cytosorb

1. CYTOSORB THERAPY IN
CARDIAC SURGERY

2. CYTOSORB THERAPY IN CARDIAC SURGERY

3. ENDOCARDITIS
SEPSIS
PERI OP INFECTIONS
DHCA
CARDIOPLEGIA
HYPOTHERMIA
CPB
DRUGS
TISSUE FACTORS
CYTOSORB THERAPY IN CARDIAC SURGERY

4. CYTOSORB THERAPY IN CARDIAC SURGERY

5. CYTOSORB THERAPY IN CARDIAC SURGERY

6. CYTOSORB THERAPY IN CARDIAC SURGERY

7. Antibiotics
Ticagrelor, Rivaroxban
CYTOSORB THERAPY IN CARDIAC SURGERY

8. Physiologic levels are maintained
CYTOSORB THERAPY IN CARDIAC SURGERY

9. CYTOSORB THERAPY IN CARDIAC SURGERY
Usage time is maximum 24 hrs need to change if
required to continue further cycles
With CRRT 14-16 hrs

10. CYTOSORB THERAPY IN CARDIAC SURGERY

12.  YES
IS CYTOSORB SAFE ?
CYTOSORB THERAPY IN CARDIAC SURGERY

13. Results:
 No removal of albumin
 No serious adverse events
 80% lower expression of PCT
 No influence on perioperative course
 After HA long lasting effect on IL - 10
CYTOSORB THERAPY IN CARDIAC SURGERY

14.  Preventive vs Therapeutic
CYTOSORB THERAPY IN CARDIAC SURGERY
Intraoperative Postoperative
Intraoperative PostopertiveOR
COMBINED

15. CYTOSORB THERAPY IN CARDIAC SURGERY

16. CYTOSORB THERAPY IN CARDIAC SURGERY

17. CYTOSORB THERAPY IN CARDIAC SURGERY

18. CYTOSORB THERAPY IN CARDIAC SURGERY

19. CYTOSORB THERAPY IN CARDIAC SURGERY

20. CYTOSORB THERAPY IN CARDIAC SURGERY

21. CYTOSORB THERAPY IN CARDIAC SURGERY

22. Cost and complications of transfusion vs cost of device
Morbidity of perioperative bleeding
CYTOSORB THERAPY IN CARDIAC SURGERY

23. Pre existing hyperinflammation
CYTOSORB THERAPY IN CARDIAC SURGERY
Cardiogenic shock

24. DUAL FUNCTION – IMMUNOMODULATOR, CYTOTOXIN ADSORBENT
? LEVEL OF EVIDENCE - INVITRO
CYTOSORB THERAPY IN CARDIAC SURGERY

25. CYTOSORB THERAPY IN CARDIAC SURGERY

26. Intraoperative
CYTOSORB THERAPY IN CARDIAC SURGERY

27. CYTOSORB THERAPY IN CARDIAC SURGERY

28. CYTOSORB THERAPY IN CARDIAC SURGERY

29. CYTOSORB THERAPY IN CARDIAC SURGERY
However not a substitute for RRT

30.  Cytosorb therapy is beneficial
 Surgical outcome reducing sepsis or sepsis related deaths
 Studies retrospective and small
 First beneficial hints in endocarditis
 No device-related SAEs
 Further investigation / larger RCTs needed
 ……guidelines?
CYTOSORB THERAPY IN CARDIAC SURGERY

31.  Revealing mechanisms and investigating efficacy of hemoadsorption for
prevention of vasodilatory shock in cardiac surgery patients with infective
endocarditis – a multicentric randomized controlled trial
CYTOSORB THERAPY IN CARDIAC SURGERY

32.  Should we continue post op use of
cytosorb ?
CYTOSORB THERAPY IN CARDIAC SURGERY

33. Retrospective case series
20 patients with endocarditis (aortic/mitral valve)
10 - intraoperative use v/s 10 - intra and postoperative use
Indications for continuing post operative cytosorb therapy i,e 2nd group is
sicker !
• Higher Risk Evaluation score,
• Longer cardiopulmonary bypass times
• Worse inflammatory status, and
• Perioperative worsening of renal function or liver function
CYTOSORB THERAPY IN CARDIAC SURGERY

34. CYTOSORB THERAPY IN CARDIAC SURGERY

35. CYTOSORB THERAPY IN CARDIAC SURGERY
Intraoperative plus postoperative group showed an equal intensive
care unit and 90-day survival compared to patients treated only
intraoperatively

