Intraoperative hemoadsorption in high-risk patients with infective endocarditis

Use of intraoperative haemoadsorption in patients undergoing heart transplantation: a proof-of-concept randomized trial

AIMS

The aim of this trial was to compare the clinical effects of intraoperative haemoadsorption versus standard care in patients undergoing orthotopic heart transplantation (OHT).

METHODS AND RESULTS

In a randomized, controlled trial, OHT recipients were randomized to receive intraoperative haemoadsorption or standard care. Outcomes were vasoactive-inotropic score (VIS), frequency of vasoplegic syndrome (VS) in the first 24 h; post-operative change in procalcitonin (PCT) and C-reactive protein (CRP) levels; intraoperative change in mycophenolic acid (MPA) concentration; frequency of post-operative organ dysfunction, major complications, adverse immunological events and length of in-hospital stay and 1-year survival. Sixty patients were randomized (haemoadsorption group N = 30, control group N = 25 plus 5 exclusions). Patients in the haemoadsorption group had a lower median VIS and rate of VS (VIS: 27.2 [14.6-47.7] vs. 41.9 [22.4-63.2], P = 0.046, and VS: 20.0% vs. 48.0%, P = 0.028, respectively), a 6.4-fold decrease in the odds of early VS (OR: 0.156, CI: 0.029-0.830, P = 0.029), lower PCT levels, shorter median mechanical ventilation (MV: 25 [19-68.8] hours vs. 65 [23-287] hours, P = 0.025, respectively) and intensive care unit stay (ICU stay: 8.5 [8.0-10.3] days vs. 12 [8.5-18.0] days, P = 0.022, respectively) than patients in the control group. Patients in the haemoadsorption versus control group experienced lower rates of acute kidney injury (AKI: 36.7% vs. 76.0%, P = 0.004, respectively), renal replacement therapy (RRT: 0% vs. 16.0%, P = 0.037, respectively) and lower median per cent change in bilirubin level (PCB: 2.5 [-24.6 to 71.1] % vs. 72.1 [11.2-191.4] %, P = 0.009, respectively) during the post-operative period. MPA concentrations measured at pre-defined time points were comparable in the haemoadsorption compared to control groups (MPA pre-cardiopulmonary bypass: 2.4 [1.15-3.60] μg/mL vs. 1.6 [1.20-3.20] μg/mL, P = 0.780, and MPA 120 min after cardiopulmonary bypass start: 1.1 [0.58-2.32] μg/mL vs. 0.9 [0.45-2.10] μg/mL, P = 0.786). The rates of cardiac allograft rejection, 30-day mortality and 1-year survival were similar between the groups.

CONCLUSIONS

Intraoperative haemoadsorption was associated with better haemodynamic stability, mitigated PCT response, lower rates of post-operative AKI and RRT, more stable hepatic bilirubin excretion, and shorter durations of MV and ICU stay. Intraoperative haemoadsorption did not show any relevant adsorption effect on MPA. There was no increase in the frequency of early cardiac allograft rejection related to intraoperative haemoadsorption use.

A Contemporary Review of the Use of Extracorporeal CytoSorb® Hemoadsorption Therapy in Patients with Infective Endocarditis

Infective endocarditis (IE) is a rare but severe disease with high morbidity and mortality. Cardiac surgery plays a major role in the contemporary clinical management of IE patients. During cardiac surgery, cardiopulmonary bypass significantly contributes to an increased risk of organ dysfunction and mortality by inducing an acute inflammatory response, vascular endothelial cell injury, impairment of the coagulation cascade, and ischemia-reperfusion injury. During the past decade, the use of extracorporeal hemoadsorption therapy with the CytoSorb® hemoadsorber (CytoSorbents Europe GmbH, Berlin, Germany) has been proposed as an adjuvant therapy to mediate inflammatory responses in IE patients undergoing cardiac surgery with cardiopulmonary bypass. However, there is currently no systematic evaluation of the effect of CytoSorb® hemoadsorption on clinical outcomes such as hemodynamics, organ dysfunction, and mortality in patients with IE. Therefore, in this review, we exclusively discuss contemporary findings concerning the rationale, clinical evidence, and future perspectives for CytoSorb® hemoadsorption therapy in IE patients.

