Safety and efficacy of hemoperfusion in cardiopulmonary bypass for postoperative inflammatory response in patients with acute Stanford type A aortic dissection: A randomized controlled trial_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

BIAN Longrong ¹ , CUI Ying ² , LUO Chong ¹ , LI Mei ¹ , XIONG Jiyue ² , DU Lei ² ,  WU Zhong ¹

1. Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;
2. Department of Anesthesia, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;

Corresponding author：

WU Zhong, Email: wuzhong71@scu.edu.cn

Keywords：

Hemoperfusion; cardiopulmonary bypass; aortic dissection; cytokines; randomized controlled trial

DOI：

10.7507/1007-4848.202205082

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Objective To explore the clinical effect of hemoperfusion (HP) in cardiopulmonary bypass (CPB) on postoperative inflammation in patients with acute type A aortic dissection (AAD). Methods Adult patients with AAD who planned to undergo total aortic arch replacement from July 2020 to November 2021 were continuously enrolled in our heart center. Patients were randomly divided into a HP group and a control (C) group. The HP group was treated with disposable HP device (Model: HA380, Zhuhai Jafron Biomedical, China) in CPB during the operation. Results Finally, 70 patients were included with 59 males and 11 females at an age range of 21-67 years. There were 35 patients in both groups. In this study, 3 patients died within 3 days after surgery, 2 in the HP group and 1 in the C group, and the remaining 67 patients survived to the follow-up end point (30 days after surgery). There was no statistical difference in preoperative baseline data, operative method, CPB time, block time, or other intraoperative data between the two groups. Blood product dosage, intubation time, hospital stays, and hospitalization expenses were similar between the two groups. Intraoperative hemoglobin (82.70±2.31 g/L vs. 82.50±1.75 g/L, P=0.954] and platelet concentration [(77.87±7.99)×10⁹/L vs. (89.17±9.99)×10⁹/L, P=0.384] were not statistically different between the HP group and C group. In the HP group, postoperative (ICU-12 h) interleukin-6 (IL-6) [338.14 (128.00, 450.70) pg/mL vs. 435.75 (180.50, 537.00) pg/mL, P=0.373], IL-8 [35.04 (18.02, 40.35) pg/mL vs. 43.50 (17.70, 59.95) pg/mL, P=0.383], and IL-10 [21.19 (6.46, 23.50) pg/mL vs. 43.41 (6.34, 50.80) pg/mL, P=0.537] were slightly lower than those in the C group, and the difference was not statistically different. The incidences of pulmonary infection (0.00% vs. 11.76%, P=0.042) and liver injury (2.94% vs. 20.58%, P=0.027) in the HP group were significantly lower than those in the C group, and the incidence of other postoperative complications, such as arrhythmia, nervous system complications and urinary system complications, showed no statistical difference between the two groups. Conclusion HP therapy in CPB is safe, but its effect on reducing postoperative inflammatory factors, postoperative inflammatory reactions and postoperative complications in the patients with AAD is limited, and it may be of application value to some high-risk patients with lung and liver injury.

Citation： BIAN Longrong, CUI Ying, LUO Chong, LI Mei, XIONG Jiyue, DU Lei, WU Zhong. Safety and efficacy of hemoperfusion in cardiopulmonary bypass for postoperative inflammatory response in patients with acute Stanford type A aortic dissection: A randomized controlled trial. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2023, 30(4): 532-539. doi: 10.7507/1007-4848.202205082 Copy

