Effective Apixaban removal using hemoadsorption during emergent open-heart surgery: a case report and narrative literature review

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.

Comparison of Perioperative and Postoperative Outcomes Among 3 Left Atrial Incisions: Conventional Direct, Transseptal, and Superior Septal Left Atriotomy

BACKGROUND

Achieving optimal exposure of the mitral valve during surgical intervention poses a significant challenge. This study aimed to compare perioperative and postoperative outcomes associated with 3 left atriotomy techniques in mitral valve surgery-the conventional direct, transseptal, and superior septal approaches-and assess differences during the surgical procedure and the postoperative period.

METHODS

Inclusion criteria were patients undergoing mitral valve surgery from January 2010 to December 2020, categorized into 3 cohorts: group 1 (conventional direct; n = 115), group 2 (transseptal; n = 33), and group 3 (superior septal; n = 59). To bolster sample size, the study included patients undergoing mitral valve surgery independently or in conjunction with other procedures (eg, coronary artery bypass grafting, aortictricuspid surgery, or maze procedure).

RESULTS

No substantial variance was observed in the etiology of mitral valve disease across groups, except for a higher incidence of endocarditis in group 3 (P = .01). Group 1 exhibited a higher frequency of elective surgeries and isolated mitral valve procedures (P = .008), along with reduced aortic clamping and cardiopulmonary bypass durations (P = .002). Conversely, group 3 patients represented a greater proportion of emergency procedures (P = .01) and prolonged intensive care unit and hospital stays (P = .001). No significant disparities were detected in terms of permanent pacemaker implantation, postoperative complications, or mortality among the groups.

CONCLUSION

Mitral valve operations that employed these 3 atriotomy techniques demonstrated a safe profile. The conventional direct approach notably reduced aortic clamping and cardiopulmonary bypass durations. The superior septal method was primarily employed for acute pathologies, with no significant escalation in postoperative arrhythmias or permanent pacemaker implantation, although these patients had prolonged intensive care unit and hospital stays. These outcomes may be linked to the underlying pathology and nature of the surgical intervention rather than the incision method itself.

Case Report: Right atrial mass arising from the Eustachian valve

A mass in the right atrium (RA) is an unusual finding that warrants further investigation. We report the case of a 72-year-old male patient who underwent a Bentall operation with a biological composite graft and closure of patent foramen ovale 18 months prior to his presentation with an incidental new RA mass during follow-up echocardiography. Transesophageal echocardiography and thoracic CT angiography confirmed a right atrial mass attached to the Eustachian valve and additionally revealed a non-occlusive pulmonary embolism in the inferior lobar artery of the left lung. Despite 2 months of anticoagulation treatment, the size of the mass did not decrease. Further MRI imaging showed a central mass enhancement which raised concerns about a tumoral lesion. Following a discussion with the local Heart Team, management with surgical treatment was decided. The intraoperative findings revealed a 2.5 cm × 2.1 cm mass arising from the Eustachian valve and a non-diagnosed Chiari network in the RA. Both were resected and sent for a frozen section procedure which excluded a malignancy. The final histopathological analysis described fibrotic tissues compatible with an organized thrombus. The patient was discharged on postoperative day 7 without any complications. Although imaging studies are useful for the initial and differential diagnosis of RA masses, it is not always possible to get the final diagnosis without surgery. In case of a suspicion of a potentially malignant pathology, surgical exploration and resection are necessary.

Triple switch' aortic and pulmonary root inversion and modified Senning procedure for anatomically complex left transposition of the great arteries with inlet ventricular septal defect and pulmonary stenosis

Left transposition of the great arteries with inlet ventricular septal defect and pulmonary stenosis is a relatively uncommon cardiac malformation. Two surgical treatments are available: double switch or physiological correction. The choice of surgical technique depends on the results of a discussion between the family and the surgeon. Choosing the appropriate technique is challenging because all options present various complications and benefits. We present a 'triple switch' aortic and pulmonary root inversion and modified Senning procedure for an anatomically complex left transposition of the great arteries with an inlet ventricular septal defect and pulmonary stenosis.