Standardized in vitro bleeding tests in a non-coated novel hybrid prosthesis for frozen elephant trunk demonstrates minimal oozing during full heparinization, supported by clinical data

Introduction

Recent reports have questioned the blood impermeability of the novel frozen elephant trunk (FET) device E-vita Open NEO© (EO-NEO). Therefore, standardized in vitro bleeding tests using porcine heparinized blood were performed, as well as stress testing on the blood tightness of the collar suture line, to investigate this observation.

Material and methods

EO-NEO prostheses were examined in vitro for blood permeability in three test series. Initially, antegrade perfusion with heparinized porcine blood [activated clotting time (ACT) of 500 s, with a 60 min duration] was performed, followed by ante/retrograde testing via the EO-NEO side port. Testing of the collar suture line under a tension of 10 Newton (N) within a suspension device (blood pressure 120 mmHg, ACT of 560 s, 1 min duration) was carried out with the suture material force fiber white (FFWs) yarn, using standard fixation (5 stitches/cm), FFWh yarn in hemostatic fixation (15 stitches/cm), and flow weave yarn (FWYh).

Results

Blood permeability testing of EO-NEO through the prosthetic lumen or via the side port demonstrated minor leakage without statistical difference between the standard and hemostatic suture lines or suture materials used, or positioning on the crimped or tapered portion (p > 0.05). The specific collar anastomosis testing demonstrated leakage volumes of 140 ml/min for FFWs vs. 16 ml/min for FFWh (p = 0.02), vs. 9 ml/min with the FWYh (p = 0.01).

Conclusion

Different blood leakage tests showed minimal oozing and no difference in blood loss through the fabric and different collar suture lines, but unphysiological pressurized retrograde perfusion of the collar region showed significantly less leakage using FWYh and FFWh, prompting production modification of EO-NEO. Clinical results confirmed low blood loss using this novel FET device.

Successful Extracorporeal Cytokine Hemoadsorption in a Marfan Syndrome Patient with COVID-19 Undergoing Redo Bentall Procedure

BACKGROUND Patients with COVID-19 undergoing emergency or complex surgical procedures are at increased risk of developing perioperative complications. CytoSorb is a blood purification therapy used to remove circulating cytokines in conditions of hyperinflammation. This report is of a patient with COVID-19 requiring redo replacement of the aortic valve and aorta due to aortic aneurysm of the ascending aorta (Bentall procedure) associated with Marfan syndrome. The patient was successfully treated with extracorporeal cytokine hemoadsorption. CASE REPORT A 34-year-old man with Marfan syndrome, who had undergone a Bentall procedure in 2018, was admitted with symptoms of worsening dyspnea, tachycardia, fever, and confirmed COVID-19. Further diagnostic workup revealed dehiscence of the aortic root as well as moderate aortic regurgitation, in the context of a hyperinflammatory state. Anti-infective treatment was initiated. Given the severity of symptoms, COVID-19, echocardiography findings, and risk of aortic rupture, urgent Bentall surgery was performed. Additionally, a CytoSorb hemoadsorber was integrated into the cardiopulmonary bypass circuit to attenuate the anticipated systemic hyperinflammation. Intraoperatively, several blood products were administered due to excessive bleeding from the friable tissues and the pre-existing anemia and thrombocytopenia. Treatment was associated with marked improvements in vital parameters and inflammatory markers, and weaning from the ventilator and inotropes was possible after 48 hours. The remaining time in hospital was uneventful. CONCLUSIONS This report supports the findings from recent studies and reports that extracorporeal cytokine hemoadsorption has a role to play in reducing the systemic effects of cytokine storm associated with complex surgery involving cardiopulmonary bypass alongside severe infections, including COVID-19.

Perioperative Complications in Infective Endocarditis

Infective endocarditis is a challenging condition to manage, requiring collaboration among various medical professionals. Interdisciplinary teamwork within endocarditis teams is essential. About half of the patients diagnosed with the disease will ultimately have to undergo cardiac surgery. As a result, it is vital for all healthcare providers involved in the perioperative period to have a comprehensive understanding of the unique features of infective endocarditis, including clinical presentation, echocardiographic signs, coagulopathy, bleeding control, and treatment of possible organ dysfunction. This narrative review provides a summary of the current knowledge on the incidence of complications and their management in the perioperative period in patients with infective endocarditis.

