Cytosorb Adsorption During Emergency Cardiac Operations in Patients at High Risk of Bleeding

Hassan, Kambiz; Kannmacher, J.; Wohlmuth, Peter; Budde, Ulrich; Schmoeckel, Michael; Geidel, Stephan

doi:10.1016/j.athoracsur.2018.12.032

Cited by 96 publications

(97 citation statements)

References 18 publications

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“…CytoSorb ® (Cytosorbents Corporation, Monmouth Junction, NJ, USA) is an extracorporeal blood purification technology that has been demonstrated to remove ticagrelor from blood and reduce surgical resource use during cardiac surgery [16,17]. The device consists of a 300 mL cartridge containing small adsorbent polymer beads that permit removal of hydrophobic substances up to a molecular weight of approximately 60 kDa from whole blood by irreversible adsorption.…”

Section: Model Overviewmentioning

confidence: 99%

Ticagrelor Removal by CytoSorb® in Patients Requiring Emergent or Urgent Cardiac Surgery: A UK-Based Cost-Utility Analysis

Javanbakht

Trevor

Hemami

et al. 2019

PharmacoEconomics Open

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Background Acute coronary syndrome patients receiving dual antiplatelet therapy who need emergent or urgent cardiac surgery are at high risk of major bleeding, which can impair postoperative outcomes. CytoSorb ® , a blood purification technology based on adsorbent polymer, has been demonstrated to remove ticagrelor from blood during on-pump cardiac surgery. Objective The aim of this study was to evaluate the cost utility of intraoperative removal of ticagrelor using CytoSorb versus usual care among patients requiring emergent or urgent cardiac surgery in the UK. Methods A de novo decision analytic model, based on current treatment pathways, was developed to estimate the short-and long-term costs and outcomes. Results from randomised clinical trials and national standard sources such as National Health Service (NHS) reference costs were used to inform the model. Costs were estimated from the NHS and Personal Social Services perspective. Deterministic and probabilistic sensitivity analyses (PSAs) explored the uncertainty surrounding the input parameters. Results In emergent cardiac surgery, intraoperative removal of ticagrelor using CytoSorb was less costly (£12,933 vs. £16,874) and more effective (0.06201vs. 0.06091 quality-adjusted life-years) than cardiac surgery without physiologic clearance of ticagrelor over a 30-day time horizon. For urgent cardiac surgery, the use of CytoSorb was less costly than any of the three comparators-delaying surgery for natural washout without adjunctive therapy, adjunctive therapy with short-acting antiplatelet agents, or adjunctive therapy with low-molecular-weight heparin. Results from the PSAs showed that CytoSorb has a high probability of being cost saving (99% in emergent cardiac surgery and 53-77% in urgent cardiac surgery, depending on the comparators). Cost savings derive from fewer transfusions of blood products and re-thoracotomies, and shorter stay in the hospital/intensive care unit. Conclusions The implementation of CytoSorb as an intraoperative intervention for patients receiving ticagrelor undergoing emergent or urgent cardiac surgery is a cost-saving strategy, yielding improvement in perioperative and postoperative outcomes and decreased health resource use.

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Section: Model Overviewmentioning

confidence: 99%

Ticagrelor Removal by CytoSorb® in Patients Requiring Emergent or Urgent Cardiac Surgery: A UK-Based Cost-Utility Analysis

Javanbakht

Trevor

Hemami

et al. 2019

PharmacoEconomics Open

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“…CytoSorbents Corporation, Monmouth Jct., NJ) porous polymer beads 16 , suggesting that hemoperfusion with CS could be useful in the treatment of acute mycotoxin exposure, such as might be predicted in a bioterrorist attack. In addition, intra-operative use of the device has been reported to reduce bleeding complications in patients who present for emergency cardiac surgery by the removal of the coagulation-active substances rivaroxaban and ticagrelor 17 . As such, it was of interest to evaluate if CS treatment could effectively mitigate the toxicity of an acutely lethal dose of AFB 1 with systemic administration.…”

mentioning

confidence: 99%

Hemoadsorption Improves Survival of Rats Exposed to an Acutely Lethal Dose of Aflatoxin B1

