Hemadsorption treatment for antithrombotic drug removal in emergency cardiac surgery – cost-benefit analysis comparing patient outcomes

Background

Intraoperative hemadsorption is indicated for ticagrelor and rivaroxaban removal in patients undergoing urgent cardiac surgery and has been previously shown to reduce bleeding complications. However, whether this application is cost effective is currently unknown.

Methods

Between June 2017 and June 2021, we evaluated the outcomes of 72 consecutive patients (age 65±11 years) with acute coronary syndrome (ACS) pretreated with ticagrelor who underwent urgent coronary artery bypass grafting (CABG) at our institution. Intraoperative hemoadsorption (IH) was used in all cases (IH-Pat). We estimated the mean cost per patient, and a bootstrap analysis was performed based on individual data from the case series. We compared the results with “historical patients” who were operated under the same conditions between June 2015 and June 2017 but without IH (n=22).

Results

Bilateral internal mammary artery (BIMA) was used in 67.7% of all cases. Use of IH was associated with significantly shorter operation times (277±65 min vs. 320±75 min; P=0.014) and significantly less postoperative 24-hours chest tube drainage (277±65 mL vs. 866±262 mL; P<0.001). Only two rethoracotomies (2.8%) had to be performed. In addition, patients operated without IH required significantly more blood products and had a significantly higher rate of rethoracotomy, resulting in longer ICU stays. The variable that had the highest impact on the level of cost savings was the operation duration. The overall cost saving with IH were calculated at over 4200±1100€ with operation time, ICU stay and blood product costs being the top contributors.

Conclusions

The results suggest that the clinical benefits derived from IH in ticagrelor-treated patients requiring urgent cardiac surgery patients could result in significant cost savings of over 4200±1100 € per patient.

Funding Acknowledgement

Type of funding sources: None.

Hybrid-ALPPS followed by Ante Situm with Cardiopulmonary Bypass: Rapid Liver Augmentation and Complex Surgery

BACKGROUND

Tumors invading the inferior vena cava (IVC) and hepatic veins pose a challenge for surgeons. Hannoun et al.1 were able to show that the resection of these tumors can be done under hypothermia in the Ante-Situm position. Additionally, not only the localization of the tumor but the remaining volume of the remnant liver (FLR) needs to be considered. Schnitzbauer et al.2 were able to induce massive liver hypertrophy in a short period, combining an in-situ split with a portal vein ligation (ALPPS). As this controversial technique has evolved, a safe ALPPS can be performed nowadays.3 To our knowledge, this is the first case that combines a laparoscopic partial ALPPS with an extended resection requiring cardiopulmonary bypass (CPB).

METHODS

A 58-year-old female presented with a known chronic hepatitis C suffered from a pulmonary embolism, caused by a large, central hepatocellular carcinoma (HCC) with invasion of the suprahepatic IVC and continuous growth into the right atrium (RA). Due to the small FLR, we performed a laparoscopic hybrid-partial-ALPPS with an embolization of the right portal vein. We were able to remove the mass with an Ante-Situm position and resection of the RA under CPB.

RESULTS

The postoperative course was complicated by posthepatic liver failure and bleeding. However, after 28 days the patient was discharged in a good medical condition.

CONCLUSIONS

Although tumors invading the suprahepatic IVC and RA pose a surgical challenge, patients can be treated adequately with multidisciplinary management. Advanced HCCs have high recurrence rates; however, a R0 resection might improve overall survival. Wakayma et al. showed in their retrospective study with 13 patients a median survival of 30.8 months when a complete resection was performed.4 Our patient had a disease-free survival of 11 months and is still alive after 24 months. Taking the complexity of the operation and the oncological prospect with a probable recurrence into account, indication for surgery needs to be considered on an individual basis.

[Caspofungin after solid organ transplantation in Germany: observational study on treatment of invasive fungal infections]

BACKGROUND

This study was a pre-planned country-specific secondary analysis of results in Germany from a multinational multicenter observational study to retrospectively evaluate clinical outcomes with caspofungin in patients with probable and proven invasive fungal infection following solid organ transplantation (SOT).

METHODS

Data were retrospectively collected on a single episode of invasive fungal infection (IFI) in patients who had a SOT between January 2004 and June 2007. Effectiveness was reported as the proportion of patients who received at least five doses of caspofungin with a favorable (complete or partial) response. Safety was assessed for patients who received at least one dose of caspofungin. Descriptive statistics were employed for all evaluations.