Hemoadsorption Using CytoSorb® in Patients with Infective Endocarditis: A German-Based Budget Impact Analysis

A considerable number of infective endocarditis (IE) patients require cardiac surgery with an increased risk for postoperative sepsis. Intraoperative hemoadsorption may diminish the risk of postoperative hyperinflammation with potential economic implications for intensive care unit (ICU) occupation. The present study aimed to theoretically investigate the budget impact of a reduced length of ICU stay in IE patients treated with intraoperative hemoadsorption in the German healthcare system. Data on ICU occupation were extrapolated from a retrospective study on IE patients treated with hemoadsorption. An Excel-based budget impact model was developed to simulate the patient course over the ICU stay. A base-case scenario without therapy reimbursement and a scenario with full therapy reimbursement were explored. The annual eligible German IE patient population was derived from official German Diagnostic-Related Group (DRG) volume data. One-way deterministic sensitivity analysis and multivariate analysis were performed to evaluate the uncertainty over the model results. The use of intraoperative hemoadsorption resulted in EUR 2298 being saved per patient in the base-case scenario without therapy reimbursement. The savings increased to EUR 3804 per patient in the case of full device-specific reimbursement. Deterministic and probabilistic sensitivity analyses confirmed the robustness of savings, with a probability of savings of 87% and 99% in the base-case and full reimbursement scenario, respectively. Intraoperative hemoadsorption in IE patients might have relevant economic benefits related to reduced ICU stays, resulting in improved resource use. Further evaluations in larger prospective cohorts are warranted.

Limited Versus Radical Resection in Mitral Valve Infective Endocarditis Surgery

Background: Mitral valve repair is preferred in patients undergoing surgical treatment for infective endocarditis (IE) of the native mitral valve, however, radical resection of infected tissue and patch-plasty might potentially lead to low or non-durable repair. We aimed to compare a limited-resection and non-patch technique with the classic radical-resection technique. Methods: Eligible candidates were patients with definitive IE of the native mitral valve undergoing surgery between January 2013 and December 2018. Patients were classified according to the surgical strategy into two groups: limited- versus radical-resection strategy. Propensity score matching was used. Endpoints were repair rate, all-cause mortality (30-day and 2-year), re-endocarditis and reoperation at q-year follow-up. Results: After propensity score matching, 90 patients were included. Follow-up was 100% complete. Mitral valve repair rate was 84% in the limited-resection versus 18% in the radical-resection strategy, p < 0.001. The 30-day and 2-year mortality were 20% versus 13% (p = 0.396) and 33% versus 27% (p = 0.490) in the limited-resection versus radical-resection strategy, respectively. The incidence of re-endocarditis during the 2-year follow-up was 4% in the limited-resection strategy versus 9% in the radical-resection strategy, p = 0.677. Three patients in the limited-resection strategy underwent reoperation of the mitral valve, while there were none in the radical-resection strategy (p = 0.242). Conclusions: Although mortality in patients with IE of the native mitral valve remains high, the limited-resection and non-patch surgical strategy is associated with a significantly higher repair rates with comparable 30-day and mid-term mortality, risk of re-endocarditis and re-operation compared to the radical-resection strategy.

Effect of intraoperative haemoadsorption therapy on cardiac surgery for active infective endocarditis with confirmed Staphylococcus aureus bacteraemia

OBJECTIVES

Sepsis caused by infective endocarditis (IE), due to Staphylococcus aureus, is associated with significant morbidity and mortality. Blood purification using haemoadsorption (HA) may attenuate the inflammatory response. We investigated the effect of intraoperative HA on postoperative outcomes in S. aureus IE.

METHODS

Patients with confirmed S. aureus IE undergoing cardiac surgery were included in a dual-centre study between January 2015 and March 2022. Patients treated with intraoperative HA (HA group) were compared to patients not treated with HA (control group). The primary outcome was vasoactive-inotropic score within the first 72 h postoperatively and secondary outcomes were sepsis-related mortality (SEPSIS-3 definition) and overall mortality at 30 and 90 days.

