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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; 57:888-897. [PMID: 38709456 PMCID: PMC11315775 DOI: 10.1007/s11239-024-02996-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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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Forni L, Aucella F, Bottari G, Büttner S, Cantaluppi V, Fries D, Kielstein J, Kindgen-Milles D, Krenn C, Kribben A, Meiser A, Mitzner S, Ostermann M, Premuzic V, Rolfes C, Scharf C, Schunk S, Molnar Z, Zarbock A. Hemoadsorption therapy for myoglobin removal in rhabdomyolysis: consensus of the hemoadsorption in rhabdomyolysis task force. BMC Nephrol 2024; 25:247. [PMID: 39085790 PMCID: PMC11293130 DOI: 10.1186/s12882-024-03679-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 07/18/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND Rhabdomyolysis describes a syndrome characterized by muscle necrosis and the subsequent release of creatine kinase and myoglobin into the circulation. Myoglobin elimination with extracorporeal hemoadsorption has been shown to effectively remove myoglobin from the circulation. Our aim was to provide best practice consensus statements developed by the Hemoadsorption in Rhabdomyolysis Task Force (HRTF) regarding the use of hemadsorption for myoglobin elimination. METHODS A systematic literature search was performed until 11th of January 2023, after which the Rhabdomyolysis RTF was assembled comprising international experts from 6 European countries. Online conferences were held between 18th April - 4th September 2023, during which 37 consensus questions were formulated and using the Delphi process, HRTF members voted online on an anonymised platform. In cases of 75 to 90% agreement a second round of voting was performed. RESULTS Using the Delphi process on the 37 questions, strong consensus (> 90% agreement) was achieved in 12, consensus (75 to 90% agreement) in 10, majority (50 to 74%) agreement in 13 and no consensus (< 50% agreement) in 2 cases. The HRTF formulated the following recommendations: (1) Myoglobin contributes to the development of acute kidney injury; (2) Patients with myoglobin levels of > 10,000 ng/ml should be considered for extracorporeal myoglobin removal by hemoadsorption; (3) Hemoadsorption should ideally be started within 24 h of admission; (4) If myoglobin cannot be measured then hemoadsorption may be indicated based on clinical picture and creatinine kinase levels; (5) Cartridges should be replaced every 8-12 h until myoglobin levels < 10,000 ng/ml; (6) In patients with acute kidney injury, hemoadsorption can be discontinued before dialysis is terminated and should be maintained until the myoglobin concentration values are consistently < 5000 ng/ml. CONCLUSIONS The current consensus of the HRTF support that adjuvant hemoadsorption therapy in severe rhabdomyolysis is both feasible and safe and may be an effective method to reduce elevated circulating levels of myoglobin.
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Affiliation(s)
- Lui Forni
- Critical Care Unit, Royal Surrey Hospital, Guildford, Surrey, UK.
- School of Medicine, University of Surrey, Kate Granger Building, Guildford, UK.
