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Pausch J, Mersmann J, Bhadra OD, Barten MJ, Alassar YA, Schulte-Uentrop L, Reichenspurner H, Bernhardt AM. Preliminary Experience of Extracorporeal Cytokine Hemoadsorption during Left Ventricular Assist Device Implantation in Cardiogenic Shock Patients. Thorac Cardiovasc Surg 2024; 72:266-272. [PMID: 36216331 DOI: 10.1055/s-0042-1757300] [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: 10/17/2022]
Abstract
BACKGROUND Systemic inflammation due to cardiogenic shock is associated with vasoplegia leading to organ hypoperfusion, right heart failure, and poor clinical outcome. Extracorporeal cytokine hemoadsorption emerged to attenuate excessive levels of inflammatory cytokines, potentially improving patient outcomes. Nevertheless, its prognostic impact during high-risk left ventricular assist device (LVAD) implantation remains unknown. METHODS In total, 40 consecutive patients with advanced heart failure underwent continuous-flow LVAD implantation at our institution between 2018 and 2020. Out of 25 high-risk patients in cardiogenic shock (Interagency Registry for Mechanically Assisted Circulatory Support profile 1 and 2), 9 patients (CytoSorb group) underwent LVAD implantation with and 16 patients (control group) without simultaneous cytokine hemoadsorption during cardiopulmonary bypass. Besides preoperative patient characteristics, postoperative lactate clearance, vasopressor administration and mean arterial pressure, perioperative complication, and 30-day mortality rates were retrospectively analyzed. RESULTS Apart from an increased rate of reoperations within the CytoSorb group, baseline characteristics including the severity of ventricular dysfunction and consecutive signs of end-organ failure were similar in both groups. Preoperative short-term mechanical circulatory support bridging was comparable (66.7 vs. 75%; p = 0.66) prior to LVAD implantation. Procedural characteristics including intraoperative volume management and postoperative vasopressor administration were similar in both groups. There was no difference regarding postoperative lactate clearance, although postoperative mean arterial pressure was significantly higher in the control group (71.3 vs. 57.4 mm Hg; p < 0.01). Furthermore, the 30-day mortality rate was significantly higher in the CytoSorb group (33.3 vs. 0.0%; p = 0.01). CONCLUSION Extracorporeal cytokine hemoadsorption during high-risk LVAD implantation was not associated with a decrease of postoperative vasopressor support, improved hemodynamics, or an accelerated lactate clearance.
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Affiliation(s)
- Jonas Pausch
- Univeristy Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Mersmann
- Univeristy Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver D Bhadra
- Univeristy Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus J Barten
- Univeristy Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yousuf Al Alassar
- Univeristy Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Leonie Schulte-Uentrop
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Reichenspurner
- Univeristy Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander M Bernhardt
- Univeristy Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Matejic-Spasic M, Lindstedt S, Lebreton G, Dzemali O, Suwalski P, Folliguet T, Geidel S, Klautz RJM, Baufreton C, Livi U, Gunaydin S, Deliargyris EN, Wendt D, Thielmann M. The role of hemoadsorption in cardiac surgery - a systematic review. BMC Cardiovasc Disord 2024; 24:258. [PMID: 38762715 PMCID: PMC11102180 DOI: 10.1186/s12872-024-03938-4] [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: 02/05/2024] [Accepted: 05/13/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND Extracorporeal blood purification has been widely used in intensive care medicine, nephrology, toxicology, and other fields. During the last decade, with the emergence of new adsorptive blood purification devices, hemoadsorption has been increasingly applied during CPB in cardiac surgery, for patients at different inflammatory risks, or for postoperative complications. Clinical evidence so far has not provided definite answers concerning this adjunctive treatment. The current systematic review aimed to critically assess the role of perioperative hemoadsorption in cardiac surgery, by summarizing the current knowledge in this clinical setting. METHODS A literature search of PubMed, Cochrane library, and the database provided by CytoSorbents was conducted on June 1st, 2023. The search terms were chosen by applying neutral search keywords to perform a non-biased systematic search, including language variations of terms "cardiac surgery" and "hemoadsorption". The screening and selection process followed scientific principles (PRISMA statement). Abstracts were considered for inclusion if they were written in English and published within the last ten years. Publications were eligible for assessment if reporting on original data from any type of study (excluding case reports) in which a hemoadsorption device was investigated during or after cardiac surgery. Results were summarized according to sub-fields and presented in a tabular view. RESULTS The search resulted in 29 publications with a total of 1,057 patients who were treated with hemoadsorption and 988 control patients. Articles were grouped and descriptively analyzed due to the remarkable variability in study designs, however, all reported exclusively on CytoSorb® therapy. A total of 62% (18/29) of the included articles reported on safety and no unanticipated adverse events have been observed. The most frequently reported clinical outcome associated with hemoadsorption was reduced vasopressor demand resulting in better hemodynamic stability. CONCLUSIONS The role of hemoadsorption in cardiac surgery seems to be justified in selected high-risk cases in infective endocarditis, aortic surgery, heart transplantation, and emergency surgery in patients under antithrombotic therapy, as well as in those who develop a dysregulated inflammatory response, vasoplegia, or septic shock postoperatively. Future large randomized controlled trials are needed to better define proper patient selection, dosing, and timing of the therapy.
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Affiliation(s)
| | - Sandra Lindstedt
- Department of Cardiothoracic Surgery and Transplantation, Skane University Hospital, Lund, Sweden
| | - Guillaume Lebreton
- Thoracic and Cardiovascular Surgery Department, Pitié-Salpêtrière University Hospital, Paris, France
| | - Omer Dzemali
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, City Hospital Triemli, Zurich, Switzerland
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
| | | | - Stephan Geidel
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Robert J M Klautz
- Department of Cardio-Thoracic Surgery, University Medical Center, Leiden, The Netherlands
| | - Christophe Baufreton
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France
| | - Ugolino Livi
- Department of Cardiothoracic Surgery, University Hospital, Udine, Italy
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital Campus, Ankara, Turkey
| | | | - Daniel Wendt
- CytoSorbents Europe GmbH, Berlin, Germany
- Department of Thoracic- and Cardiovascular Surgery, Westgerman Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
| | - Matthias Thielmann
- Department of Thoracic- and Cardiovascular Surgery, Westgerman Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
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3
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Gong A, Li Y, Yang M, Wang S, Su B. A Contemporary Review of the Use of Extracorporeal CytoSorb ® Hemoadsorption Therapy in Patients with Infective Endocarditis. J Clin Med 2024; 13:763. [PMID: 38337456 PMCID: PMC10856698 DOI: 10.3390/jcm13030763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/17/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
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.
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Affiliation(s)
- Anan Gong
- Department of Nephrology, Kidney Research Institute, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China; (A.G.); (S.W.)
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Yupei Li
- Department of Nephrology, Kidney Research Institute, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China; (A.G.); (S.W.)
