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Thielmann M, Bonaros N, Barbato E, Barili F, Folliguet T, Friedrich G, Gottardi R, Legutko J, Parolari A, Punjabi P, Sandner S, Suwalski P, Shehada SE, Wendt D, Czerny M, Muneretto C. Hybrid coronary revascularization: position paper of the European Society of Cardiology Working Group on Cardiovascular Surgery and European Association of Percutaneous Cardiovascular Interventions. Eur J Cardiothorac Surg 2024; 66:ezae271. [PMID: 39142801 DOI: 10.1093/ejcts/ezae271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 05/17/2024] [Accepted: 07/10/2024] [Indexed: 08/16/2024] Open
Abstract
Myocardial revascularization in coronary artery disease via percutaneous coronary intervention or coronary artery bypass graft (CABG) surgery effectively relieves symptoms, significantly improves prognosis and quality of life when combined with guideline-directed medical therapy. Hybrid coronary revascularization is a promising alternative to percutaneous coronary intervention or CABG in selected patients and is defined as a planned and/or intended combination of consecutive CABG surgery using at least 1 internal mammary artery to the left anterior descending (LAD), and catheter-based coronary intervention to the non-LAD vessels for the treatment of multivessel disease. The main indications for hybrid coronary revascularization are (i) to achieve complete revascularization in patients who cannot undergo conventional CABG, (ii) to treat patients with acute coronary syndromes and multivessel disease with a non-LAD vessel as the culprit lesion that needs revascularization and (iii) in highly select patients with multivessel disease with complex LAD lesions and simple percutaneous coronary intervention targets for all other vessels. Hybrid coronary revascularization patients receive a left internal mammary artery graft to the LAD artery through a minimal incision along with percutaneous coronary intervention to the remaining diseased coronary vessels using latest generation drug-eluting stents. A collaborative environment with a dedicated heart team is the optimal platform to perform such interventions, which aim to improve the quality and outcome of myocardial revascularization. This position paper analyses the rationale of hybrid coronary revascularization and the currently available evidence on the various techniques and delves into the sequence of the interventions and pharmacological management during and after the procedure.
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Affiliation(s)
- Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Austria
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
- Cardiovascular Research Center Aalst OLV Hospital, Aalst, Belgium
| | - Fabio Barili
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Thierry Folliguet
- Chirurgie Cardiaque et Transplantation, Assistance Publique Hôpital Henri Mondor, Université Paris UPEC, Paris, France
| | - Guy Friedrich
- Department of Cardiology, Innsbruck Medical University, Innsbruck, Austria
| | - Roman Gottardi
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany
| | - Jacek Legutko
- Department of Interventional Cardiology, Jagiellonian University Medical College, Institute of Cardiology, The John Paul II Hospital, Krakow, Poland
| | - Alessandro Parolari
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Prakash Punjabi
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Piotr Suwalski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre for Postgraduate Medical Education, Warsaw, Poland
| | - Sharaf-Eldin Shehada
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Daniel Wendt
- Faculty of Medicine, University Hospital Essen, Essen, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Claudio Muneretto
- Department and School of Cardiovascular Surgery, University of Brescia Medical School, Spedali Civili di Brescia, Brescia, Italy
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2
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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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3
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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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Levy JH, Shaw JR, Castellucci LA, Connors JM, Douketis J, Lindhoff-Last E, Rocca B, Samama CM, Siegal D, Weitz JI. Reversal of direct oral anticoagulants: guidance from the SSC of the ISTH. J Thromb Haemost 2024:S1538-7836(24)00426-4. [PMID: 39029742 DOI: 10.1016/j.jtha.2024.07.009] [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: 05/15/2024] [Revised: 07/04/2024] [Accepted: 07/08/2024] [Indexed: 07/21/2024]
Abstract
The currently approved direct oral anticoagulants (DOACs) are increasingly used in clinical practice. Although serious bleeding risks are lower with DOACs than with vitamin K antagonists, bleeding remains the most frequent side effect. Andexanet alfa and idarucizumab are the currently approved specific reversal agents for oral factor (F)Xa inhibitors and dabigatran, respectively. Our prior guidance document was published in 2016, but with more information available on the utility and increased use of these reversal agents and other bleeding management strategies, we have updated this International Society on Thrombosis and Haemostasis guidance document on DOAC reversal. In this narrative review, we compare the mechanism of action of specific and nonspecific reversal agents, review the clinical data supporting their use, and provide guidance on when reversal is indicated. In addition, we briefly discuss the reversal of oral FXIa inhibitors, a new class of DOACs currently under clinical development.
