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CytoSorb® usage in a dual antiplatelet agent treated patient during CABG and broken guidewire retrieval from right coronary artery ostium

Kumar N., Keshri V. K., Bhuyan R. R. | Fortis Escorts Heart Institute, New Delhi, India | IJMDAT 2022; 5: e379: epub
04/27/2022
New!Peer Reviewed Published DataSafetyTransfusionsAnti throm. removalAnticoagulation HeparinCardiac surgeryCase of the weekCase reportCPBIntra-Op
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Summary

CoW 17/2022 – A 66-year-old male patient presented to the hospital with complaints of left sided chest pain radiating to left arm for 1 week as well as acute/severe pain over the last 2 days.

Summary
In this case report a 66-year-old male patient on doublet antiplatelet therapy (DAPT) with ticagrelor and ecospirin underwent percutaneous transluminal coronary angioplasty (PTCA) for triple vessel disease (TVD). During withdrawal part of the guidewire became stuck in the right coronary artery. The patient began to deteriorate clinically (left ventricular ejection fraction reduced to 40% with akinetic walls and early pulmonary edema) so he was taken for emergency on-pump coronary artery bypass graft (CABG) surgery, despite being on DAPT. CytoSorb was added to the cardiopulmonary bypass circuit in an effort to remove the ticagrelor and reduce the risk of bleeding. Post-operatively no bleeding was recorded. The patient demonstrated good pump function and sinus rhythm and was able to be discharged in a stable condition within 7 days of hospitalization including 3 days of intensive care unit stay. According to the authors use of intraoperative CytoSorb – in line with earlier reports – prevented expected substantial postoperative bleeding, which led to short ICU stay and total hospitalization time. The authors conclude that intra-operative use of CytoSorb during emergency cardiac surgery in patients treated with ticagrelor is an effective option which reduces risk of bleeding complications, thereby improving outcomes, reducing costs and minimizing morbidity and mortality.

Case presentation

The patient had a history of type 2 diabetes mellitus and acute coronary syndrome (ACS) with a recent inferior wall myocardial infarction
He was under dual antiplatelet therapy (DAPT) with ticagrelor (90 mg twice daily) and aspirin (150 mg once daily). Additional current medication included the statin rosuvastatin (20 mg once daily), the angiotensin II receptor blocker telmisartan (40 mg once daily), the diuretics furosemide/spironolacton (50 mg once daily), and anti-diabetic metformin (500 mg once daily)
Coronary angiography revealed multiple coronary artery lesions
Overall, the patient had coronary artery disease, inferior wall myocardial infarction and critical triple vessel disease
For treatment of his acute myocardial infarction, primary percutaneous transluminal coronary angioplasty (PTCA) of the right coronary artery (RCA) was performed immediately and thrombolysis in the myocardial infarction (TIMI) III flow was achieved
However, during wire withdrawal, the guidewire got entangled in one of the stent struts and the floppy part was separated from the wire shaft in the RCA ostium
The next day, 2D echocardiography revealed moderate left ventricular dysfunction (left ventricular ejection fraction [LVEF] of 40%) with an akinetic posterior wall, basal inferior wall, and mid basal lateral wall as well as an elevated heart rate of 105/min, and mild mitral regurgitation
A CT scan one day later revealed ground glass opacities with both central and peripheral distribution pointing towards early pulmonary edema
Following several attempts of percutaneous retrieval procedures and given the reduction in LVEF to 40%, the decision was made for surgical removal of the guidewire
The next day, the patient underwent on-pump coronary artery bypass graft surgery (CABG) along with antibiotics and intravenous fluids. Midline sternotomy showed mild cardiomegaly, a dilated aorta, and the PTCA guidewire stuck in the RCA ostium. The patient was heparinized and cardiopulmonary bypass was placed using right axillary artery (RAA) cannulation. During the procedure, the floppy part of the PTCA wire was pulled out gently with forceps. One left internal mammary artery (LIMA) and three reversed saphenous vein grafts (RSVG) were used. Two pacing wires (right atrium and right ventricular) and two chest drains (anterior mediastinal and left pleural) were placed
In order to help reduce bleeding complications in this emergency cardiac surgery scenario by accelerating the removal of the platelet aggregation inhibitor ticagrelor, a CytoSorb hemoadsorption device was integrated into the heart lung machine circuit
Treatment

One CytoSorb adsorber was used for a total surgery time of 6 hours
The CytoSorb cartridge was directly integrated into the heart lung machine circuit
Anticoagulation: heparin
Measurements

Intra- and postoperative blood loss
Cardiac function
Lactate
Renal function
Results

Intraoperatively, optimal hemostasis was achieved. No post-operative bleeding was recorded
The patient demonstrated good pump function and sinus rhythm
Serum lactate decreased from 3.1 pre-surgery to 2.1 mg/dl two days later
Also renal function considerably improved within 2 days following the procedure (urine output from 1750 to 3470 ml/day)
Patient Follow-up

Postoperatively, the patient was transferred to the intensive care unit in a stable state for further observation
He was extubated one day following the surgical procedure
Three units of packed cell volume and fresh frozen plasma were administered during his stay
With a total hospitalization time of 7 days (3 days on intensive care ), the patient was discharged in a stable condition
Conclusion

To the authors’ knowledge, this is the first case to be reported from India utilizing CytoSorb for antiplatelet drug removal during a CABG procedure including guidewire retrieval
In this patient, the intraoperative use of CytoSorb prevented expected substantial postoperative bleeding
Therefore, the intra-operative usage of CytoSorb during emergency cardiac surgery in a patient treated with anti-platelet agents (i.e. ticagrelor) represents an effective option which can help to reduce the risk of bleeding complications, thereby improve outcomes, reduce costs and minimizing morbidity and mortality rates.