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Mei Yang
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu 610041, China;
- Department of Nephrology, The First People’s Hospital of Shuangliu District, Chengdu 610200, China
| | - Shujing Wang
- Department of Nephrology, Kidney Research Institute, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China; (A.G.); (S.W.)
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Baihai Su
- Department of Nephrology, Kidney Research Institute, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China; (A.G.); (S.W.)
- West China School of Medicine, Sichuan University, Chengdu 610041, China
- Med+ Biomaterial Institute of West China Hospital/West China School of Medicine, Sichuan University, Chengdu 610041, China
- Med-X Center for Materials, Sichuan University, Chengdu 610041, China
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4
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Caldonazo T, Kirov H, Doenst T, Tasoudis P, Moschovas A, Faerber G, Treml RE, Sá MP, Mukharyamov M, Diab M. Outcomes of Concomitant Coronary Artery Bypass Grafting in Patients With Infective Endocarditis: A Systematic Review and Meta-Analysis. Am J Cardiol 2023; 205:354-359. [PMID: 37639761 DOI: 10.1016/j.amjcard.2023.07.164] [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: 05/24/2023] [Revised: 07/20/2023] [Accepted: 07/30/2023] [Indexed: 08/31/2023]
Abstract
It is current practice to perform concomitant coronary artery bypass grafting (CABG) in patients with infective endocarditis who have relevant coronary artery disease. However, CABG may add complexity to the operation. We performed a systematic review and a meta-analysis of studies that presented outcomes from patients who underwent valve surgery because of infective endocarditis with or without concomitant CABG. Three databases were assessed. Perioperative mortality was the primary outcome. Long-term mortality and postoperative stroke were the secondary outcomes. Inverse variance method and random model were performed. Five studies with a total of 5,408 patients were included. Mean follow-up was 8.2 years. Just 1 study addressed exclusively patients with documented coronary artery disease. Perioperative mortality did not differ between patients with or without concomitant CABG (odds ratio 1.53, 95% confidence interval 0.52 to 4.48, p = 0.44). Long-term mortality did not differ between patients who received and those who did not receive concomitant CABG (odds ratio 1.79, confidence interval 0.88 to 3.65, p = 0.11). Only 1 study from a multicenter registry reported data on the occurrence of postoperative stroke, which demonstrated that its incidence after adjustment was 26% in patients with concomitant CABG versus 21% in patients without concomitant CABG (p = 0.003). The results suggest that in endocarditis patients, adding CABG to valve surgery does not affect perioperative or long-term mortality. Data available on the impact of concomitant CABG on neurologic outcomes are limited to a retrospective multicenter registry and suggest that concomitant CABG may be associated with higher postoperative stroke.
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Affiliation(s)
- Tulio Caldonazo
- Departments of Cardiothoracic Surgery, Friedrich-Schiller-University Jena, Jena, Germany
| | - Hristo Kirov
- Departments of Cardiothoracic Surgery, Friedrich-Schiller-University Jena, Jena, Germany
| | - Torsten Doenst
- Departments of Cardiothoracic Surgery, Friedrich-Schiller-University Jena, Jena, Germany
| | - Panagiotis Tasoudis
- Division of Cardiothoracic Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Alexandros Moschovas
- Department of Cardiothoracic Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Gloria Faerber
- Departments of Cardiothoracic Surgery, Friedrich-Schiller-University Jena, Jena, Germany
| | - Ricardo E Treml
- Departments of Anesthesiology and Intensive Care Medicine, Friedrich-Schiller-University Jena, Jena, Germany
| | - Michel Pompeu Sá
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Murat Mukharyamov
- Departments of Cardiothoracic Surgery, Friedrich-Schiller-University Jena, Jena, Germany
| | - Mahmoud Diab
- Departments of Cardiothoracic Surgery, Friedrich-Schiller-University Jena, Jena, Germany; Department of Cardiac Surgery, Herz- und Kreislaufzentrum, Rotenburg an der Fulda, Germany.
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5
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Hermanns H, Alberts T, Preckel B, Strypet M, Eberl S. Perioperative Complications in Infective Endocarditis. J Clin Med 2023; 12:5762. [PMID: 37685829 PMCID: PMC10488631 DOI: 10.3390/jcm12175762] [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: 08/04/2023] [Revised: 08/27/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
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.
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Affiliation(s)
| | - Tim Alberts
- Department of Anesthesiology, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (H.H.); (B.P.); (M.S.); (S.E.)
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6
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Habes QLM, Kant N, Beunders R, van Groenendael R, Gerretsen J, Kox M, Pickkers P. Relationships Between Systemic Inflammation, Intestinal Damage and Postoperative Organ Dysfunction in Adults Undergoing Low-Risk Cardiac Surgery. Heart Lung Circ 2023; 32:395-404. [PMID: 36621395 DOI: 10.1016/j.hlc.2022.12.006] [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: 04/22/2022] [Revised: 11/14/2022] [Accepted: 12/04/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Approximately half of patients who undergo cardiac surgery develop systemic inflammatory response syndrome. Extracorporeal circulation and intestinal injury may play a role in this inflammatory response, although their relative contributions remain elusive. Moreover, it is largely unknown to what extent these factors contribute to cardiac surgery-induced postoperative organ dysfunction. METHOD In this secondary analysis, we measured circulating levels of the intestinal damage marker intestinal fatty acid binding protein (I-FABP) and of the inflammatory cytokines tumour necrosis factor (TNF)-α, interleukin (IL)-6, IL-8, IL-10, IL-1RA, monocyte chemoattractant protein (MCP)-1, macrophage inflammatory protein (MIP)-1α, and MIP-1β in 180 patients undergoing on-pump cardiac surgery. The average Z-score of levels of the different cytokines was used as an integral measure of the cytokine response. Relationships between duration of extracorporeal circulation, extent of intestinal injury, inflammation, and postoperative organ dysfunction were explored. RESULTS Plasma I-FABP levels increased during surgery, with peak levels observed at the end of cardiopulmonary bypass (CPB). Except for TNF-α, the levels of all cytokines increased during surgery, with peak levels observed either 2 (MCP-1, MIP-1α, and MIP-1β), 4 (IL-6, IL-8, and IL-1RA) or 6 (IL-10) hours after the end of CPB. While the duration of CPB significantly correlated with cytokine Z-score (r=0.544, p<0.05), no relationship with I-FABP levels was found. Furthermore, no significant correlations between I-FABP and cytokine levels were observed. The duration of CPB correlated with a deterioration in postoperative kidney function (estimated glomerular filtration rate [eGFR]) and troponin levels. Cytokine Z-score was associated with postoperative troponin levels, fluid administration, inotropic score, pulmonary alveolar-arterial gradient on the first postoperative morning, and deterioration of kidney function (eGFR). I-FABP levels did not correlate with any of the cardiovascular, pulmonary, or renal parameters. CONCLUSIONS In patients undergoing low-risk cardiac surgery, the duration of CPB represents an important determinant of the systemic cytokine response, whereas both the CPB duration and the systemic inflammatory response contribute to subsequent organ dysfunction. Intestinal damage does not appear to play a relevant role in the postoperative inflammatory response and development of postoperative organ dysfunction in these patients.