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Affiliation(s)
- Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Joseph R Shaw
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Ontario, Canada
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Jean M Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James Douketis
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Edelgard Lindhoff-Last
- Department of Vascular Medicine and Hemostaseology, Coagulation Research Centre Bethanien Hospital, Frankfurt, Germany
| | - Bianca Rocca
- Department of Safety and Bioethics-Section of Pharmacology, Catholic University School of Medicine, Rome, Italy; NeuroFarBa Department, University of Florence, Florence, Italy
| | - Charles Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, Groupement Hospitalier Universitaire Assistance Publique - Hôpitaux de Paris Centre, Université Paris Cité, Paris, France
| | - Deborah Siegal
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
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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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6
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Guinn N, Tanaka K, Erdoes G, Kwak J, Henderson R, Mazzeffi M, Fabbro M, Raphael J. The Year in Coagulation and Transfusion: Selected Highlights from 2022. J Cardiothorac Vasc Anesth 2023; 37:2435-2449. [PMID: 37690951 DOI: 10.1053/j.jvca.2023.08.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 09/12/2023]
Abstract
This is an annual review to cover highlights in transfusion and coagulation in patients undergoing cardiovascular surgery. The goal of this article is to provide readers with a focused summary of the most important transfusion and coagulation topics published in 2022. This includes a discussion covering the management of anemia and red blood cell transfusion, the management of factor Xa inhibitors, updates in coagulation testing, updates in the use of factor concentrates, advances in platelet therapy, advances in anticoagulation management of patients on extracorporeal membrane oxygenation and other forms of mechanical circulatory support, and advances in the diagnosis and management of heparin-induced thrombocytopenia.
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Affiliation(s)
- Nicole Guinn
- Chief of Neuroanesthesiology, Otolaryngology and Offsite Anesthesia Division, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Jenny Kwak
- Division of Cardiac Anesthesia, Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Maywood, IL
| | - Reney Henderson
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia Medical Center, Charlottesville, VA
| | - Michael Fabbro
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, Miami, FL
| | - Jacob Raphael
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA.
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Hassan K, Geidel S, Zamvar V, Tanaka K, Knezevic-Woods Z, Wendt D, Deliargyris EN, Storey RF, Schmoeckel M. Intraoperative ticagrelor removal via hemoadsorption during on-pump coronary artery bypass grafting. JTCVS OPEN 2023; 15:190-196. [PMID: 37808047 PMCID: PMC10556833 DOI: 10.1016/j.xjon.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/04/2023] [Accepted: 04/07/2023] [Indexed: 10/10/2023]
Abstract
Objectives Patients on ticagrelor undergoing urgent cardiac surgery are at high risk for perioperative bleeding complications. We sought to determine whether intraoperative hemoadsorption could remove ticagrelor and lower circulating drug concentrations. Methods The hemoadsorption device was incorporated in the cardiopulmonary bypass (CPB) circuit and remained active for the duration of the pump run. Blood samples were collected before and after CPB. The main objective of the current analysis was to compare mean total plasma ticagrelor levels (ng/mL) at baseline with ticagrelor levels obtained at the end of CPB. Plasma ticagrelor levels were measured at a certified outside laboratory (LabConnect). Data are presented as mean ± standard deviation. Results A total of 11 patients undergoing urgent coronary artery bypass grafting at 3 institutions were included (mean age, 67.9 ± 9.9 years; 91% male; mean European System for Cardiac Operative Risk Evaluation II of 3.0 ± 3.3%; range, 0.7%-12.4%). Mean intraoperative hemoadsorption duration was 97.1 ± 43.4 minutes with a mean flow rate through the device of 422.9 ± 40.3 mL/min. Mean ticagrelor levels pre-CPB were 103.5 ± 63.8 ng/mL compared with mean post-CPB levels of 34.0 ± 17.5 ng/mL, representing a significant 67.1% reduction (P < .001). Intraoperative integration of the device was simple and safe without any device-related adverse events reported. Conclusions This is the first in vivo report demonstrating that intraoperative hemoadsorption can efficiently remove ticagrelor and significantly reduce circulating drug levels. Whether active ticagrelor removal can reduce serious perioperative bleeding in patients undergoing urgent cardiac surgery is currently being evaluated in the double-blinded, randomized Safe and Timely Antithrombotic Removal-Ticagrelor (STAR-T) trial.
