Case of the week 33/2016
Use of CytoSorb in mitral- and aortic valve endocarditis
Dr. med. Gerhard Valicek, Senior Physician Intensive Care Unit 2, University Hospital St.Pölten, Department for Anaesthesiology and Intensive Care Medicine, St. Pölten, Austria
This case study reports on a 63-year-old male patient with mitral and aortic valve endocarditis, who underwent two cardiac surgeries for valve replacement.
Case presentation
The patient had already been treated in the cardiologic intensive care unit for 17 days due to a Staph aureus sepsis
Due to a florid mitral valve endocarditis with large vegetations (2×2 cm in size) and consecutive mitral regurgitation as well as relevant risk of embolism, the decision was made to perform mitral valve replacement
Even prior to admission to the cardiosurgical operating theatre, the patient was already in dialysis-dependent renal failure, required low-dose vasoconstrictor support and was tracheostomized due to long-term ventilation
Relevant secondary diagnoses: IDDM, previous history of atrial flutter
During mitral valve replacement on cardiopulmonary bypass patient had high demand for vasoconstrictor support with norepinephrine, yet still displayed ongoing and insufficient perfusion pressures, even post cardiopulmonary bypass (a hyperdynamic circulatory situation)
After transfer to the anesthesiology ICU the patient exhibited signs of peripheral circulatory failure. Echocardiography confirmed hypovolemia and pulse contour analysis showed reduced peripheral vascular resistance
Therapy was extended to vasopressin and hydrocortisone, and later to epinephrine
After 48 hours with increasing hemodynamic stabilization, the vasopressin and epinephrine were discontinued, and norepinephrine reduced.
A follow-up echocardiogy showed that the mitral valve prosthesis was functionally regularly, however, there was a high-grade aortic regurgitation with suspicion for endocarditic vegetations and massive calcification of the non-coronary sail
On postoperative day 5 the patient underwent a second cardio-surgical revision followed by aortic valve replacement
Treatment
In total two treatments with CytoSorb – treatments were performed postoperatively after mitral valve replacement (=1st treatment for 24 hours) and intra- and postoperatively during/after the aortic valve replacement procedure (=2nd treatment for 24 hours)
CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
Anticoagulation: citrate
CytoSorb adsorber position: pre-hemofilter
Measurements
Hemodynamic parameters and demand for catecholamines
Inflammatory parameters (PCT, IL-1 beta,IL-6, IL-8,IL-10, IL-17, TNF alpha)
Results
During the first treatment no relevant changes in hemodynamics were observed
Of the inflammatory mediators analyzed, the course of IL-6 showed a significant reduction when compared to the time prior to therapy initiation
The 2nd treatment, beginning with the revision surgery (aortic valve replacement) was associated with a hemodynamically and inflammatory stable course
The catecholamine demand remained virtually unchanged when comparing the intra- and postoperative with preoperative levels, hemodynamically there was no occurrence of vasoplegia, no significant increase in inflammatory mediators, and clinically no SIRS symptoms could be observed
Patienten Follow-Up
The further stay in the anesthetics ICU proved stable, especially in the light of his pre-existing multi-organ failure
The longer-term follow-up care was carried out by the coronary care unit
The patient unfortunately died three weeks after his aortic valve replacement due to a repeated multiple organ failures
CONCLUSIONS
Lack of hemodynamic effects after the first treatment with CytoSorb may have been due to the delayed start of treatment (postoperatively) as well as the pre-existing and long-lasting inflammatory condition of the patient
The early use in acute endocarditis (early intraoperative start during the 2nd surgery) could possibly have contributed positively to the clinical course of the patient in terms of potential suppression of recurrence of an inflammatory surge, which might have helped stabilize the inflammatory and hemodynamic situation
Treatment with CytoSorb was safe and easy to use