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Affiliation(s)
- Quirine L M Habes
- Radboud University Medical Center, Department of Intensive Care, Nijmegen, The Netherlands
| | - Niels Kant
- Radboud University Medical Center, Department of Intensive Care, Nijmegen, The Netherlands
| | - Remi Beunders
- Radboud University Medical Center, Department of Intensive Care, Nijmegen, The Netherlands
| | - Roger van Groenendael
- Radboud University Medical Center, Department of Intensive Care, Nijmegen, The Netherlands
| | - Jelle Gerretsen
- Radboud University Medical Center, Department of Intensive Care, Nijmegen, The Netherlands
| | - Matthijs Kox
- Radboud University Medical Center, Department of Intensive Care, Nijmegen, The Netherlands.
| | - Peter Pickkers
- Radboud University Medical Center, Department of Intensive Care, Nijmegen, The Netherlands
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Haidari Z, Leiler S, Mamdooh H, Fittkau M, Boss K, Tyczynski B, Thielmann M, Bagaev E, El Gabry M, Wendt D, Kribben A, Bertsch T, Ruhparwar A, Fischlein T, Kalisnik JM. Effect of intraoperative haemoadsorption therapy on cardiac surgery for active infective endocarditis with confirmed Staphylococcus aureus bacteraemia. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 36:7008331. [PMID: 36802263 PMCID: PMC9931064 DOI: 10.1093/icvts/ivad010] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Zaki Haidari
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Spela Leiler
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Hazem Mamdooh
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Matthias Fittkau
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Kristina Boss
- Department of Nephrology, University Hospital Essen, Essen, Germany
| | | | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Erik Bagaev
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Mohamed El Gabry
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany,Cytosorbents Inc., Princeton, NJ, USA
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, Essen, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Theodor Fischlein
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Jurij Matija Kalisnik
- Corresponding author. Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany. Tel: +49-911-398-5441; fax: +49-911-398-5443; e-mail: (J.M. Kalisnik)
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Sponholz C, Sommerfeld O, Moehl C, Lehmann T, Franz M, Bauer M, Doenst T, Faerber G, Diab M. Intraoperative Cell Savage, Infection and Organ Failure in Infective Endocarditis Patients-A Retrospective Single Center Evaluation. J Clin Med 2023; 12:jcm12010382. [PMID: 36615185 PMCID: PMC9821775 DOI: 10.3390/jcm12010382] [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: 11/30/2022] [Revised: 12/27/2022] [Accepted: 12/29/2022] [Indexed: 01/05/2023] Open
Abstract
Surgery is indicated in about 50% of infective endocarditis patients, and bleeding or the transfusion of blood a common finding. The intraoperative use of cell salvage may reduce the perioperative transfusion requirement, but its use is limited in the underlying disease. In this retrospective study, we therefore evaluated n = 335 patients fulfilling the modified Duke criteria for infective endocarditis characterized by the use of intraoperative cell salvage with autologous blood retransfusion. Inflammation markers and organ dysfunction, including catecholamine dependency, were evaluated by using linear regression analysis. Between 2015 and 2020, 335 patients underwent surgery for left-sided heart valve endocarditis. Intraoperative cell salvage was used in 40.3% of the cases, especially in complex scenarios and reoperation. Intraoperative cell salvage significantly altered the white blood cell count after surgery. On average, leucocytes were 3.0 Gpt/L higher in patients with intraoperative cell salvage compared to patients without after adjustment for confounders (95% CI: 0.39-5.54). Although the difference in WBC was statistically significant, i.e., higher in the ICS group compared to the no-ICS group, this difference may be clinically unimportant. Organ dysfunction, including hemodynamic instability and lactate values, were comparable between groups. In conclusion, intraoperative cell salvage enhanced the re-transfusion of autologous blood, with minor effects on the postoperative course of inflammatory markers, but was not associated with increased hemodynamic instability or organ dysfunction in general. The restriction of intraoperative cell salvage in surgery for infective endocarditis should be re-evaluated, and more prospective data in this topic are needed.
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Affiliation(s)
- Christoph Sponholz
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
- Correspondence: ; Tel.: +49-(36)-419322225
| | - Oliver Sommerfeld
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - Caroline Moehl
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - Thomas Lehmann
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - Marcus Franz
- Department of Internal Medicine I, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - Michael Bauer
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - Torsten Doenst
- Clinic for Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - Gloria Faerber
- Clinic for Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - Mahmoud Diab
- Clinic for Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
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9
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Diab M, Faerber G, Doenst T. Response by Diab et al to Letter Regarding Article, "Cytokine Hemoadsorption During Cardiac Surgery Versus Standard Surgical Care for Infective Endocarditis (REMOVE): Results From a Multicenter Randomized Controlled Trial". Circulation 2022; 146:e140. [PMID: 36067279 DOI: 10.1161/circulationaha.122.061219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Mahmoud Diab
- Department of Cardiothoracic Surgery (M.D., G.F., T.D.), Jena University Hospital-Friedrich Schiller University of Jena, Germany.,Center for Sepsis Control and Care (M.D.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
| | - Gloria Faerber
- Department of Cardiothoracic Surgery (M.D., G.F., T.D.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery (M.D., G.F., T.D.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
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Haidari Z, Demircioglu E, Boss K, Tyczynski B, Thielmann M, Schmack B, Kribben A, Weymann A, El Gabry M, Ruhparwar A, Wendt D. Intraoperative hemoadsorption in high-risk patients with infective endocarditis. PLoS One 2022; 17:e0266820. [PMID: 35900987 PMCID: PMC9333242 DOI: 10.1371/journal.pone.0266820] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 03/29/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Postoperative sepsis is an important cause of morbidity and mortality in patients with infective endocarditis undergoing surgical therapy. Blood purification using hemoadsorption therapy shows promising results in the treatment of sepsis. In this study, the clinical effects of intraoperative hemoadsorption in high-risk patients with infective endocarditis were evaluated.
Methods
Eligible candidates were high-risk patients with infective endocarditis undergoing cardiac surgery between January 2014 and December 2019. Patients with intraoperative hemoadsorption (hemoadsorption) were compared to patients without hemoadsorption (control). The endpoints were the incidence of postoperative sepsis, sepsis-associated death and in-hospital mortality. Additionally, postoperative vasopressor need, systemic vascular resistance indices and Sequential Organ Failure Assessment (SOFA) scores were compared.
