The effect of perioperative hemadsorption in patients operated for acute infective endocarditis—A randomized controlled study

Abstract

Patients operated for infective endocarditis (IE) are at high risk of developing an excessive systemic hyperinflammatory state, resulting in systemic inflammatory response syndrome and septic shock. Hemoadsorption (HA) by cytokine adsorbers has been successfully applied to remove inflammatory mediators. This randomized controlled trial investigates the effect of perioperative HA therapy on inflammatory parameters and hemodynamic status in patients operated for IE. A total of 20 patients were randomly assigned to either HA therapy or the control group. HA therapy was initiated intraoperatively and continued for 24 hours postoperatively. Cytokine levels (IL‐6, IL‐1b, TNF‐α), leukocytes, C‐reactive protein (CRP), and Procalcitonin (PCT) as well as catecholamine support, and volume requirement were compared between both groups. Operative procedures included aortic (n = 7), mitral (n = 6), and multiple valve surgery (n = 7). All patients survived to discharge. No significant differences concerning median cytokine levels (IL‐6 and TNF‐α) were observed between both groups. CRP and PCT baseline levels were significantly higher in the HA group (59.5 vs. 26.3 mg/dL, P = .029 and 0.17 vs. 0.05 µg/L, P = .015) equalizing after surgery. Patients in the HA group required significantly higher doses of vasopressors (0.093 vs. 0.025 µg/kg/min norepinephrine, P = .029) at 12 hours postoperatively as well as significantly more overall volume replacement (7217 vs. 4185 mL at 12 hours, P = .015; 12 021 vs. 4850 mL at 48 hours, P = .015). HA therapy did neither result in a reduction of inflammatory parameters nor result in an improvement of hemodynamic parameters in patients operated for IE. For a more targeted use of HA therapy, appropriate selection criteria are required.

Application of Adsorptive Blood Purification Techniques during Cardiopulmonary Bypass in Cardiac Surgery

“…The retrospective studies of Haidari et al [ 78 ] included 58 patients. In univariate analysis, hemadsorption therapy showed a significant benefit for sepsis-related death, although this benefit disappeared in a multiple regression model, while Asch et al [ 77 ] found no difference in“risk of mortality” scores on the ICU and the ICU and 90-day survival showed no differences in case series by Kühne et al [ 81 ], either.…”

“…The valve surgery mentioned in the above elective heart surgery did not indicate whether they were performed for infective endocarditis or for other reasons, and one study [ 70 ] even directly excluded patients with infective endocarditis. There were five studies involving only patients with infective endocarditis, including one RCT [ 77 ], two retrospective studies [ 78 , 79 ], and two case series [ 80 , 81 ].…”

“…A recent RCT reported by Asch et al [ 77 ] attempted to evaluate the effect of prolonged use of CytoSorb (continued for 24 hours postoperatively) in patients with infective endocarditis at high risk of inflammation with potential intraoperative bacterial dissemination. But there were no significant differences in median cytokine levels (IL-6 and TNF- α ) and infection parameters (CRP and PCT) between the two groups.…”

“…(1) Hemodynamic Stability . In the RCT study [ 77 ], the hemadsorption (HA) group had higher catecholamine and fluid requirements in the early postoperative period. Three observational studies [ 78 , 80 , 81 ] all suggested that the HA group had better hemodynamic stability, while only Santer et al [ 79 ] observed that the HA group had significantly increased demand for norepinephrine, milrinone, erythrocyte concentrate, platelets, and FFP.…”

“…(2) Length of ICU Stay . As a secondary outcome, in the RCT [ 77 ] that included 20 patients with infective endocarditis, all patients in the HA group survived, but the ICU stay was significantly prolonged. The same results were observed by Santer et al [ 79 ] and Kühne et al [ 81 ].…”