vitanova K, Liebold A, Marczin N, Bernardi MH, Tandler R, Lindstedt S, Matejic-Spasic M, Wendt D, Deliargyris EN, Storey RF. Intraoperative haemoadsorption for antithrombotic drug removal during cardiac surgery: initial report of the international safe and timely antithrombotic removal (STAR) registry. J Thromb Thrombolysis 2024:10.1007/s11239-024-02996-x. [PMID: 38709456 DOI: 10.1007/s11239-024-02996-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2024] [Indexed: 05/07/2024]
Abstract
Intraoperative antithrombotic drug removal by haemoadsorption is a novel strategy to reduce perioperative bleeding in patients on antithrombotic drugs undergoing cardiac surgery. The international STAR registry reports real-world clinical outcomes associated with this application. All patients underwent cardiac surgery before completing the recommended washout period. The haemoadsorption device was incorporated into the cardiopulmonary bypass (CPB) circuit. Patients on P2Y12 inhibitors comprised group 1, and patients on direct-acting oral anticoagulants (DOAC) group 2. Outcome measurements included bleeding events according to standardised definitions and 24-hour chest-tube-drainage (CTD). 165 patients were included from 8 institutions in Austria, Germany, Sweden, and the UK. Group 1 included 114 patients (62.9 ± 11.6years, 81% male) operated at a mean time of 33.2 h from the last P2Y12 inhibitor dose with a mean CPB duration of 117.1 ± 62.0 min. Group 2 included 51 patients (68.4 ± 9.4years, 53% male), operated at a mean time of 44.6 h after the last DOAC dose, with a CPB duration of 128.6 ± 48.4 min. In Group 1, 15 patients experienced a BARC-4 bleeding event (13%), including 3 reoperations (2.6%). The mean 24-hour CTD was 651 ± 407mL. In Group 2, 8 patients experienced a BARC-4 bleeding event (16%) including 4 reoperations (7.8%). The mean CTD was 675 ± 363mL. This initial report of the ongoing STAR registry shows that the intraoperative use of a haemoadsorption device is simple and safe, and may potentially mitigate the expected high bleeding risk of patients on antithrombotic drugs undergoing cardiac surgery before completion of the recommended washout period.Clinical registration number: ClinicalTrials.gov identifier: NCT05077124.
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Affiliation(s)
- Michael Schmoeckel
- Department of Cardiac Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University, Marchioninistr. 15, Munich, D-81377, Germany.
| | - Matthias Thielmann
- Department of Thoracic- and Cardiovascular Surgery, West German Heart and Vascular Center, Essen, Germany
| | - Kambiz Hassan
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Stephan Geidel
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Jan Schmitto
- Department of Cardiac-, Thoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Anna L Meyer
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Keti Vitanova
- Department of Cardiovascular Surgery, German Heart Centre, Munich, Germany
| | - Andreas Liebold
- Department of Cardiothoracic and Vascular Surgery, Ulm University Medical Center, Ulm, Germany
| | - Nandor Marczin
- Department of Anaesthesia, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Martin H Bernardi
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Rene Tandler
- Department of Cardiac Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Sandra Lindstedt
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden
| | | | - Daniel Wendt
- Department of Thoracic- and Cardiovascular Surgery, West German Heart and Vascular Center, Essen, Germany
- CytoSorbents Europe GmbH, Berlin, Germany
| | | | - Robert F Storey
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Røed-Undlien H, Schultz NH, Lunnan A, Husebråten IM, Wollmann BM, Molden E, Bjørnstad JL. In Vitro Apixaban Removal By CytoSorb Whole Blood Adsorber: An Experimental Study. J Cardiothorac Vasc Anesth 2022; 36:1636-1644. [PMID: 35272914 DOI: 10.1053/j.jvca.2022.01.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/13/2022] [Accepted: 01/21/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The use of unopposed oral anticoagulants while undergoing cardiothoracic surgery is associated with severe bleeding and increased morbidity. The aim of this experimental study was to examine if the apixaban concentration in reconstituted blood could be reduced in an in vitro setup by the use of CytoSorb whole blood adsorber, and to study how this affected global coagulation assays. DESIGN AND SETTING An experimental study performed in a laboratory. PARTICIPANTS An in vitro setup with reconstituted whole blood. INTERVENTIONS Reconstituted whole blood spiked with apixaban circulated in an in vitro circuit with the CytoSorb 300 mL device connected. MEASUREMENTS AND MAIN RESULTS Blood samples were drawn at 0, 5, 15, 30, 60, and 120 minutes of adsorption. The apixaban concentration was measured at each time point. In addition, the global coagulation assays, thromboelastometry clotting time and thrombin generation, were performed, and the results were compared with baseline values obtained before spiking blood with apixaban. After 30 minutes of adsorption, the mean apixaban concentration was reduced from 414.3 (±69.1) ng/mL to 33 (±11.4) ng/mL. Thrombin generation showed maximum effect after 60 minutes, and the thromboelastometry clotting time was close to baseline values after 120 minutes. CONCLUSIONS In this in vitro study, apixaban concentrations were effectively reduced, and the clotting time and thrombin generation assays were normalized by the use of CytoSorb whole blood adsorber.
