Intraoperative Cytokine Hemoadsorption Treatment may Prevent Vasoplegic Syndrome during Orthotopic Heart Transplantation

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Abstract

Introduction

Perioperative severe vasoplegia is a common complication among patients undergoing heart transplantation which can negatively influence outcome. This hemodynamic disturbance is presumed to be linked to an amplified inflammatory response determined by the immune priming, Cardiopulmonary Bypass surgery, perioperative reperfusion injuries, the graft tissue induced host immune response and their interactions. Extracorporeal cytokine hemoadsorption is a novel non-pharmacologic technology aimed at modifying pathological inflammatory responses by removing mid-molecular weight (up to 55 kDa) pro- and anti-inflammatory cytokines and other vasoactive agents. Animal and human data from severe sepsis models has confirmed its effectiveness on hemodynamic stability and outcome.

Introduction

In our observational study we assessed the impact of pre-emptive, intraoperative extracorporeal cytokine hemoadsorption on the severity of perioperative vasoplegia and outcome in patients undergoing heart transplantation.

Materials and Methods

84 of the 91 consecutively enlisted heart transplant patients were finally analyzed. N=24 patients had intraoperative cytokine hemoadsorption treatment (CytoSorbTM, CytoSorbents Europe GmbH, Berlin, Germany) and N=60 patients were treated conventionally (controls). Vasoplegic syndrome (VS) was defined by noradrenaline (NA) ≥0.2 μg/kg/min and need for secondary vasopressor during the first 24 hours. Vasopressor requirements during the first 48 hours, postoperative adverse events and outcome were evaluated in the two groups using Propensity Score Matching.

Results and Discussion

The overall frequency of VS was 36.9% in the non-matched cohort (N=84), which was less in the CytoSorbTM group compared to the controls (20.8% vs 43.3%, P=0.054). In the 16 matched pairs, the median NA requirement was significantly lower in the CytoSorbTM treated patients than in the controls on the first and second postoperative days (0.14 vs 0.3 μg/kg/min, P=0.039 and 0.06 vs 0.32 μg/kg/min, P=0.047, respectively).

Results and Discussion

The frequency of complicated acute kidney injury requiring renal replacement therapy was significantly less in the CytoSorbTM treated patients than in controls (2 vs 4 cases, P=0.031). Shorter median length of postoperative mechanical ventilation (24 vs 129 hours, P>0.05) and intensive care unit stay (10 vs 20 days, P>0.05) were observed in the CytoSorbTM group compared to the control group. Postoperative bleeding, sepsis and early cardiac allograft rejection did not differ between the two groups.

Conclusion

Intraoperative CytoSorbTM treatment might have benefit in preventing postoperative VS and related complications during orthotopic heart transplantation demonstrated by the lower rate of severe vasoplegia, significantly reduced vasopressor demand, and less renal replacement therapy in this group. CytoSorbTM treatment was not linked to higher rates of complications, adverse events or longer periods of intensive care unit stay compared to controls.

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