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Affiliation(s)
- Kambiz Hassan
- Department of Cardiac Surgery, Asklepios Klinik St Georg, Hamburg, Germany
| | - Stephan Geidel
- Department of Cardiac Surgery, Asklepios Klinik St Georg, Hamburg, Germany
| | - Vipin Zamvar
- Department of Cardiac Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Kenichi Tanaka
- Department of Anesthesiology, Cardiothoracic Division, University of Maryland School of Medicine, Baltimore, Md
| | - Zelka Knezevic-Woods
- Department of Anaesthetics, Aberdeen Royal Infirmary, Aberdeen, Scotland, United Kingdom
| | - Daniel Wendt
- University Hospital Essen, Essen Medical School, Essen, Germany
- CytoSorbents Inc, Princeton, NJ
| | | | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Michael Schmoeckel
- Department of Cardiac Surgery, Asklepios Klinik St Georg, Hamburg, Germany
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8
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Hemoadsorption in Complex Cardiac Surgery-A Single Center Experience. J Clin Med 2022; 11:jcm11237005. [PMID: 36498579 PMCID: PMC9735704 DOI: 10.3390/jcm11237005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/09/2022] [Accepted: 11/15/2022] [Indexed: 11/29/2022] Open
Abstract
(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.
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Mair H, Micka N, Vogt F, Rosenzweig D, Vogel F, Baumer B, Ulrich S, Lamm P. A New Apheresis Device for Antithrombotic Drug Removal during Off-Pump Coronary Artery Bypass Surgery. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1427. [PMID: 36295587 PMCID: PMC9609020 DOI: 10.3390/medicina58101427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 09/30/2022] [Accepted: 10/04/2022] [Indexed: 12/03/2022]
Abstract
Background and Objectives: The hemoadsorption device CytoSorb® (CytoSorbents Inc., Princeton, NJ, USA) has been shown to efficiently remove ticagrelor from whole blood in vitro. A promising clinical experience was made with the integration of the hemoadsorption cartridge on the cardiopulmonary bypass (CPB) circuit during cardiac surgery to reduce adverse events. Materials and Methods: In this report, we describe a novel approach using a new apheresis platform, PUR-01 (Nikkisio Co., Ltd., Tokyo, Japan), which was used as the extracorporeal circuit where CytoSorb® could be installed for the removal of ticagrelor during off-pump coronary artery bypass (OPCAB) procedures. Results: In a 74-year-old male (index case) with coronary artery disease and dual antiplatelet therapy, hemoadsorption was initiated with a skin incision for OPCAB surgery and was continued for 221 min to eliminate ticagrelor. The blood volume that had circulated through the CytoSorb® was 39.04 L in total. Thus far, this treatment strategy has been used in four cases with CHD and DAPT who needed OPCAB surgery. The intraoperative and postoperative courses were uneventful in all patients. No device-related adverse events occurred. Conclusions: The combination of the PUR-01 apheresis pump and hemoadsorption with the CytoSorb® column during OPCAB procedures appears to be safe and effective in eliminating antiplatelet drugs.