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Affiliation(s)
| | - Nina Haagenrud Schultz
- Research Institute for Internal Medicine, Oslo University Hospital, Oslo, Norway; Department of Haematology, Akershus University Hospital, Lørenskog, Norway; Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - Asbjørn Lunnan
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | | | | | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway; Department of Pharmacy, University of Oslo, Norway
| | - Johannes Lagethon Bjørnstad
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway.
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Bolliger D, Mauermann E, Erdoes G. A New Tool in the Management of Direct-Acting Oral Anticoagulants in Emergency Cardiac Surgery. J Cardiothorac Vasc Anesth 2022; 36:1645-1647. [PMID: 35351396 DOI: 10.1053/j.jvca.2022.02.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Eckhard Mauermann
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital/University Hospital Bern, Bern, Switzerland
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4
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Sromicki J, Van Hemelrijck M, Schmiady MO, Krüger B, Morjan M, Bettex D, Vogt PR, Carrel TP, Mestres CA. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6544114. [PMID: 35258082 PMCID: PMC9252133 DOI: 10.1093/icvts/ivac037] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/20/2022] [Accepted: 01/31/2022] [Indexed: 11/21/2022] Open
Affiliation(s)
- Juri Sromicki
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Corresponding author. Department of Cardiac Surgery, University Hospital Zürich, Rämistrasse 100, CH-8091 Zürich, Switzerland. Tel: +41 44 255 95 82; fax: +41 44 255 44 67; e-mail:
| | | | - Martin O Schmiady
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Bernard Krüger
- Institute of Anesthesiology. University Hospital Zurich, Zurich, Switzerland
| | - Mohammed Morjan
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, Herzzentrum Duisburg, Duisburg, Germany
| | - Dominique Bettex
- Institute of Anesthesiology, University Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Paul R Vogt
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Thierry P Carrel
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Carlos-A Mestres
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
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Harky A, Badran A. Reducing antithrombotic-related bleeding risk in urgent and emergency cardiac surgery. THE BRITISH JOURNAL OF CARDIOLOGY 2021; 28:26. [PMID: 35747456 PMCID: PMC8988220 DOI: 10.5837/bjc.2021.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This review focuses on the role of CytoSorb® (CytoSorbents Corporation, Monmouth Junction, New Jersey, USA), a technology for purifying extracorporeal blood. The technology is designed for several indications to prevent bleeding complications during on-pump cardiac surgery, including removal of the antiplatelet agent, ticagrelor, and the oral anticoagulant, rivaroxaban, from the blood. Recent clinical studies are briefly reviewed.
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Affiliation(s)
- Amer Harky
- Cardiothoracic Surgery SpR Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool, L14 3PE
| | - Abdul Badran
- Cardiothoracic Surgery Registrar, and Honorary Clinical Lecturer (University of Southampton) Department of Cardiothoracic Surgery, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD
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6
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Alwis S, Raja SG. Emergency cardiac surgery for patients on NOACs in the NOAC era - Perspective. Int J Surg 2021; 87:105893. [PMID: 33577930 DOI: 10.1016/j.ijsu.2021.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/02/2021] [Indexed: 11/25/2022]
Abstract
Excessive bleeding is an important cause of morbidity and mortality after cardiac surgery. Bleeding after cardiac surgery is multifactorial. Adherence to the proverbial 6 Ps remains the cornerstone of any strategy for management of postoperative bleeding after cardiac surgery. Recent years have seen a surge in the number of patients who have been prescribed novel oral anticoagulants (NOACs) for the prevention and treatment of thromboembolic events. This phenomenon has significant repercussions particularly for patients presenting for emergency cardiac surgery. The published evidence guiding management of such patients is limited and in the form of expert consensus. Plasma levels of NOAC >30 ng/ml necessitate specific therapeutic interventions to tackle excessive bleeding attributed to NOAC intake. Current recommendation is to consider using specific reversal agent if available. Otherwise, use of prothrombin complex concentrates is recommended.
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Affiliation(s)
- Shehani Alwis
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom
| | - Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom.
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