Results
After propensity score matching, 70 high-risk patients were included. Postoperative sepsis occurred in 14 patients in the hemoadsorption group and in 16 patients in the control group, p = 0.629. Four patients died due to postoperative sepsis in the hemoadsorption group, while 11 postoperative septic patients died in the control group, p = 0.041. In-hospital mortality was 34% in the hemoadsorption group versus 43% in the control group, p = 0.461. On ICU-admission and the first postoperative day, the cumulative vasopressor need was 0.17 versus 0.25 μg/kgBW/min, p = 0.123 and 0.06 versus 0.11 μg/kgBW/min, p = 0.037, and the systemic vascular resistance index was 1448 versus 941 dyn·s·cm-5, p = 0.013 and 1156 versus 858 dyn·s·cm-5, p = 0.110 in the hemoadsorption versus control group, respectively. Postoperative course of SOFA score normalized significantly (p = 0.01) faster in the hemoadsorption group.
Conclusions
In high-risk cardiac surgical patients with infective endocarditis, intraoperative hemoadsorption significantly reduced sepsis-associated mortality. Furthermore, intraoperative hemoadsorption resulted in significant faster recovery of hemodynamics and organ function. Intraoperative hemoadsorption seems to attenuate the severity of postoperative sepsis.
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Affiliation(s)
- Zaki Haidari
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, Essen, Germany
- * E-mail:
| | - Ender Demircioglu
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, Essen, Germany
| | - Kristina Boss
- Department of Nephrology, University Hospital Essen, Essen, Germany
| | | | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, Essen, Germany
| | - Bastian Schmack
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, Essen, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, Essen, Germany
| | - Mohamed El Gabry
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, Essen, Germany
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, Essen, Germany
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11
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Kalisnik JM, Leiler S, Mamdooh H, Zibert J, Bertsch T, Vogt FA, Bagaev E, Fittkau M, Fischlein T. Single-Centre Retrospective Evaluation of Intraoperative Hemoadsorption in Left-Sided Acute Infective Endocarditis. J Clin Med 2022; 11:jcm11143954. [PMID: 35887719 PMCID: PMC9317304 DOI: 10.3390/jcm11143954] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/29/2022] [Accepted: 06/30/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Cardiac surgery in patients with infective endocarditis (IE) is still associated with high mortality and morbidity; an already present inflammation might further be aggravated due to a cardiopulmonary bypass-induced dysregulated immune response. Intraoperative hemoadsorption therapy may attenuate this septic response. Our objective was therefore to assess the efficacy of intraoperative hemoadsorption in active left-sided native- and prosthetic infective endocarditis. Methods: Consecutive high-risk patients with active left-sided infective endocarditis were enrolled between January 2015 and April 2021. Patients with intraoperative hemoadsorption (Cytosorbents, Princeton, NJ, USA) were compared to patients without hemoadsorption (control). Endpoints were the incidence of postoperative sepsis, sepsis-associated death and in-hospital mortality. Predictors for sepsis-associated mortality and in-hospital mortality were analysed by multivariable logistic regression. Results: A total of 202 patients were included, 135 with active left-sided native and 67 with prosthetic valve infective endocarditis. Ninety-nine patients received intraoperative hemoadsorption and 103 patients did not. Ninety-nine propensity-matched pairs were selected for final analyses. Postoperative sepsis and sepsis-related mortality was reduced in the hemoadsorption group (22.2% vs. 39.4%, p = 0.014 and 8.1% vs. 22.2%, p = 0.01, respectively). In-hospital mortality tended to be lower in the hemoadsorption group (14.1% vs. 26.3%, p = 0.052). Key predictors for sepsis-associated mortality and in-hospital mortality were preoperative inotropic support, lactate-levels 24 h after surgery, C-reactive protein levels on postoperative day 1, chest tube output, cumulative inotropes and white blood cell counts on postoperative day 2, and new onset of dialysis. Multivariate regression analysis revealed intraoperative hemoadsorption to be associated with lower sepsis-associated (OR 0.09, 95% CI 0.013–0.62, p = 0.014) as well as in-hospital mortality (OR 0.069, 95% CI 0.006–0.795, p = 0.032). Conclusions: Intraoperative hemoadsorption holds promise to reduce sepsis and sepsis-associated mortality after cardiac surgery for active left-sided native and prosthetic valve infective endocarditis.
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Affiliation(s)
- Jurij Matija Kalisnik
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (S.L.); (H.M.); (E.B.); (M.F.); (T.F.)
- Medical School, University of Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence: ; Tel.: +49-0-911-398-5441
| | - Spela Leiler
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (S.L.); (H.M.); (E.B.); (M.F.); (T.F.)
| | - Hazem Mamdooh
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (S.L.); (H.M.); (E.B.); (M.F.); (T.F.)
| | - Janez Zibert
- Department of Biostatistics, Faculty of Health Sciences, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Paracelsus Medical University, 90471 Nuremberg, Germany;
| | - Ferdinand Aurel Vogt
- Department of Cardiac Surgery, Artemed Clinic Munich-South, 81379 Munich, Germany;
| | - Erik Bagaev
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (S.L.); (H.M.); (E.B.); (M.F.); (T.F.)
| | - Matthias Fittkau
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (S.L.); (H.M.); (E.B.); (M.F.); (T.F.)
| | - Theodor Fischlein
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (S.L.); (H.M.); (E.B.); (M.F.); (T.F.)
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12
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Diab M, Lehmann T, Bothe W, Akhyari P, Platzer S, Wendt D, Deppe AC, Strauch J, Hagel S, Günther A, Faerber G, Sponholz C, Franz M, Scherag A, Velichkov I, Silaschi M, Fassl J, Hofmann B, Lehmann S, Schramm R, Fritz G, Szabo G, Wahlers T, Matschke K, Lichtenberg A, Pletz MW, Gummert JF, Beyersdorf F, Hagl C, Borger MA, Bauer M, Brunkhorst FM, Doenst T. Cytokine Hemoadsorption During Cardiac Surgery Versus Standard Surgical Care for Infective Endocarditis (REMOVE): Results From a Multicenter Randomized Controlled Trial. Circulation 2022; 145:959-968. [PMID: 35213213 DOI: 10.1161/circulationaha.121.056940] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Cardiac surgery often represents the only treatment option in patients with infective endocarditis (IE). However, IE surgery may lead to a sudden release of inflammatory mediators, which is associated with postoperative organ dysfunction. We investigated the effect of hemoadsorption during IE surgery on postoperative organ dysfunction. METHODS This multicenter, randomized, nonblinded, controlled trial assigned patients undergoing cardiac surgery for IE to hemoadsorption (integration of CytoSorb to cardiopulmonary bypass) or control. The primary outcome (change in sequential organ failure assessment score [ΔSOFA]) was defined as the difference between the mean total postoperative SOFA score, calculated maximally to the 9th postoperative day, and the basal SOFA score. The analysis was by modified intention to treat. A predefined intergroup comparison was performed using a linear mixed model for ΔSOFA including surgeon and baseline SOFA score as fixed effect covariates and with the surgical center as random effect. The SOFA score assesses dysfunction in 6 organ systems, each scored from 0 to 4. Higher scores indicate worsening dysfunction. Secondary outcomes were 30-day mortality, duration of mechanical ventilation, and vasopressor and renal replacement therapy. Cytokines were measured in the first 50 patients. RESULTS Between January 17, 2018, and January 31, 2020, a total of 288 patients were randomly assigned to hemoadsorption (n=142) or control (n=146). Four patients in the hemoadsorption and 2 in the control group were excluded because they did not undergo surgery. The primary outcome, ΔSOFA, did not differ between the hemoadsorption and the control group (1.79±3.75 and 1.93±3.53, respectively; 95% CI, -1.30 to 0.83; P=0.6766). Mortality at 30 days (21% hemoadsorption versus 22% control; P=0.782), duration of mechanical ventilation, and vasopressor and renal replacement therapy did not differ between groups. Levels of interleukin-1β and interleukin-18 at the end of integration of hemoadsorption to cardiopulmonary bypass were significantly lower in the hemoadsorption than in the control group. CONCLUSIONS This randomized trial failed to demonstrate a reduction in postoperative organ dysfunction through intraoperative hemoadsorption in patients undergoing cardiac surgery for IE. Although hemoadsorption reduced plasma cytokines at the end of cardiopulmonary bypass, there was no difference in any of the clinically relevant outcome measures. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03266302.
