Cytosorb – Case Of The Week 27 / 2018

Bei diesem 57jährigen Kardiologie-Patienten mit einer Giant Cell Myocarditis setzte die Medizinische Hochschule Hannover in zwei Behandlungszyklen insgesamt neun Filter ein. In beiden Zyklen konnten alle gemessenen Entzündungsmarker deutlich reduziert weden. Weiterhin und wiederum spricht man von einem „efficient removal of bilirubin“.

An dieser Stelle: ich bin schwer begeistert davon, wie hier insbesondere deutsche Ärzte um das Leben ihrer Patienten kämpfen und im Vergleich zu einem Land wie den USA neue Behandlungsmethoden Jahre vorher zum Einsatz bringen. Sehr geil!

Summary

CoW 27/2018 – This study reports on a 57-year-old patient, who was transferred to Hannover Medical School from an external hospital due to hemodynamic instability as well as markedly elevated markers of cardiac insufficiency.

Case presentation:

  • Subsequent chest X-ray performed directly after admission confirmed pulmonary congestion while the patient’s respiratory situation became progressively compromised
  • Four biopsies of the cardiac tissue were taken and an Impella CP microaxial pump was implanted
  • At the same time, anesthesia and intubation were started
  • Over time, the patient developed ventricular tachycardia and amiodarone was administered to achieve cardioversion
  • Subsequently, the development of fulminant right heart failure was noted accompanied by increasing requirements for catecholamines, loss of pulsatility and rhythm instability, lactic acidosis, a progressive oxygenation problem, as well as oliguric–anuric renal failure refractory to furosemide resulting in the initiation of continuous veno-venous hemodialysis
  • Since adequate hemodynamic stabilization could not be achieved despite continuously high catecholamine support, and due to increasing inflammatory mediators and bilirubin levels, a CytoSorb hemoadsorber was integrated into the CRRT circuit
  • Due to persisting right heart failure, the decision was made to implant an Extra Corporeal Llfe Support (ECLS), initially resulting in a decrease in norepinephrine dose, improved diuresis, metabolic rebalancing, and the chance to reduce Impella support
  • Notwithstanding these initial improvements, ventricular tachycardia persisted despite multiple frustrating electrical cardioversion attempts and the application of amiodarone
  • Simultaneously, due to non-pulsatility and acontractility of the left ventricle, as well as a heavily reduced right ventricular function, the Cardiac Team decided to implant a left ventricular assist device (LVAD) the next day
  • Biopsy findings arriving later that day confirmed severe acute giant-cell myocarditis
  • Operation the next day included LVAD implantation, implantation of a veno-pulmonary arterial (VPA) ECMO as a weaning therapy due to temporary right heart failure, ECLS explantation (removal of the arterial cannula), as well as the explantation of the Impella
  • Importantly, CRRT and CytoSorb were simultaneously stopped preoperatively and CytoSorb was installed into the VPA ECMO circuit with continued treatment for the next 3 days
  • Upon postoperative admission to the ICU, the patient required very high doses of catecholamines and antibiotic therapy was commenced including daptomycin, meropenem, and posaconazole, while immunosuppressive therapy included ciclosporin, mycophenolate mofetil, methylprednisolone, and prednisolone with no dose adjustment being necessary
  • After the first treatment block, the patients’ condition improved, he could be extubated on the 8th postoperative day while renal function continued to improve with decreasing retention parameters and adequate diuresis
  • On the 10th postoperative day, the patient experienced a secondary septic surge (pulmonary infection) accompanied by an increase in inflammatory parameters, severely compromised hemodynamics requiring an increase in catecholamine doses as well as reintubation and tracheotomy, again associated with VPA ECMO + LVAD escalation (increase in flow) and need for renal replacement therapy accompanied by re-inititation of CytoSorb for a second treatment block

Treatment:

  • In total, nine treatments with CytoSorb were performed over 23 days with a 7-day pause interval
  • The first CytoSorb treatment block included four adsorbers (adsorber 1 in conjunction with CVVHD running for 48 h, adsorbers 2–4 in combination with VPA ECMO which ran for 24 h each)
  • After the pause interval CytoSorb was applied for another five treatment cycles in conjunction with VPA ECMO 

CVVHD settings

  • During the first treatment, CytoSorb was used in conjunction with CRRT (Genius, Fresenius Medical Care) performed in CVVHD mode
  • Blood flow rate: 200 ml/min
  • Dialysate flow: 2500 ml/h
  • Anticoagulation: Citrate
  • CytoSorb adsorber position in CVVHD: pre-hemofilter

VPA ECMO settings

  • For the remaining 8 treatments, CytoSorb was used in conjunction with an ECMO machine (Rotaflow; Maquet, Rastatt, Germany)
  • Blood flow rate: mainline blood flow 4.2–4.57 ml/min, bypass blood flow 300 ml/min
  • VPA ECMO anticoagulation: heparin, targeting an activated partial thromboplastin time (aPTT) of 50–60 s
  • CytoSorb adsorber position in VPA ECMO: CytoSorb bypass from VPA ECMO mainline—bypass inflow from pre-oxygenator (high-pressure side), backflow pre-pump (before low-pressure system) as a passive shunt

Measurements:

  • Hemodynamics and need for catecholamines
  • Inflammatory parameters (procalcitonin, IL-6 and C-reactive protein)
  • Lactate
  • Bilirubin, free hemoglobin 

Results:

  • The first treatment block comprising 4 CytoSorb treatments resulted in a clear and steady improvement in hemodynamics and the inflammatory condition with marked reductions in all measured parameters throughout the treatment period including IL-6. In addition, metabolic acidosis resolved and liver function improved as shown by a reduction in parameters for liver dysfunction including an efficient removal of bilirubin
  • The five treatment cycles of the second treatment block were associated with a clear and steady decline in catecholamines, inflammatory markers, bilirubin, and free hemoglobin

Patient Follow-Up:

  • Together with the last CytoSorb treatment, the right ventricular bypass was explanted followed by mobilization and discharge to a high-care program

Conclusion:

  • This is the first clinical case report in a patient with giant-cell myocarditis and fulminant cardiac failure treated with CytoSorb hemoadsorption in combination with CRRT, VPA ECMO, and LVAD therapy. Key results include a clear and steady improvement in the inflammatory condition and organ functions
  • The combination of all techniques applied was practical, technically feasible, and highly beneficial for the patient and no adverse or device-related side effects were noticed during or after the treatment sessions
  • In general, there is a need for studies for new therapeutic procedures, which are, however, challenging for rare indications as presented herein. Further insights on treatment modalities and efficacies might therefore be expected from the International CytoSorb registry in the future

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