Case of the Week
Literature Database
Use of CytoSorb hemoadsorption column during prolonged cardiopulmonary bypass in complex cardiac surgery patient
Marianne Alarie*, Maggie Savelberg, Danika Vautour and Igo B. Ribeiro | Kingston Health Sciences Centre, Kingston, ON, Canada | J Cardiothorac Surg 2022 Jul 7;17(1):172
07/27/2022
New!Peer Reviewed Published DataReduction in catecholaminesSafetyCardiac surgeryCase of the weekCase reportCPBIntra-Op
Download documentDownload documentLink to source
Summary
CoW 30/2022 – This case reports on a 61-year-old male, who was assessed by cardiac surgery in consideration for mitral valve surgery following presentation for congestive heart failure.
Summary
In this report a 61-year-old male with congestive heart failure was assessed for cardiac surgery, and was found to require mitral valve replacement, aortic valve replacement, tricuspid valve repair, single coronary artery bypass grafting and a left atrial appendage clip. Given the complexity of the surgery, the anticipated prolonged length of cardiopulmonary bypass, the associated risk of significant vasoplegia and his preoperative kidney dysfunction, the decision was made to integrate the CytoSorb cartridge into the cardiopulmonary bypass (CPB) circuit. One CytoSorb hemoadsorber was used intraoperatively throughout the CPB time (154 min). Despite an initial rise in vasopressor requirements, the mean arterial pressure (MAP) gradually improved during the time on by-pass whilst vasopressors could be weaned off completely. However, ten minutes post-bypass (i.e. after discontinuation of CytoSorb), the patient once again required multiple vasopressors to support his MAP. Despite the presence of postoperative thrombocytopenia, postoperative platelet counts did not significantly differ from baseline. Treatment was safe and feasible while integration into the cardiopulmonary bypass circuit was uncomplicated with no device-related complications. In this complex cardiac surgery patient, the authors state that the application of CytoSorb during cardiopulmonary bypass contributed to a decreased need for vasoactive support during and after surgery as well as improved postoperative outcomes, rendering it a promising therapeutic option in critically ill patients at risk of significant postoperative vasoplegia and multiorgan injury following prolonged and complex cardiac surgery.
Case presentation
Transthoracic echocardiography showed significant mitral valve calcification resulting in severe mitral regurgitation and moderate mitral stenosis. The right and left ventricles both had mild dysfunction with an ejection fraction of 46%. Further evaluation with transesophageal echocardiography revealed moderate aortic cusp calcification with moderate stenosis. Moderate tricuspid regurgitation was also noted. Coronary angiography revealed the presence of significant coronary artery disease with second diagonal ostial stenosis
The patient’s medical history included end-stage renal disease requiring intermittent hemodialysis, autoimmune cytopenia (severe thrombocytopenia, neutropenia) with mild responsiveness to preoperative steroids, New York Heart Association class III heart failure, hypertension, chronic obstructive pulmonary disease, severe untreated sleep apnea, previous Graves` disease diagnosis and atrial fibrillation
The patients’ preoperative blood work included a platelet count of 74?×?109/L, hemoglobin 91 g/L and hematocrit 29%. Preoperative creatinine was 598 µmol/L and glomerular filtration rate (GFR) was 8 mL/min/1.73 m2
The procedure included mitral valve replacement, aortic valve replacement, tricuspid valve repair, single coronary artery bypass grafting and left atrial appendage clip. Total cardiopulmonary bypass (CPB) time was 154 min, with a cross-clamp time of 115 min
Following induction of anesthesia and prior to commencement of the CPB, the patient required norepinephrine at 2 µg/min for hemodynamic support
A total of 3 units of packed red blood cells (pRBC), 2 units of platelets and 1 unit of prothrombin complex concentrate were administered to treat his perioperative anemia and coagulopathy
Given the complexity of the surgery (triple valve surgery), the anticipated prolonged length of cardiopulmonary bypass, the associated risk of significant vasoplegia and the preoperative kidney dysfunction, the decision was made to integrate the CytoSorb cartridge into the cardiopulmonary bypass circuit in this critically ill patient
Treatment
One CytoSorb hemoadsorber was used intraoperatively throughout the CPB time (154 min)
The CytoSorb device was inserted between the recirculation line (high-pressure line) and the venous reservoir of the CPB circuit. The cartridge was placed in a parallel fashion with the hemoconcentrator. The cartridge was primed and flushed with one liter of Ringer’s Lactate
Estimated blood flow rates through the CytoSorb: 200-230 mL/min
Anticoagulation: heparin with target activated clotting times (ACT) greater than 400 s, monitored every 20 to 30 min
Measurements
Hemodynamics and requirements for vasoactive substances
Total chest tube drainage volume
Ultrafiltration rate
Thrombocytes
Safety
Results
Following initiation of CPB and CytoSorb, norepinephrine infusion was increased to 5 µg/min for the first half hour of the bypass run under which the mean arterial pressure (MAP) could be sustained at around 45–50 mmHg. At the 40 min mark, MAP increased to a mean of 65–70 mmHg and the norepinephrine dose was reduced to 2 µg/min. After one hour on bypass, MAP increased to 70–75 mmHg and norepinephrine was discontinued. MAP levels above 60 mmHg were sustained for the remainder of the bypass run and there was no additional need for vasoactive support. Ten min post-bypass (i.e. after discontinuation of CytoSorb), the patient required dobutamine 5 µg/kg/min, norepinephrine 4 µg/min, epinephrine 5 µg/min and vasopressin 0.04 units/min for support. The patient was transferred to the cardiac intensive care unit on 5 µg/kg/min of dobutamine, 6 µg/min of norepinephrine, 5 µg/min of epinephrine and 0.04 units/min of vasopressin. Dobutamine was discontinued within the first postoperative hour. Vasopressin was stopped 24 h postoperatively. Norepinephrine was discontinued by the end of the 2nd postoperative day while epinephrine was eventually discontinued 48 h postoperatively
Total chest tube drainage was measured to be 1080 mL
Zero balance ultrafiltration was performed during bypass, with a total of 2.2 L of dialysate solution administered and 5.2 L of fluid removed via the hemoconcentrator
Postoperative platelet counts did not significantly differ from baseline
No adverse or any device-related side effects were documented during or after CytoSorb treatment
Patient Follow-up
Early postoperative blood work showed somewhat improved kidney function, with a creatinine of 394 umol/L and a GFR of 13 mL/min/1.73 m2
Lactate levels peaked at 3.4 mmol/L on the 6th postoperative hour and quickly normalized over the next 24 hours
Following the first postoperative day, the patient received an additional 3 units of pRBC, 2 units of fresh frozen plasma and 1 unit of platelets
Surgical drains were removed on the second postoperative day
The patient was extubated 48 h post-surgery
Hemodialysis treatments were resumed on the third postoperative day
The patient was transferred to the normal ward on the 6th postoperative day and discharged on the 11th postoperative day
Conclusion
In this complex cardiac surgery patient, application of CytoSorb during cardiopulmonary bypass contributed to a decreased need for vasoactive support during and after surgery as well as improved postoperative outcomes, rendering it a promising therapeutic option in critically ill patients at risk of significant postoperative vasoplegia and multiorgan injury following prolonged and complex cardiac surgery
The authors do not believe that CytoSorb therapy significantly impacted on the platelet concentrations or perioperative transfusion requirements
Treatment was safe and feasible while integration into the cardiopulmonary bypass circuit was uncomplicated with no device-related complications observed.