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Affiliation(s)
- Mahmoud Diab
- Department of Cardiothoracic Surgery (M.D., G. Faerber, I.V., T.D.), Jena University Hospital-Friedrich Schiller University of Jena, Germany.,Center for Sepsis Control and Care (M.D., T.L., S.P., A.S., M.B., F.M.B.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
| | - Thomas Lehmann
- Center for Sepsis Control and Care (M.D., T.L., S.P., A.S., M.B., F.M.B.), Jena University Hospital-Friedrich Schiller University of Jena, Germany.,Center for Clinical Studies (T.L., S.P., A.S., F.M.B.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
| | - Wolfgang Bothe
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany (W.B., F.B.)
| | - Payam Akhyari
- Department of Cardiothoracic Surgery, Heinrich-Heine-University Duesseldorf, Germany (P.A., A.L.)
| | - Stephanie Platzer
- Center for Sepsis Control and Care (M.D., T.L., S.P., A.S., M.B., F.M.B.), Jena University Hospital-Friedrich Schiller University of Jena, Germany.,Center for Clinical Studies (T.L., S.P., A.S., F.M.B.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Germany (D.W.)
| | - Antje-Christin Deppe
- Department of Cardiothoracic Surgery, Heart Center of the University of Cologne, Germany (A.-C.D., T.W.)
| | - Justus Strauch
- Department of Cardiac and Thoracic Surgery, Bergmannsheil University Hospitals, Bochum, Germany (J.S.)
| | - Stefan Hagel
- Institute for Infectious Diseases and Infection Control (S.H., M.W.P.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
| | - Albrecht Günther
- Department of Neurology (A.G.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
| | - Gloria Faerber
- Department of Cardiothoracic Surgery (M.D., G. Faerber, I.V., T.D.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
| | - Christoph Sponholz
- Department of Anesthesiology and Critical Care Medicine (C.S., M.B.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
| | - Marcus Franz
- Department of Internal Medicine I (M.F.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
| | - André Scherag
- Center for Sepsis Control and Care (M.D., T.L., S.P., A.S., M.B., F.M.B.), Jena University Hospital-Friedrich Schiller University of Jena, Germany.,Center for Clinical Studies (T.L., S.P., A.S., F.M.B.), Jena University Hospital-Friedrich Schiller University of Jena, Germany.,Institute of Medical Statistics, Computer and Data Sciences (A.S.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
| | - Ilia Velichkov
- Department of Cardiothoracic Surgery (M.D., G. Faerber, I.V., T.D.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
| | - Miriam Silaschi
- Clinic and Polyclinic for Cardiac Surgery, University Hospital Bonn, Germany (M.S.)
| | - Jens Fassl
- Institute for Cardiac Anesthesiology, Dresden Heart Center, University Hospital at the Technical University Dresden, Germany (J.F.)
| | - Britt Hofmann
- Department of Cardiac Surgery, Mid-German Heart Center, University Hospital Halle (Saale), Halle, Germany (B.H., G.S.)
| | - Sven Lehmann
- Department of Cardiac Surgery, Heart Center Leipzig, Germany (S.L., M.A.B.)
| | - Rene Schramm
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany (R.S., J.F.G.)
| | - Georg Fritz
- Department of Anesthesiology, Intensive Care and Pain Therapy, Heart Center Brandenburg, Immanuel Clinic Bernau, Germany (G. Fritz)
| | - Gabor Szabo
- Department of Cardiac Surgery, Mid-German Heart Center, University Hospital Halle (Saale), Halle, Germany (B.H., G.S.)
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center of the University of Cologne, Germany (A.-C.D., T.W.)
| | - Klaus Matschke
- Department of Cardiac Surgery, Heart Center Dresden, Germany (K.M.)
| | - Artur Lichtenberg
- Department of Cardiothoracic Surgery, Heinrich-Heine-University Duesseldorf, Germany (P.A., A.L.)
| | - Mathias W Pletz
- Institute for Infectious Diseases and Infection Control (S.H., M.W.P.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
| | - Jan F Gummert
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Bad Oeynhausen, Germany (R.S., J.F.G.)
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany (W.B., F.B.)
| | - Christian Hagl
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, Germany (C.H.).,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany (C.H.)
| | - Michael A Borger
- Department of Cardiac Surgery, Heart Center Leipzig, Germany (S.L., M.A.B.)