RESULTS

A total of 41 SOT patients (27 male, 14 female; median age 56 years, median APACHE II score at start of caspofungin therapy 23) were enrolled from 5 sites in Germany. Organs transplanted were mainly heart (51%) and liver (46%). Prevalent risk factors for IFI at baseline were use of central venous catheter (37 out of 41 patients, 90%), steroid use (37 out of 41 patients, 90%), recent stay in intensive care (36 out of 41 patients, 88%),and duration of SOT procedure >5 hours (21 out of 41 patients, 51%). Candidiasis was diagnosed in 34 patients (83%) and aspergillosis in 10 patients (24%). The lungs were the most common site of IFI (21 out of 41, 51%). Caspofungin as monotherapy was received by 28 patients (68%); 6 patients (15%) received caspofungin as salvage therapy for IFI, in most cases because they were refractory to prior antifungal drugs. Immunosuppressants were administered with caspofungin in 39 out of 41 patients (95%). In subjects with at least 5 doses of caspofungin (modified intention to treat population) the favorable response rate at the end of caspofungin therapy was 88% overall, 29 out of 33 patients; 95% confidence interval (95%-CI) 72-97%), 86% (19 out of 22 patients) with monotherapy and 91% (10 out of 11 patients) with combination therapy. No (serious) adverse events or drug interactions related to treatment with caspofungin were reported. The overall survival rate was 79% (26 out of 33 patients; 95%-CI 61-91%) at 7 days after completion of caspofungin treatment.

CONCLUSION

Caspofungin was found to be an effective treatment of probable and proven invasive fungal infections in patients following SOT in Germany.

A beta-adrenergic antagonist reduces traumatic memories and PTSD symptoms in female but not in male patients after cardiac surgery

BACKGROUND

Epinephrine enhances emotional memory whereas beta-adrenoceptor antagonists (beta-blockers, BBs) impair it. However, the effects of BB administration on memory are sex dependent. Therefore, we predicted differential effects of epinephrine and the BB metoprolol given to male and female patients after cardiac surgery (CS) on traumatic memories and post-traumatic stress disorder (PTSD) symptoms.

METHOD

We performed a prospective observational study and determined the number of standardized traumatic memories (NTRM) and PTSD symptom intensity in cardiac surgical patients at 1 day before surgery, and at 1 week and 6 months after the procedure. PTSD symptoms and NTRM were quantified using validated questionnaires. Metoprolol could be administered any time post-operatively.

RESULTS

Baseline NTRM was not significantly different between male (n=95) and female patients (n=33). One week after CS, the NTRM in male patients was significantly higher. Metoprolol had no significant effect in either sex. At 6 months, females with metoprolol (n=18) showed a significantly lower NTRM and significantly lower PTSD symptom scores than females without BBs (n=15, p=0.02). By contrast, the totally administered dosage of epinephrine correlated with NTRM in males (r=0.33, p<0.01) but not in females (r=0.21, p=0.29).

CONCLUSIONS

beta-Adrenergic stimulation with epinephrine enhances memory for adverse experiences in males but not in females whereas beta-blockade selectively reduces memory for post-operative adverse events and PTSD symptoms in females.

Successful ABO-incompatible heart transplantation in a child despite blood-group sensitization after ventricular assist device support

In the first two yr of life blood-group incompatible (ABO-incompatible) heart transplantation can be performed leading to immune tolerance to donor blood group. Antibody titers should be below 1:4. VAD use is correlated with sensitization toward blood-group antigens. A boy was diagnosed with dilated cardiomyopathy at nine months of age and listed for 0-compatible transplantation. Progressive heart failure required implantation of a left VAD. His listing was extended for ABO-incompatible transplantation despite antibody titers of 1:32 anti-A and 1:8 anti-B. After 26 days on VAD, he was transplanted with a B donor heart. No hyperacute or acute rejection occurred in 12 months post-transplant. Anti-B antibodies rose to a maximum of 1:2. No use of rituximab or plasmapheresis was required. There are no signs of graft vasculopathy. This indicates that inclusion criteria for ABO-incompatible transplantation may be extended to immediate cases. This is the first case with a healthy immune system to show signs of tolerance development after ABO-incompatible heart transplantation with increased prior antibody titers and without specific treatment.