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Affiliation(s)
- Helmut Mair
- Department of Cardiac Surgery, Artemed Klinikum München Süd, 81379 Munich, Germany
| | - Norman Micka
- Department of Cardiac Surgery, Artemed Klinikum München Süd, 81379 Munich, Germany
| | - Ferdinand Vogt
- Department of Cardiac Surgery, Artemed Klinikum München Süd, 81379 Munich, Germany
- Department of Cardiac Surgery, Paracelsus Medical University, 40791 Nuremberg, Germany
| | - Dow Rosenzweig
- Department of Cardiac Surgery, Artemed Klinikum München Süd, 81379 Munich, Germany
| | - Frank Vogel
- Department of Anesthesiology, Artemed Klinikum München Süd, 81379 Munich, Germany
| | - Benedikt Baumer
- Department of Cardiac Surgery, Artemed Klinikum München Süd, 81379 Munich, Germany
| | - Stephanie Ulrich
- Department of Cardiology, Benedictus Krankenhaus Tutzing, 82327 Tutzing, Germany
| | - Peter Lamm
- Department of Cardiac Surgery, Artemed Klinikum München Süd, 81379 Munich, Germany
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Nierhaus A, Morales J, Wendt D, Scheier J, Gutzler D, Jarczak D, Born F, Hagl C, Deliargyris E, Mehta Y. Comparison of the CytoSorb ® 300 mL and Jafron HA380 hemoadsorption devices: an in vitro study. MINIM INVASIV THER 2022; 31:1058-1065. [PMID: 35913784 DOI: 10.1080/13645706.2022.2104617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION We performed an analysis of two blood purification systems to determine their performance for removing interleukins (ILs)-6 and 10, tumor necrosis factor (TNF)-α and monocyte chemoattractant protein (MCP)-1 from blood. MATERIAL AND METHODS An in vitro hemoperfusion blood recirculation circuit was used to compare the CytoSorb® 300 mL (CytoSorbents Inc., Princeton, NJ) and Jafron HA 380 (Jafron Biomedical Co., Ltd., Zhuhai City, China) devices. The removal of purified recombinant human IL-6, IL-10, TNFα and MCP-1 by the adsorbers was compared at various timepoints. Three runs were completed and removal was evaluated as the mean area under the curve (AUC). RESULTS Both devices showed effective removal of the tested cytokines. IL-6, IL-10, TNFα and MCP-1 were removed faster and to a higher extent by the CytoSorb® 300 mL device. At maximal time of 12 h, overall removal according to AUC of remaining concentrations was significantly lower with CytoSorb® 300 mL compared with HA 380 (IL-6: 1075.5 ± 665.9 vs. 4345.1 ± 1499.3 (p = 0.01), IL-10: 5065.7 ± 882.5 vs. 11,939.7 ± 4523.1 (p = 0.03), TNF-α: 6519.9 ± 997.6 vs. 10,303.7 ± 2347.0 (p = 0.03) and MCP-1: 278.9 ± 40.7 vs. 607.3 ± 84.4 (p = 0.001)). CONCLUSIONS Both the CytoSorb® and the Jafron HA 380 devices are capable of removing cytokines from blood in a benchtop model. The CytoSorb® 300 device was significantly more efficient achieving the bulk of the removal in the first 120 min.
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Affiliation(s)
- Axel Nierhaus
- Clinic for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg, Hamburg, Germany.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Daniel Wendt
- CytoSorbents, Princeton, NJ, USA.,Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, Essen, Germany
| | | | | | - Dominik Jarczak
- Clinic for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg, Hamburg, Germany.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Frank Born
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | | | - Yatin Mehta
- Medanta Institute of Critical Care and Anesthesiology, Gurgaon, India
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