| | - Michael Bauer
- Center for Sepsis Control and Care (M.D., T.L., S.P., A.S., M.B., F.M.B.), Jena University Hospital-Friedrich Schiller University of Jena, Germany.,Department of Anesthesiology and Critical Care Medicine (C.S., M.B.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
| | - Frank M Brunkhorst
- Center for Sepsis Control and Care (M.D., T.L., S.P., A.S., M.B., F.M.B.), Jena University Hospital-Friedrich Schiller University of Jena, Germany.,Center for Clinical Studies (T.L., S.P., A.S., F.M.B.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery (M.D., G. Faerber, I.V., T.D.), Jena University Hospital-Friedrich Schiller University of Jena, Germany
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13
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Hillinger P, Mayr VD, Luger M, Tauber H, Luckner G, Morgenthaler NG, Dünser M, Jochberger S. The course of adrenomedullin and endothelin levels in patients with vasodilatory shock after cardiac surgery compared to patients after uncomplicated elective cardiac surgery. J Crit Care 2022; 69:154009. [PMID: 35183040 DOI: 10.1016/j.jcrc.2022.154009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE The aim of this study was to analyse the course of adrenomedullin (ADM) and endothelin-1 (ET-1) levels in patients with vasodilatory shock after cardiac surgery and to explore differences compared to patients after uncomplicated coronary artery bypass graft (CABG) surgery. ADM and ET-1 are involved in the vasomotor response during vasodilatory shock. MATERIALS AND METHODS We included 32 patients with vasodilatory shock (study group) and 10 patients after uncomplicated CABG surgery (control group). Daily measurements of MR-proADM and CT-proET-1 (stable surrogate markers for ADM and ET-1) were collected during the first 7 postoperative days. RESULTS MR-proADM and CT-proET-1 levels were significantly elevated in the study group when compared to the control group. In addition, the course of both biomarkers was significantly different in the study versus control group. Higher levels of both biomarkers were associated with organ dysfunction (higher maximum multiple organ dysfunction score, acute kidney injury). CONCLUSIONS Significantly higher levels of MR-proADM and CT-proET-1 and a different course of both biomarkers were observed in patients with vasodilatory shock after cardiac surgery and seemed to be associated with organ dysfunction.
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Affiliation(s)
- Petra Hillinger
- Department of Anaesthesia and Intensive Care Medicine, University Hospital Innsbruck, Innsbruck, Austria.
| | - Viktoria D Mayr
- Department of Anaesthesia, Landesklinik Hallein, Hallein, Austria
| | - Markus Luger
- Department of Anaesthesia and Intensive Care Medicine, University Hospital Innsbruck, Innsbruck, Austria
| | - Helmuth Tauber
- Department of Anaesthesia and Intensive Care Medicine, University Hospital Innsbruck, Innsbruck, Austria
| | - Günter Luckner
- Department of Anaesthesia and Intensive Care Medicine, University Hospital Innsbruck, Innsbruck, Austria
| | | | - Martin Dünser
- Department of Anaesthesia and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria
| | - Stefan Jochberger
- Department of Anaesthesia and Intensive Care Medicine, University Hospital Innsbruck, Innsbruck, Austria
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14
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Norouzi M, Nadjarzadeh A, Maleki M, Khayyatzadeh SS, Hosseini S, Yaseri M, Fattahi H. The effects of preoperative supplementation with a combination of beta-hydroxy-beta-methylbutyrate, arginine, and glutamine on inflammatory and hematological markers of patients with heart surgery: a randomized controlled trial. BMC Surg 2022; 22:51. [PMID: 35148750 PMCID: PMC8832784 DOI: 10.1186/s12893-022-01495-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/24/2022] [Indexed: 11/17/2022] Open
Abstract
Background Cardiac surgery is associated with a widespread inflammatory response, by an additional release of free radicals. Due to the importance of these patient’s nutritional status, the present study was designed to evaluate the effectiveness of supplementation with a combination of glutamine, β-hydroxy-β-methylbutyrate (HMB) and arginine in patients undergoing to the heart surgery. Methods The experiment was performed in 1 month (30 days) before cardiac surgery. patients were asked to take 2 sachets of Heallagen® (a combination of 7 g l-arginine, 7 g l-glutamine, and 1.5 g daily HMB) or placebo with identical appearance and taste (maltodextrin) with 120 cc of water. Clinical and biochemical factors were evaluated in the baseline and end of the study. Results Totally, 60 preoperative patients (30 interventions and 30 placeboes) with a mean age of 53.13 ± 14.35 years participated in the study. Subjects in Heallagen® group had a lower serum levels of interleukin-6 (P = 0.023), erythrocyte sedimentation rate (P < 0.01), high sensitivity C-reactive protein (P < 0.01), and lymphocyte number (P = 0.007) compared to the placebo, at end of the study. Conclusion In the patients undergoing heart surgery, Heallagen® significantly improved some of the inflammatory factors and hematological parameters. These results need to be confirmed in a larger trial. Trial registration: The protocol of the study was registered in the IRCT.ir with registration no. IRCT20120913010826N31 at 13/10/2020.
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Affiliation(s)
- Mona Norouzi
- Department of Nutrition, International Campus of Shahid Sadoughi University of Medical Science, Yazd, Iran.,Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Azadeh Nadjarzadeh
- Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran. .,Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
| | - Majid Maleki
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Sayyed Saeid Khayyatzadeh
- Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.,Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Saeid Hosseini
- Heart Valve Disease Research Center, Shahid Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mehdi Yaseri
- Department of Epidemiology and Biostatistics, Tehran University of Medical Science, Tehran, Iran
| | - Hamed Fattahi
- Cardiovascular Medical and Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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15
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Abstract
The management of infective endocarditis is complex and inherently requires multidisciplinary cooperation. About half of all patients diagnosed with infective endocarditis will meet the criteria to undergo cardiac surgery, which regularly takes place in urgent or emergency settings. The pathophysiology and clinical presentation of infective endocarditis make it a unique disorder within cardiac surgery that warrants a thorough understanding of specific characteristics in the perioperative period. This includes, among others, echocardiography, coagulation, bleeding management, or treatment of organ dysfunction. In this narrative review article, the authors summarize the current knowledge on infective endocarditis relevant for the clinical anesthesiologist in perioperative management of respective patients. Furthermore, the authors advocate for the anesthesiologist to become a structural member of the endocarditis team.
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16
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Diab M, Lehmann T, Weber C, Petrov G, Luehr M, Akhyari P, Tugtekin SM, Schulze PC, Franz M, Misfeld M, Borger MA, Matschke K, Wahlers T, Lichtenberg A, Hagl C, Doenst T. Role of Concomitant Coronary Artery Bypass Grafting in Valve Surgery for Infective Endocarditis. J Clin Med 2021; 10:jcm10132867. [PMID: 34203358 PMCID: PMC8267636 DOI: 10.3390/jcm10132867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 05/31/2021] [Accepted: 06/24/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND It is current practice to perform concomitant coronary artery bypass grafting (CABG) in patients with infective endocarditis (IE) who have relevant coronary artery disease (CAD). However, CABG may add complexity to the operation. We aimed to investigate the impact of concomitant CABG on perioperative outcomes in patients undergoing surgery for IE. METHODS We retrospectively used data of surgically treated IE patients between 1994 and 2018 in six German cardiac surgery centers. We performed inverse probability weighting (IPW), multivariable adjustment, chi-square analysis, and Kaplan-Meier survival estimates. RESULTS CAD was reported in 1242/4917 (25%) patients. Among them, 527 received concomitant CABG. After adjustment for basal characteristics between CABG and no-CABG patients using IPW, concomitant CABG was associated with higher postoperative stroke (26% vs. 21%, p = 0.003) and a trend towards higher postoperative hemodialysis (29% vs. 25%, p = 0.052). Thirty-day mortality was similar in both groups (24% vs. 23%, p = 0.370). Multivariate Cox regression analysis after IPW showed that CABG was not associated with better long-term survival (HR: 1.00, 95% CI: 0.82-1.23, p = 0.998). CONCLUSION In endocarditis patients with CAD, adding CABG to valve surgery may be associated with a higher likelihood of postoperative stroke without adding long-term survival benefits. Therefore, in the absence of critical CAD, concomitant CABG may be omitted without impacting outcome. The results are limited due to a lack of data on the severity of CAD, and therefore there is a need for a randomized trial.