RESULTS

No differences in baseline characteristics were observed between groups (haemoadsorption group, n = 75, control group, n = 55). Significantly decreased vasoactive-inotropic score was observed in the haemoadsorption group at all time points [6 h: 6.0 (0-17) vs 17 (3-47), P = 0.0014; 12 h: 2 (0-8.3) vs 5.9 (0-37), P = 0.0138; 24 h: 0 (0-5) vs 4.9 (0-23), P = 0.0064; 48 h: 0 (0-2.1) vs 0.1 (0-13), P = 0.0192; 72 h: 0 (0) vs 0 (0-5), P = 0.0014]. Importantly, sepsis-related mortality (8.0% vs 22.8%, P = 0.02) and 30-day (17.3% vs 32.7%, P = 0.03) and 90-day overall mortality (21.3% vs 40%, P = 0.03) were also significantly lower with haemoadsorption.

CONCLUSIONS

Intraoperative HA during cardiac surgery for S. aureus IE was associated with significantly lower postoperative vasopressor and inotropic requirements and resulted in lower sepsis-related and overall 30- and 90-day mortality. In this high-risk population, improved postoperative haemodynamic stabilization by intraoperative HA appears to improve survival and should be further tested in future randomized trials.

Intraoperative Hemoadsorption (Cytosorb™) during Open Thoracoabdominal Aortic Repair: A Pilot Randomized Controlled Trial

BACKGROUND

The efficacy of cytokine adsorption in controlling the early inflammation cascade after open thoracoabdominal aortic (TAAA) repair has not been investigated. The aim of this pilot randomized controlled trial was to assess the feasibility and effect of perioperative hemoadsorption during open TAAA repair.

METHODS

Patients scheduled for open TAAA repair with the use of cardiopulmonary bypass (CPB) were included. The patients were randomized the day before surgery to either intraoperative hemoadsorption during CPB or standard of care.

RESULTS

A total of 10 patients were randomly assigned to the intervention group, whereas the control group consisted of 17 patients (mean age of the total cohort, 51.1 ± 11.2 years, 67% male, 3 patients not randomized). The majority of baseline and perioperative characteristics were similar, and no device-related adverse events were reported. A trend to shorter ventilation times in the intervention group was observed (median 88 h vs. 510 h, p = 0.08, Δ422). Severe acute respiratory distress syndrome was significantly less in the intervention patients (p = 0.02).

CONCLUSIONS

This is the first pilot study showing that the intraoperative use of hemoadsorption in open TAAA repair patients may be feasible and safe, yet larger trials are needed to evaluate whether intraoperative hemoadsorption is associated with improved clinical outcomes.

Hemoadsorption in Complex Cardiac Surgery-A Single Center Experience

(1) Background: Cardiac surgery may evoke a generalized inflammatory response, typically magnified in complex, combined, redo, and emergency procedures with long aortic cross-clamp times. Various treatment options have been introduced to help regain control over post-cardiac surgery hyper-inflammation, including hemoadsorptive immunomodulation with CytoSorb^®. (2) Methods: We conducted a single-center retrospective observational study of patients undergoing complex cardiac surgery. Patients intra-operatively treated with CytoSorb^® were compared to a control group. The primary outcome was the change in the vasoactive-inotropic score (VIS) from pre-operatively to post-operatively. (3) Results: A total of 52 patients were included in the analysis, where 23 were treated with CytoSorb^® (CS) and 29 without (controls). The mean VIS increase from pre-operative to post-operative values was significantly lower in the CS group compared to the control group (3.5 vs. 5.5, respectively, p = 0.05). In-hospital mortality in the control group was 20.7% (6 patients) and 9.1% (2 patients) in the CS group (p = 0.26). Lactate level changes were comparable, and the median intensive care unit and hospital lengths of stay were similar between groups. (4) Conclusions: Despite notable imbalances between the groups, the signals revealed point toward better hemodynamic stability with CytoSorb^® hemoadsorption in complex cardiac surgery and a trend of lower mortality.