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

Abstract

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.

Hemoadsorption during Cardiopulmonary Bypass in Patients with Endocarditis Undergoing Valve Surgery: A Retrospective Single-Center Study

“…Recent unmatched reports suggested a reduction of the duration of the ICU stay in HA-treated patients [ 9 , 10 ], as well as potential financial savings by the use of HA [ 37 ], which could not be confirmed in our patient cohort. In our study, the HA group presented a prolonged length of in-hospital stay and a higher demand for blood products.…”

“…In this retrospective study, however, the use of HA did not improve short-term outcomes of IE patients after valve surgery. With this small retrospective study, we cannot provide evidence of reduction in treatment costs, since the rate of reoperation for bleeding and rate of administration of blood products were significantly increased in HA in our study [ 37 ]. Further prospective and randomized investigations need to verify whether HA has an effect on coagulation, which might have an impact on reoperation rates and neurological complications.…”

“…Cortisol increases response to catecholamines via steroid receptors [33] ↓ [27] Thromboxane vasoconstrictor and promoter of platelet aggregation [34] ↓ [35] Big-endothelin-1 precursor of vasoconstricting Endothelin-1 [30] ↓ [36] Albumin Maintenance of plasma colloid oncotic pressure [31] and effect on cardiac preload [32] ↓ [21] Recent unmatched reports suggested a reduction of the duration of the ICU stay in HA-treated patients [9,10], as well as potential financial savings by the use of HA [37], which could not be confirmed in our patient cohort. In our study, the HA group presented a prolonged length of in-hospital stay and a higher demand for blood products.…”

In Vitro Apixaban Removal By CytoSorb Whole Blood Adsorber: An Experimental Study

“…The adsorber column can easily be added to a cardiopulmonary bypass (CPB) circuit and the method is in previous studies considered safe and feasible (10,11). The adsorber has also been found to adsorb several drug molecules, and is now EU approved for use in patients treated with rivaroxaban or ticagrelor in need of on-pump cardiovascular surgery (12)(13)(14).…”

Therapeutic Modulation of the Host Defense by Hemoadsorption with CytoSorb®—Basics, Indications and Perspectives—A Scoping Review

“…These molecules often contain central hydrophobic structures (e.g., benzene rings) that are adsorbed on the polymer beads even in case of high plasma protein binding [139]. As example, therapeutic levels of rivaroxaban or ticagrelor can be eliminated before emergency surgery [59,140]. Maximization of blood flow rapidly leads to high clearance in time-critical situations.…”