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Affiliation(s)
- Mahmoud Diab
- Department of Cardiothoracic Surgery, Jena University Hospital-Friedrich Schiller University of Jena, 07747 Jena, Germany;
| | - Thomas Lehmann
- Center of Clinical Studies, Jena University Hospital-Friedrich Schiller University of Jena, 07747 Jena, Germany;
| | - Carolyn Weber
- Department of Cardiothoracic Surgery, Heart Center of the University of Cologne, 50937 Colonge, Germany; (C.W.); (M.L.); (T.W.)
| | - Georgi Petrov
- Department of Cardiothoracic Surgery, Heinrich-Heine-University Duesseldorf, 40225 Duesseldof, Germany; (G.P.); (P.A.); (A.L.)
| | - Maximilian Luehr
- Department of Cardiothoracic Surgery, Heart Center of the University of Cologne, 50937 Colonge, Germany; (C.W.); (M.L.); (T.W.)
| | - Payam Akhyari
- Department of Cardiothoracic Surgery, Heinrich-Heine-University Duesseldorf, 40225 Duesseldof, Germany; (G.P.); (P.A.); (A.L.)
| | - Sems-Malte Tugtekin
- Department of Cardiac Surgery, Heart Center Dresden, 01307 Dresden, Germany; (S.-M.T.); (K.M.)
| | - P. Christian Schulze
- Department of Internal Medicine I, Jena University Hospital-Friedrich Schiller University of Jena, 07747 Jena, Germany; (P.C.S.); (M.F.)
| | - Marcus Franz
- Department of Internal Medicine I, Jena University Hospital-Friedrich Schiller University of Jena, 07747 Jena, Germany; (P.C.S.); (M.F.)
| | - Martin Misfeld
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney 2050, Australia;
- Department of Cardiac Surgery, Heart Center Leipzig, 04289 Leipzig, Germany;
| | - Michael A. Borger
- Department of Cardiac Surgery, Heart Center Leipzig, 04289 Leipzig, Germany;
| | - Klaus Matschke
- Department of Cardiac Surgery, Heart Center Dresden, 01307 Dresden, Germany; (S.-M.T.); (K.M.)
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center of the University of Cologne, 50937 Colonge, Germany; (C.W.); (M.L.); (T.W.)
| | - Artur Lichtenberg
- Department of Cardiothoracic Surgery, Heinrich-Heine-University Duesseldorf, 40225 Duesseldof, Germany; (G.P.); (P.A.); (A.L.)
| | - Christian Hagl
- Department of Cardiac Surgery, Ludwig Maximilian University Munich, 80539 Munich, Germany;
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital-Friedrich Schiller University of Jena, 07747 Jena, Germany;
- Correspondence:
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17
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Asch S, Kaufmann TP, Walter M, Leistner M, Danner BC, Perl T, Kutschka I, Niehaus H. The effect of perioperative hemadsorption in patients operated for acute infective endocarditis-A randomized controlled study. Artif Organs 2021; 45:1328-1337. [PMID: 34152632 DOI: 10.1111/aor.14019] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/27/2021] [Accepted: 06/18/2021] [Indexed: 12/14/2022]
Abstract
Patients operated for infective endocarditis (IE) are at high risk of developing an excessive systemic hyperinflammatory state, resulting in systemic inflammatory response syndrome and septic shock. Hemoadsorption (HA) by cytokine adsorbers has been successfully applied to remove inflammatory mediators. This randomized controlled trial investigates the effect of perioperative HA therapy on inflammatory parameters and hemodynamic status in patients operated for IE. A total of 20 patients were randomly assigned to either HA therapy or the control group. HA therapy was initiated intraoperatively and continued for 24 hours postoperatively. Cytokine levels (IL-6, IL-1b, TNF-α), leukocytes, C-reactive protein (CRP), and Procalcitonin (PCT) as well as catecholamine support, and volume requirement were compared between both groups. Operative procedures included aortic (n = 7), mitral (n = 6), and multiple valve surgery (n = 7). All patients survived to discharge. No significant differences concerning median cytokine levels (IL-6 and TNF-α) were observed between both groups. CRP and PCT baseline levels were significantly higher in the HA group (59.5 vs. 26.3 mg/dL, P = .029 and 0.17 vs. 0.05 µg/L, P = .015) equalizing after surgery. Patients in the HA group required significantly higher doses of vasopressors (0.093 vs. 0.025 µg/kg/min norepinephrine, P = .029) at 12 hours postoperatively as well as significantly more overall volume replacement (7217 vs. 4185 mL at 12 hours, P = .015; 12 021 vs. 4850 mL at 48 hours, P = .015). HA therapy did neither result in a reduction of inflammatory parameters nor result in an improvement of hemodynamic parameters in patients operated for IE. For a more targeted use of HA therapy, appropriate selection criteria are required.
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Affiliation(s)
- Silke Asch
- Department of Thoracic- and Cardiovascular Surgery, University Hospital, Georg-August-University, Göttingen, Germany.,Department of Cardiac and Thoracic Surgery, Hospital Fulda, Fulda, Germany
| | - Tobias Peter Kaufmann
- Department of Thoracic- and Cardiovascular Surgery, University Hospital, Georg-August-University, Göttingen, Germany
| | - Michaela Walter
- Department of Thoracic- and Cardiovascular Surgery, University Hospital, Georg-August-University, Göttingen, Germany
| | - Marcus Leistner
- Department of Thoracic- and Cardiovascular Surgery, University Hospital, Georg-August-University, Göttingen, Germany.,Department of Anesthesiology, University Hospital Würzburg, Würzburg, Germany
| | - Bernd C Danner
- Department of Thoracic- and Cardiovascular Surgery, University Hospital, Georg-August-University, Göttingen, Germany
| | - Thorsten Perl
- Department of Anaesthesiology, University Hospital, Georg-August-University, Göttingen, Germany
| | - Ingo Kutschka
- Department of Thoracic- and Cardiovascular Surgery, University Hospital, Georg-August-University, Göttingen, Germany
| | - Heidi Niehaus
- Department of Thoracic- and Cardiovascular Surgery, University Hospital, Georg-August-University, Göttingen, Germany.,Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hannover, Germany
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18
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Lehnert T, Leonhardt I, Timme S, Thomas-Rüddel D, Bloos F, Sponholz C, Kurzai O, Figge MT, Hünniger K. Ex vivo immune profiling in patient blood enables quantification of innate immune effector functions. Sci Rep 2021; 11:12039. [PMID: 34103589 PMCID: PMC8187451 DOI: 10.1038/s41598-021-91362-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/25/2021] [Indexed: 02/05/2023] Open
Abstract
The assessment of a patient's immune function is critical in many clinical situations. In complex clinical immune dysfunction like sepsis, which results from a loss of immune homeostasis due to microbial infection, a plethora of pro- and anti-inflammatory stimuli may occur consecutively or simultaneously. Thus, any immunomodulatory therapy would require in-depth knowledge of an individual patient's immune status at a given time. Whereas lab-based immune profiling often relies solely on quantification of cell numbers, we used an ex vivo whole-blood infection model in combination with biomathematical modeling to quantify functional parameters of innate immune cells in blood from patients undergoing cardiac surgery. These patients experience a well-characterized inflammatory insult, which results in mitigation of the pathogen-specific response patterns towards Staphylococcus aureus and Candida albicans that are characteristic of healthy people and our patients at baseline. This not only interferes with the elimination of these pathogens from blood, but also selectively augments the escape of C. albicans from phagocytosis. In summary, our model could serve as a valuable functional immune assay for recording and evaluating innate responses to infection.