| | - Filippo Aucella
- "Casa Sollievo della Sofferenza" Foundation, Scientific Institut for Research and Health Care, Viale Cappuccini, 1, San Giovanni Rotondo (FG), 71013, Italy
| | - Gabriella Bottari
- Pediatric Intensive Care Unit, Bambino Gesu Children's Hospital, IRCCS, Rome, 00165, Italy
| | - Stefan Büttner
- Cardiology, Pulmonology, Nephrology and Intensive Care Medicine, Klinikum Aschaffenburg- Alzenau, Academic Teaching Hospital of Julius-Maximilians-University Würzburg, Aschaffenburg, Germany
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale (UPO), Novara, Italy
- "Maggiore della Carità" University Hospital, via Gen. P. Solaroli 17, Novara, 28100, Italy
| | - Dietmar Fries
- Department for Anaesthesia and Critical Care Medicine, Medical University, Christoph-Probst- Platz 1, Innrain 52 A, Fritz-Pregl-Straße 3, Innsbruck, 6020, Austria
| | - Jan Kielstein
- Medical Clinic V, Nephrology, Rheumatology, Blood Purification, Academic Teaching Hospital Braunschweig, Naumburgstraße 15, D-38124, Braunschweig, Germany
| | - Detlef Kindgen-Milles
- Department of Anesthesiology, University Hospital Duesseldorf, Heinrich-Heine University, Moorenstr.5, D-40225, Duesseldorf, Germany
| | - Claus Krenn
- Clinic for Anaesthesia, General Intensive Care Medicine and Pain Therapy, Medical University of Vienna, Wahringer Gurtel 18-20, Vienna, 1090, Austria
| | - Andreas Kribben
- Universitätsklinikum Essen (AöR) Nephrology Clinic, Medizinisches Zentrum, 2.104 Hufelandstraße 55, D-45147, Essen, Germany
| | - Andreas Meiser
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Saarland University Hospital, D-66424, Homburg, Germany
| | - Steffen Mitzner
- Fraunhofer IZI Rostock, Schillingallee 68, 18057, Rostock, Germany
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St. Thomas' Hospital, London, SE1 9RT, UK
| | - Vedran Premuzic
- Department for Nephrology, Hypertension, Dialysis and Transplantation, School of Medicine, UHC Zagreb Croatia, University of Zagreb, Šalata ul. 2, Zagreb, 10000, Croatia
| | - Caroline Rolfes
- Department for Anesthesiology, Intensive Care Medicine, Pain Therapy and Emergency Medicine, GNH Klinikum Kassel, Mönchebergstraße 41-43, D-34125, Kassel, Germany
| | - Christina Scharf
- Department of Anesthesiology, LMU University Hospital, LMU Munich, Geschwister-Scholl- Platz 1, D-80539, München, Germany
| | - Stefan Schunk
- Department of Internal Medicine 4, Nephrology and Hypertension, Saarland University Hospital, Kirrberger Str. 100, D-66421, Homburg/Saar, Germany
| | - Zsolt Molnar
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Üllői út 78, Budapest, H-1082, Hungary
- Department of Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Collegium Maius, Fredry 10, Poznan, 61-701, Poland
- CytoSorbents Europe, Müggelseedamm 131, D-12587, Berlin, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, D-48149, Münster, Germany
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Mair H, Ulrich S, Rosenzweig D, Goeppl J, Jurma C, Vogt F, Baumer B, Vogel F, Lamm P. Antithrombotic drug removal with hemoadsorption during off-pump coronary artery bypass grafting. J Cardiothorac Surg 2024; 19:246. [PMID: 38632635 PMCID: PMC11025220 DOI: 10.1186/s13019-024-02772-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/30/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Patients requiring coronary artery bypass grafting (CABG) are often loaded with antithrombotic drugs (AT) and are at an increased risk for perioperative bleeding complications. Active AT removal by a hemoadsorption cartridge integrated in the cardiopulmonary bypass circuit is increasingly used in this setting to reduce bleeding, and herein we describe the extension of this application in patients on AT undergoing off-pump coronary artery bypass (OPCAB). METHODS Ten patients (80% male; mean age: 67.4 ± 9.2years) were treated with ticagrelor (eight patients), rivaroxaban and ticagrelor (one patient), and rivaroxaban (one patient) prior to OPCAB surgery. AT's were discontinued one day before surgery in nine patients and on the day of surgery in one patient, and all patients were also on aspirin. The cohort mean EuroSCORE-II was 2.9 ± 1.5%. A hemoadsorption cartridge was integrated into a dialysis device (n=4) or a stand-alone apheresis pump (n=6) periprocedural, for a treatment time of 145 ± 33 min. Outcome measures included bleeding according to Bleeding Academic Research Consortium (BARC)-4 and 24-hour chest-tube-drainage (CTD). RESULTS Mean operation time was 184 ± 35 min. All patients received a left internal thoracic artery with a mean of 2.3 ± 0.9 total grafts. One patient had a BARC-4 bleeding event and there were no surgical re-explorations for bleeding. Mean 24-hours CTD was 680 ± 307mL. During follow-up of 19.5 ± 17.0 months, none of the patients died or required further reinterventions. No device-related adverse events were reported. CONCLUSIONS Hemoadsorption via a stand-alone apheresis pump during OPCAB surgery was feasible and safe. This innovative and new approach showed favorable bleeding rates in patients on antithrombotic drugs requiring bypass surgery.