Ruggeberg

O’Sullivan

Kovacs

et al. 2020

Sci Rep

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Mycotoxins, such as aflatoxin B 1 (AFB 1), pose a serious threat as biological weapons due to their high toxicity, environmental stability, easy accessibility and lack of effective therapeutics. This study investigated if blood purification therapy with CytoSorb (CS) porous polymer beads could improve survival after a lethal aflatoxin dose (LD 90). The effective treatment window and potential therapeutic mechanisms were also investigated. Sprague Dawley rats received a lethal dose of AFB 1 (0.5-1.0 mg/ kg) intravenously and hemoperfusion with a cS or control device was initiated immediately, or after 30, 90, or 240-minute delays and conducted for 4 hours. The CS device removes AFB 1 from circulation and significantly improves survival when initiated within 90 minutes of toxin administration. Treated subjects exhibited improved liver morphology and health scores. changes in the levels of cytokines, leukocytes and platelets indicate a moderately-severe inflammatory response to acute toxin exposure. Quantitative proteomic analysis showed significant changes in the level of a broad spectrum of plasma proteins including serine protease/endopeptidase inhibitors, coagulation factors, complement proteins, carbonic anhydrases, and redox enzymes that ostensibly contribute to the therapeutic effect. Together, these results suggest that hemoadsorption with cS could be a viable countermeasure against acute mycotoxin exposure. Aflatoxins are toxic secondary fungal metabolites (mycotoxins) produced by fungus from the genus Aspergillus that cause severe acute reactions that can be lethal. Aspergillus species are important human pathogens and the toxic metabolites appear to act as virulence factors to suppress the immune system in invasive aspergillosis 1. Aflatoxins cause damage to the liver resulting in hemorrhagic liver necrosis, steatosis, bile duct proliferation and subsequent organ failure and have been detected in pulmonary lesions of immune-compromised patients with systemic aspergillosis 2. Aflatoxin B 1 (AFB 1), the most potent toxin of the 14 naturally occurring aflatoxin variants, is extremely cytotoxic, genotoxic, and carcinogenic 3,4. In the liver, cytochrome P450-modified AFB 1 forms DNA adducts that lead to impaired cellular function, carcinogenesis and/or cell death and organ failure 5,6. Acute aflatoxin poisoning from mold contaminated foods has been linked with numerous deaths in several instances 7,8. Importantly, mycotoxins pose a serious threat as potential biowarfare agents due to their inherent stability and ease of manufacture. The toxins can be readily weaponized into aerosol form and dispersed over a wide area to elicit mass casualties through both inhalation and dermal exposure 9. There have been several reported incidents of use of mycotoxins as bioweapons in Southeast Asia and the Gulf States 10,11. Early symptoms of mycotoxin exposure in bio-warfare manifest rapidly in minutes to hours and can include burning, pain, wheezing, nausea, vomiting, tearing, weakness, bleeding and a host of other symptoms...

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“…However, in the case of severe bleeding due to those drugs, it could be used as a treatment option. In a study by Hassan et al, the use of Cytosorb during emergency cardiac surgeries was presented as likely to be beneficial in patients treated with ticagrelor or rivaroxaban [21]. In a retrospective study, Cytosorb significantly reduced the number of transfusions of red blood cell units and platelets concentrate units, shortened the ICU stay and lowered the frequency of re-thoracotomy.…”

Section: State Of Knowledgementioning

confidence: 99%

Applications of Cytosorb in clinical practice

Kutnik¹,

Borys²

2019

J Pre Clin Clin Res.

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Introduction and objective. Cytososorb is haemadsorption device approved in the European Union in 2011 for cytokine adsorption. Recently, in 2018, new indications for the device use have been added, including bilirubin and myoglobin removal. This study aimed to present the results of studies pertaining to Cytosorb use in clinical practice. In subsequent sections of this review, indications for Cytosorb therapy and clinical relevance of presented evidence are listed. State of knowledge. In clinical practice, Cytosorb has been reported as one of potential supportive therapies in patients with septic shock. There is evidence of significant reduction of interleukin 6 and vasopressors when Cytosorb is implemented. However, the decreased mortality after Cytosorb has yet to be reported. Besides cytokine adsorption, Cytosorb also collects drugs, a property that can have a beneficial effect on acute drug poisoning (anticoagulants). However, Cytosorb lowers the plasma concentration of some antibiotics which might affect the outcome of patients in septic shock. The haemadsorption device has also been researched in cardiac patients, and some reports suggest a reduced need for vasopressors and blood transfusions when therapy is installed during surgery. Other indications for Cytosorb are also reported, especially the effectiveness in decreasing bilirubin serum concentrations as treatment or bridge therapy, without affecting the albumins. Cytosorb might also be the last resort treatment in acquired haemophagocytic lymphohistiocytosis. Conclusions. The evidence supporting the use of CytoSorb remains elusive. There is lack of large prospective studies which could provide definitive answers about the place of Cytosorb in clinical practice. There are no reports of safety and feasibility issues in all presented studies.

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Cytosorb Adsorption During Emergency Cardiac Operations in Patients at High Risk of Bleeding

Cited by 96 publications

References 18 publications

Ticagrelor Removal by CytoSorb® in Patients Requiring Emergent or Urgent Cardiac Surgery: A UK-Based Cost-Utility Analysis

Ticagrelor Removal by CytoSorb® in Patients Requiring Emergent or Urgent Cardiac Surgery: A UK-Based Cost-Utility Analysis

Hemoadsorption Improves Survival of Rats Exposed to an Acutely Lethal Dose of Aflatoxin B1

Applications of Cytosorb in clinical practice

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