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Affiliation(s)
- Teresa Lehnert
- grid.418398.f0000 0001 0143 807XResearch Group Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology ‐ Hans Knöll Institute, Jena, Germany ,grid.275559.90000 0000 8517 6224Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
| | - Ines Leonhardt
- grid.275559.90000 0000 8517 6224Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany ,grid.418398.f0000 0001 0143 807XResearch Group Fungal Septomics, Leibniz Institute for Natural Product Research and Infection Biology ‐ Hans Knöll Institute, Jena, Germany
| | - Sandra Timme
- grid.418398.f0000 0001 0143 807XResearch Group Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology ‐ Hans Knöll Institute, Jena, Germany
| | - Daniel Thomas-Rüddel
- grid.275559.90000 0000 8517 6224Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany ,grid.275559.90000 0000 8517 6224Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Frank Bloos
- grid.275559.90000 0000 8517 6224Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany ,grid.275559.90000 0000 8517 6224Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Christoph Sponholz
- grid.275559.90000 0000 8517 6224Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Oliver Kurzai
- grid.275559.90000 0000 8517 6224Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany ,grid.418398.f0000 0001 0143 807XResearch Group Fungal Septomics, Leibniz Institute for Natural Product Research and Infection Biology ‐ Hans Knöll Institute, Jena, Germany ,grid.8379.50000 0001 1958 8658Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | - Marc Thilo Figge
- grid.418398.f0000 0001 0143 807XResearch Group Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology ‐ Hans Knöll Institute, Jena, Germany ,grid.275559.90000 0000 8517 6224Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany ,grid.9613.d0000 0001 1939 2794Institute of Microbiology, Faculty of Biological Sciences, Friedrich Schiller University Jena, Jena, Germany
| | - Kerstin Hünniger
- grid.418398.f0000 0001 0143 807XResearch Group Fungal Septomics, Leibniz Institute for Natural Product Research and Infection Biology ‐ Hans Knöll Institute, Jena, Germany ,grid.8379.50000 0001 1958 8658Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
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19
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Sinitsky MY, Tsepokina AV, Asanov MA, Kazachek YV, Evtushenko AV, Ponasenko AV. [The expression level of cytokine genes in the cases of native heart valves in infectious endocarditis]. BIOMEDIT︠S︡INSKAI︠A︡ KHIMII︠A︡ 2021; 66:406-410. [PMID: 33140735 DOI: 10.18097/pbmc20206605406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The expression level of IL1B, IL6, IL8, IL10, IL12A, IL12B, IL18, IL23, IL33, CCL2, and IL1RL1 has been investigated using biopsies of native mitral, aortic, and tricuspid valves obtained during surgical correction of acquired defect from 25 patients with infectious endocarditis. Biopsies of native mitral and aortic valve cusps from 12 patients who underwent surgical correction of acquired heart disease of non-infectious etiology were used as control. We used quantitative PCR with fluorescent dye SYBR Green for determination of the cytokine gene expression level. This study revealed that genes could be subdivided into three groups: (i) genes with increased expression (IL1B, IL6, and IL8); (ii) genes with reduced expression (IL33 and IL1RL1); (iii) genes with unchanged expression (IL12A, IL18, IL23, and CCL2). The IL8 gene expression was characterized by the most pronounced increase (9.83 times versus control), while the IL1RL1 gene demonstrated the most pronounced decrease in its expression (4.17 times). Expression of IL10 and IL12B genes was negligible in all samples.
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Affiliation(s)
- M Yu Sinitsky
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - A V Tsepokina
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - M A Asanov
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - Ya V Kazachek
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - A V Evtushenko
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - A V Ponasenko
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
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20
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Manetti F, Scopetti M, Santurro A, Consoloni L, D'Errico S. Widespread septic embolization in injection drug use mitro-aortic infective endocarditis as a remote cause of death. Int J Legal Med 2020; 134:1345-1351. [PMID: 32367331 DOI: 10.1007/s00414-020-02309-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/22/2020] [Indexed: 01/09/2023]
Abstract
Injection drug use-related infective endocarditis (IDU-IE) assumes peculiar epidemiological, pathogenetic, and prognostic characteristics that allow to consider it a distinct nosological entity, as well as a current problem of considerable social weight. Incidence is reasonably underestimated because diagnosis is often accidental in postmortem examination when drug-related death is suspected. In many cases, postmortem toxicological examinations are negative for acute drug abuse, and findings of infective endocarditis became relevant in the explanation of the mechanism of death. Extracardiac involvement of infective endocarditis is rarely reported as fatal. Fragmentation and embolization of bacterial vegetations can be associated with parenchymal infarcts, systemic spread of the infectious process by formation of an abscess. A case of septic shock as a consequence of the constant bacteremia determined by the continuous proliferation and release of bacteria into the circulation is presented in an injection drug user with left-sided endocarditis and widespread septic embolization. Authors reviewed forensic and medical literature and promote epidemiological value of medical and forensic autopsy. Extracardiac involvement of infective endocarditis may represent a remote and alternative cause of death in injection drug users, and an early diagnosis can be relevant for prognosis. Postmortem examination still represents a valuable opportunity of learning for clinicians and improving diagnostic accuracy with injection drug users. A call for changing of attitudes and practice toward autopsy is finally demanded.
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Affiliation(s)
- Federico Manetti
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Matteo Scopetti
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Alessandro Santurro
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Lara Consoloni
- Department of Medicine, Surgery and Health, University of Trieste, Trieste, Italy
| | - Stefano D'Errico
- Department of Medicine, Surgery and Health, University of Trieste, Trieste, Italy.
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