36.  Both groups had marked decrease need for vasopressors and
inflammatory markers
 Beneficial in patients with endocarditis who develop
perioperative organ dysfunction.
 Renal failure
 Severe hemodynamic instability
 High ionotropes score
CYTOSORB THERAPY IN CARDIAC SURGERY

37. Emergency cardiac surgery
CYTOSORB THERAPY IN CARDIAC SURGERY

38. CYTOSORB THERAPY IN CARDIAC SURGERY

39. CYTOSORB THERAPY IN CARDIAC SURGERY

40. Shorter duration due to less time for
hemostasis
CYTOSORB THERAPY IN CARDIAC SURGERY

41. CYTOSORB THERAPY IN CARDIAC SURGERY

42. CYTOSORB THERAPY IN CARDIAC SURGERY

43. CYTOSORB THERAPY IN CARDIAC SURGERY

44. • 16 patients
• Inflammatory responses were same in control and study group
• reduced vasopressor demand
• decreased renal replacement therapy
• less mechanical ventilation and ICU stay
• No adverse events
CYTOSORB THERAPY IN CARDIAC SURGERY

45.  REFRESH I Pilot Study (low to moderate risk)
CYTOSORB THERAPY IN CARDIAC SURGERY

46. CYTOSORB THERAPY IN CARDIAC SURGERY

47. CYTOSORB THERAPY IN CARDIAC SURGERY

48. CYTOSORB THERAPY IN CARDIAC SURGERY

49. However no significant clinical outcome
CYTOSORB THERAPY IN CARDIAC SURGERY

50. Total n = 20 10 with cytosorb 10 without
cytosorb
p VALUE
RETROSPECTIVE DATA
HIGH RISK , ORGAN DYSFUNCTION
ICU STAY 3.7 4.9 0.04
VENTILATION 1.7 days 2.5 days 0.590
DEATHS Nil 2
CPB 210 +/- 59 310 +/- 82 0.22
CYTOSORB THERAPY IN CARDIAC SURGERY
Limitations : sample size is limited
Retrospective data
One patient was excluded which was put on ECMO

51. With cytosorb Without
cytosorb
P
BLEEDING 1340 +/- 680
ml
1970 +/- 430
ML
0.04
TRANSFUSIONS
- PRBC
3.9 (all required
transfusion )
4.6 ( all required
transfusion)
0.02
FFP 1.2 1.9 0.7
INFLAMMATORY
MARKERS
N/A N/A
CYTOSORB THERAPY IN CARDIAC SURGERY

52. 2.53
1.6
0
0.5
1
1.5
2
2.5
3
DIRECT INDIRECT
CYTOSORB
NO CYTOSORB
CYTOSORB THERAPY IN CARDIAC SURGERY
Bilirubin levels

53. 0
100
200
300
400
500
600
700
SGOT SGPT
147
101
667
312
CYTOSORB NO CYTOSORB
CYTOSORB THERAPY IN CARDIAC SURGERY

54. 1.17 1.25
1.48 1.5
1.37
1.21
1.45
1.78
1.65 1.64
PREOP DAY 1 DAY 2 DAY 3 PRE
DISCHARGE
S. Creat
CYTOSORB NO CYTOSORB
CYTOSORB THERAPY IN CARDIAC SURGERY

55. ORGAN DYSFUNCTION
ALTER RFT/LFT
ANTIPLATELETS
POST OPERATIVE
HYPERINFLAMATORY
CONDITIONS (High
ionotropes, sepsis)
ENDOCARDITIS
ACUTE AORTIC SYNDROME
CASES WITH DHCA
HEART TRANSPLANT
CPB TIME > 120 MINUTES
(REDO/COMBINED
PROCEDURES)
ROUTINE CARDIAC
SURGIAL
PROCEDURES
CPB <120 MIN
NO ORGAN
DYSFUNCTION
Low
risk
Moderate risk
High
risk
CYTOSORB BENEFICIAL
CYTOSORB THERAPY IN CARDIAC SURGERY
CLINICAL JUDGEMENT
NOT INDICATED

56.  Routine cardiac surgical procedures do not indicate use of Cytosorb
 Patients with exaggerated inflammation should be identified
 Modality of use – THERAPEUTIC/ PREVENTIVE,
INTRAOPERATIVE/
INTRA + POSTOPERATIVE
 EUROSCORE > 4 , CYTOSORB to be considered
 Need further studies with more subjects.
 Can we use for preoperative stabilisation?
 Cost has to be considered v/s the clinical benefits
CYTOSORB THERAPY IN CARDIAC SURGERY

57. THANK YOU