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Affiliation(s)
- Helmut Mair
- Department of Cardiac Surgery, Artemed Klinikum München Süd Am Isarkanal 30, 81379, Munich, Germany.
| | - Stephanie Ulrich
- Department of Cardiology, Benedictus Krankenhaus Tutzing, 82327, Tutzing, Germany
| | - Dow Rosenzweig
- Department of Cardiac Surgery, Artemed Klinikum München Süd Am Isarkanal 30, 81379, Munich, Germany
| | - Johannes Goeppl
- Department of Cardiac Surgery, Artemed Klinikum München Süd Am Isarkanal 30, 81379, Munich, Germany
| | - Christopher Jurma
- Department of Cardiac Surgery, Artemed Klinikum München Süd Am Isarkanal 30, 81379, Munich, Germany
| | - Ferdinand Vogt
- Department of Cardiac Surgery, Artemed Klinikum München Süd Am Isarkanal 30, 81379, Munich, Germany
- Department of Cardiac Surgery, Paracelsus Medical University, 90471, Nuremberg, Germany
| | - Benedikt Baumer
- Department of Cardiac Surgery, Artemed Klinikum München Süd Am Isarkanal 30, 81379, Munich, Germany
| | - Frank Vogel
- Department of Anesthesiology, Artemed Klinikum München Süd, 81379, Munich, Germany
| | - Peter Lamm
- Department of Cardiac Surgery, Artemed Klinikum München Süd Am Isarkanal 30, 81379, Munich, Germany
- Department of Cardiac Surgery, University of Munich, 81377, Munich, Germany
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Mendes V, Mamode J, Jolou J, Malki M, Ellenberger C, Cikirikcioglu M, Huber C. Effective Apixaban removal using hemoadsorption during emergent open-heart surgery: a case report and narrative literature review. J Cardiothorac Surg 2024; 19:185. [PMID: 38582888 PMCID: PMC10998397 DOI: 10.1186/s13019-024-02748-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/29/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND The management of hemostasis in patients medicated with apixaban (Eliquis) undergoing emergency cardiac surgery is exceedingly difficult. The body's natural elimination pathways for apixaban prove ineffective in emergency situations, and the impact of hemodialysis is limited. The application of Cytosorb® may attenuate the concentration of apixaban, thereby facilitating the stabilization of these patients. CASE PRESENTATION An 84-year-old man treated with apixaban, underwent emergency ascending aorta replacement surgery due to an acute type A aortic dissection. To address the challenges induced by apixaban, we integrated Cytosorb® cartridge into the Cardiopulmonary bypass circuit. There was a 63.7% decrease in perioperative apixaban-specific anti-factor Xa activity. The patient's postoperative course was favourable. CONCLUSION Hemoadsorption with Cytosorb® may offers a safe and feasible approach for reducing apixaban concentration in emergency cardiac surgery, thereby mitigating the risk of hemorrhagic complications.
