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Urgent Coronary Artery Bypass Grafting Complication by Systemic Inflammatory Response from Fulminant Herpes Zoster Successfully managed with Adjunct Extracorporeal Hemoadsorption: A Case Report
Zaki Haidari1, Wilko Weißenberger1, Bartosz Tyczynski2, Ender Demircioglu1, Efthymios Deliargyris3, Martin Christ4, Matthias Thielmann1, Mohamed El Gabry1, Arjang Ruhparwar1 and Daniel Wendt1 1 Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, Essen, Germany 2 Department of Nephrology, University Hospital Essen, Essen, Germany 3 Cytosorbents Inc., Princeton, USA 4 Department of Cardiology and Intensive Care Medicine, Knappschaftskrankenhaus Bottrop, Bottrop, Germany J Clinical Medicine 2022; 11:3106
06/08/2022
New!Peer Reviewed Published DataReduction in catecholaminesSafetyViral infectionCardiac surgeryCase of the weekCase reportCPBCritical CareCRRT (pre or post filter)Inflammatory parametersIntra-Op
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Summary
CoW 23/2022 – This case reports on a 56-year-old man who presented with unstable angina pectoris and severe coronary artery stenosis.
Summary
In this case report a 56 yr old man presented to hospital requiring complex cardiac surgery complicated by an outbreak of herpes zoster infection. After clinical and inflammatory improvement (requiring an 8 day stay in intensive care), he was taken for coronary artery bypass graft surgery. Immediately on induction of anesthesia, he became hemodynamically unstable requiring noradrenaline (>0.75 µg/kgbw/min). This situation worsened again once he was placed on cardiopulmonary bypass (noradrenaline 1.5 µg/kgbw/min). The patient then had a CytoSorb adsorber added to the bypass circuit resulting in stabilization of this ongoing acute situation (noradrenaline 1.0 µg/kgbw/min). His post-operative course was complicated requiring maximum pharmacological and blood product support, as well as transfer onto veno-venous extracorporeal membrane oxygenation (vvECMO). He was also placed on renal replacement therapy, including 72 hours of CytoSorb hemoadsorption (3 adsorbers for 24 hrs each). By post op day 2 his hemodynamic status, lactate levels and inflammatory parameters were all improving. Despite the fact that the patient then developed acute respiratory distress syndrome, he eventually went on to fully recover, and was asymptomatic at 6 month follow up. In this patient with a profound systemic inflammatory response during coronary artery bypass surgery and reactivated herpes zoster resulting in significant clinical instability, use of CytoSorb both intra- and post-operatively helped stabilize hemodynamics and reduce inflammatory markers suggesting that hemoadsorption was an important contributor to the favourable outcome. In conclusion this case suggests that hemoadsorption may be a vital adjunct therapeutic option for the management of a profound systemic inflammatory response in a patient requiring urgent cardiac surgery.
Case presentation
The patient’s history included arterial hypertension, severe chronic obstructive pulmonary and peripheral artery disease
Coronary angiography revealed severe three-vessel disease with high-grade stenoses of the left main, the proximal left, the anterior descending and the the ramus intermedius coronary arteries, and an occluded right coronary artery
Transthoracic echocardiography showed a good left ventricular function without any sign of valve dysfunction
Preoperative workup revealed proximal stenosis of the left subclavian artery with subclavian steal syndrome
During physical examination on admission, well-de?ned grouped vesicles could be identi?ed on an erythematous background with a segmental nerve distribution of the left thorax (Th2-3)
After dermatologic consultation, a clinical diagnosis of herpes zoster was made and antiviral therapy with intravenous acyclovir in combination with analgesics and topical therapy was started. The diagnosis was based on the classical clinical presentation and cutaneous ?ndings
The patient was under continuous monitoring and intravenous heparin and nitroglycerin therapy in the intensive care unit (ICU) and was evaluated by the dermatologists every second day
After clinical and in?ammatory improvement (eight days later), CABG surgery was performed
However, immediately after induction of anesthesia, hemodynamic instability developed requiring norepinephrine support of >0.75 µg/kg/min to maintain a systolic blood pressure of 80 mmHg
Moreover, this hemodynamic instability further worsened after going on-pump with norepinephrine requirements reaching 1.5 µg/kg/min
At this juncture, the decision was made to integrate a CytoSorb hemoadsorption device into the cardiopulmonary bypass (CPB) circuit to stabilize the ongoing acute situation
His post-operative course was complicated by an unusually exaggerated increase in procalcitonin (PCT, 344 ng/mL) and interleukin 6 (IL-6 – 66,745 pg/mL) requiring maximum pharmacological and blood product support, as well as transfer onto veno-arterial extracorporeal membrane oxygenation (vaECMO). He was also placed on renal replacement therapy, including another 72 hours of CytoSorb hemoadsorption
Treatment
One CytoSorb hemoadsorber was used intraoperatively. Additionally, 3 consecutive hemoadsorption treatments were applied for 24 hours each during the postoperative period
Intraoperatively, the CytoSorb adsorber was integrated into the CPB circuit. During the postoperative period, adsorbers were run in conjunction with continuous renal replacement therapy (CRRT)
Measurements
Hemodynamics and requirements for vasoactive substances
Markers of hyperinflammation
Lactate levels
Results
Despite maximal supportive and adjunctive therapy including CytoSorb, high vasopressor support (1.0 µg/kg/min) was required during and after weaning from CPB and subsequent veno-arterial extracorporeal membrane oxygenation (vaECMO) therapy was necessary to reduce the vasopressor needs. During the second hemoadsorption session including 3 more CytoSorb treatments, his hemodynamic status improved considerably
During the course of postoperative CytoSorb therapy, there was a gradual reduction in the circulating in?ammatory markers (IL-6 from 66,745 pg/mL to negligible levels by postoperative day 7, PCT also continuously decreased) coinciding with clinical improvement
Treatment was further associated with a decrease in lactate plasma levels from 11.5 mmol/l to normal levels by postoperative day 7
Patient Follow-up
After hemodynamic stabilization and decreasing lactate and in?ammatory parameters, vaECMO therapy was removed on the second postoperative day
The patient developed acute respiratory distress syndrome (ARDS) and required veno-venous (vv) ECMO therapy on postoperative day 3
Following gradual respiratory improvement, vvECMO was explanted on the 15th postoperative day
A broncho-alveolar lavage did not identify any evidence of herpes simplex or COVID-19 infection
After percutaneous tracheostomy, weaning from mechanical ventilation was started
At 6 months follow-up, the patient was asymptomatic and active
Conclusion
In this patient with a profound systemic inflammatory response during coronary artery bypass surgery and reactivated herpes zoster resulting in significant clinical instability, use of CytoSorb both intra- and post-operatively helped stabilize hemodynamics and reduce inflammatory markers suggesting that hemoadsorption was an important contributor to the favourable outcome
In conclusion this case suggests that hemoadsorption may be a vital adjunct therapeutic option for the management of a profound systemic inflammatory response in a patient requiring urgent cardiac surgery.
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