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Affiliation(s)
- Vitor Mendes
- Division of Cardiovascular Surgery, Department of Surgery, Geneva University Hospitals, 1205, Geneva, Switzerland.
| | - Jaid Mamode
- Division of Cardiovascular Surgery, Department of Surgery, Geneva University Hospitals, 1205, Geneva, Switzerland
| | - Jalal Jolou
- Division of Cardiovascular Surgery, Department of Surgery, Geneva University Hospitals, 1205, Geneva, Switzerland
| | - Mourad Malki
- Division of Cardiovascular Surgery, Department of Surgery, Geneva University Hospitals, 1205, Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anesthesiology, Pharmacology Division of Anesthesiology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Rue Gabrielle-Perret- Gentil 4, 1205, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Mustafa Cikirikcioglu
- Division of Cardiovascular Surgery, Department of Surgery, Geneva University Hospitals, 1205, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Christoph Huber
- Division of Cardiovascular Surgery, Department of Surgery, Geneva University Hospitals, 1205, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Schöchl H, Grottke O, Schmitt FCF. Direct oral anticoagulants in trauma patients. Curr Opin Anaesthesiol 2024; 37:93-100. [PMID: 38390987 DOI: 10.1097/aco.0000000000001356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW Direct oral anticoagulants (DOACs) are increasingly prescribed for prevention of thromboembolic events. Thus, trauma care providers are facing a steadily raising number of injured patients on DOACs. RECENT FINDINGS Despite a predictable pharmacokinetic profile, the resulting plasma levels of trauma patients upon admission and bleeding risks remain uncertain. Therefore, recent guidelines recommend the measurement of DOAC plasma concentrations in injured patients. Alternatively, DOAC specific visco-elastic tests assays can be applied to identify DOAC patients at bleeding risk.Bleeding complications in trauma patients on DOACs are generally higher compared to nonanticoagulated subjects, but comparable to vitamin K antagonists (VKAs). In particular, a traumatic brain injury does not carry an increased risk of intracranial bleeding due to a DOAK intake compared to VKAs. Current studies demonstrated that up to 14% of patients with a hip fracture are on DOACs prior to surgery. However, the majority can be operated safely within a 24h time window without an increased bleeding rate.Specific antagonists facilitate rapid reversal of patients on DOACs. Idarucizumab for dabigatran, and andexanet alfa for apixaban and rivaroxaban have been approved for life threatening bleeding. Alternatively, prothrombin complex concentrate can be used. Dialysis is a potential treatment option for dabigatran and haemoabsorption with special filters can be applied in patients on FXa-inhibitors. SUMMARY Current guidelines recommend the measurement of DOAC plasma levels in trauma patients. Compared to VKAs, DOACs do not carry a higher bleeding risk. DOAC specific antagonists facilitate the individual bleeding management.
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Affiliation(s)
- Herbert Schöchl
- Ludwig Boltzmann Institute for Traumatology, The research centre in cooperation with AUVA, Vienna, Austria
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen
| | - Felix C F Schmitt
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
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García-Villegas R, Arni S. Hemoadsorption in Organ Preservation and Transplantation: A Narrative Review. Life (Basel) 2023; 14:65. [PMID: 38255680 PMCID: PMC10817660 DOI: 10.3390/life14010065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024] Open
Abstract
Cytokine adsorption can resolve different complications characteristic of transplantation medicine, such as cytokine storm activation and blood ABO and immune incompatibilities. Cytokine adsorption is also performed for the treatment of various life-threatening conditions, such as endotoxic septic shock, acute respiratory distress syndrome, and cardiogenic shock, all potentially leading to adverse clinical outcomes during transplantation. After surgery, dysmetabolism and stress response limit successful graft survival and can lead to primary or secondary graft dysfunction. In this clinical context, and given that a major problem in transplant medicine is that the demand for organs far exceeds the supply, a technological innovation such as a hemoadsorption system could greatly contribute to increasing the number of usable organ donors. The objectives of this review are to describe the specific advantages and disadvantages of the application of cytokine adsorption in the context of transplantation and examine, before and/or after organ transplantation, the benefits of the addition of a cytokine adsorption therapy protocol.
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Affiliation(s)
- Refugio García-Villegas
- Departamento de Fisiología, Biofísica y Neurociencias, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, D.F., Mexico City 07360, Mexico;
| | - Stephan Arni
- Department of Thoracic Surgery, University Hospital Zürich, 8091 Zürich, Switzerland
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