1.	Erbel R, Aboyans V, Boileau C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases. Kardiol Pol, 2014, 72(12): 1169-1252.
2.	Levy JH, Tanaka KA. Inflammatory response to cardiopulmonary bypass. Ann Thorac Surg, 2003, 75(2): S715-S720.
3.	Ramadoss N, Dharmapuram AK, Goutami V, et al. Avoiding use of total circulatory arrest in the practice of congenital heart surgery. Indian J Thorac Cardiovasc Surg, 2021, 37(Suppl 1): 174-182.
4.	Kousoulas L, Wittel U, Fichtner-Feigl S, et al. Hemoadsorption in a case of severe septic shock and necrotizing fasciitis caused by nontraumatic renal rupture due to pyelonephritis with obstructive uropathy. Case Rep Crit Care, 2018, 2018: 5248901.
5.	Li Z, Wang G, Zhen G, et al. Effects of hemodialysis combined with hemoperfusion on severe acute pancreatitis. Turk J Gastroenterol, 2018, 29(2): 198-202.
6.	Bernardi MH, Rinoesl H, Dragosits K, et al. Effect of hemoadsorption during cardiopulmonary bypass surgery—A blinded, randomized, controlled pilot study using a novel adsorbent. Crit Care, 2016: 20: 96.
7.	Singh A, Mehta Y, Trehan N. Bilirubin removal using cytosorb filter in a cardiac surgical patient. J Cardiothorac Vasc Anesth, 2019, 33(3): 881-883.
8.	Pomarè Montin D, Ankawi G, Lorenzin A, et al. Biocompatibility and cytotoxic evaluation of new sorbent cartridges for blood hemoperfusion. Blood Purif, 2018, 46(3): 187-195.
9.	Yang J, Ji D, Zhu YQ, et al. Hemoperfusion with HA380 in acute type A aortic dissection patients undergoing aortic arch operation (HPAO): A randomized, controlled, double-blind clinical trial. Trials, 2020, 21(1): 954.
10.	Cifani N, Proietta M, Tritapepe L, et al. Stanford-A acute aortic dissection, inflammation, and metalloproteinases: A review. Ann Med, 2015, 47(6): 441-446.
11.	Gleason TG, Argenziano M, Bavaria JE, et al. Hemoadsorption to reduce plasma-free hemoglobin during cardiac surgery: Results of REFRESH Ⅰ Pilot Study. Semin Thorac Cardiovasc Surg, 2019, 31(4): 783-793.
12.	Träger K, Fritzler D, Fischer G, et al. Treatment of post-cardiopulmonary bypass SIRS by hemoadsorption: A case series. Int J Artif Organs, 2016, 39(3): 141-146.
13.	Dieleman JM, Nierich AP, Rosseel PM, et al. Intraoperative high-dose dexamethasone for cardiac surgery: A randomized controlled trial. JAMA, 2012, 308(17): 1761-1767.
14.	Pang XY, Fang CC, Chen YY, et al. Effects of ulinastatin on perioperative inflammatory response and pulmonary function in cardiopulmonary bypass patients. Am J Ther, 2016, 23(6): e1680-e1689.
15.	Dinarello CA. Historical insights into cytokines. Eur J Immunol, 2007, 37(Suppl 1): S34-S45.
16.	Kumar V. Toll-like receptors in sepsis-associated cytokine storm and their endogenous negative regulators as future immunomodulatory targets. Int Immunopharmacol, 2020, 89(Pt B): 107087.
17.	Nebelsiek T, Beiras-Fernandez A, Kilger E, et al. Routine use of corticosteroids to prevent inflammation response in cardiac surgery. Recent Pat Cardiovasc Drug Discov, 2012, 7(3): 170-174.
18.	De Iuliis V, Dadorante V, Marino A, et al. Cytokine expression profile and blood parameter evaluation of patients undergoing cardiac surgery. J Biol Regul Homeost Agents, 2017, 31(4): 1109-1113.
19.	Bernardi MH, Rinoesl H, Ristl R, et al. Hemoadsorption does not have influence on hemolysis during cardiopulmonary bypass. Asaio J, 2019, 65(7): 738-743.
20.	Carbonell R, Moreno G, Martín-Loeches I, et al. Prognostic value of procalcitonin and C-reactive protein in 1608 critically ill patients with severe influenza pneumonia. Antibiotics (Basel), 2021, 10(4): 350.
21.	Napp LC, Ziegeler S, Kindgen-Milles D. Rationale of Hemoadsorption during extracorporeal membrane oxygenation support. Blood Purif, 2019, 48(3): 203-214.
22.	Sun S, He L, Bai M, et al. High-volume hemofiltration plus hemoperfusion for hyperlipidemic severe acute pancreatitis: A control led pilot study. Ann Saudi Med, 2015, 35(5): 352-358.
23.	Kuebler WM, Goetz AE. The marginated pool. Eur Surg Res, 2002, 34(1-2): 92-100.
24.	Engels M, Bilgic E, Pinto A, et al. A cardiopulmonary bypass with deep hypothermic circulatory arrest rat model for the investigation of the systemic inflammation response and induced organ damage. J Inflamm (Lond), 2014, 11: 26.
25.	Morimoto K, Nishimura K, Miyasaka S, et al. The effect of sivelestat sodium hydrate on severe respiratory failure after thoracic aortic surgery with deep hypothermia. Ann Thorac Cardiovasc Surg, 2011, 17(4): 369-375.
26.	Hong B, Ling Z, Songmin H, et al. Continuous venovenous hemofiltration and hemoperfusion in successful treatment of a patient with crush syndrome and acute pancreatitis. Ren Fail, 2012, 34(3): 383.
27.	Scharf C, Liebchen U, Paal M, et al. Blood purification with a cytokine adsorber for the elimination of myoglobin in critically ill patients with severe rhabdomyolysis. Crit Care, 2021, 25(1): 41.

1. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases. Kardiol Pol, 2014, 72(12): 1169-1252.
2. Levy JH, Tanaka KA. Inflammatory response to cardiopulmonary bypass. Ann Thorac Surg, 2003, 75(2): S715-S720.
3. Ramadoss N, Dharmapuram AK, Goutami V, et al. Avoiding use of total circulatory arrest in the practice of congenital heart surgery. Indian J Thorac Cardiovasc Surg, 2021, 37(Suppl 1): 174-182.
4. Kousoulas L, Wittel U, Fichtner-Feigl S, et al. Hemoadsorption in a case of severe septic shock and necrotizing fasciitis caused by nontraumatic renal rupture due to pyelonephritis with obstructive uropathy. Case Rep Crit Care, 2018, 2018: 5248901.
5. Li Z, Wang G, Zhen G, et al. Effects of hemodialysis combined with hemoperfusion on severe acute pancreatitis. Turk J Gastroenterol, 2018, 29(2): 198-202.
6. Bernardi MH, Rinoesl H, Dragosits K, et al. Effect of hemoadsorption during cardiopulmonary bypass surgery—A blinded, randomized, controlled pilot study using a novel adsorbent. Crit Care, 2016: 20: 96.
7. Singh A, Mehta Y, Trehan N. Bilirubin removal using cytosorb filter in a cardiac surgical patient. J Cardiothorac Vasc Anesth, 2019, 33(3): 881-883.
8. Pomarè Montin D, Ankawi G, Lorenzin A, et al. Biocompatibility and cytotoxic evaluation of new sorbent cartridges for blood hemoperfusion. Blood Purif, 2018, 46(3): 187-195.
9. Yang J, Ji D, Zhu YQ, et al. Hemoperfusion with HA380 in acute type A aortic dissection patients undergoing aortic arch operation (HPAO): A randomized, controlled, double-blind clinical trial. Trials, 2020, 21(1): 954.
10. Cifani N, Proietta M, Tritapepe L, et al. Stanford-A acute aortic dissection, inflammation, and metalloproteinases: A review. Ann Med, 2015, 47(6): 441-446.
11. Gleason TG, Argenziano M, Bavaria JE, et al. Hemoadsorption to reduce plasma-free hemoglobin during cardiac surgery: Results of REFRESH Ⅰ Pilot Study. Semin Thorac Cardiovasc Surg, 2019, 31(4): 783-793.
12. Träger K, Fritzler D, Fischer G, et al. Treatment of post-cardiopulmonary bypass SIRS by hemoadsorption: A case series. Int J Artif Organs, 2016, 39(3): 141-146.
13. Dieleman JM, Nierich AP, Rosseel PM, et al. Intraoperative high-dose dexamethasone for cardiac surgery: A randomized controlled trial. JAMA, 2012, 308(17): 1761-1767.
14. Pang XY, Fang CC, Chen YY, et al. Effects of ulinastatin on perioperative inflammatory response and pulmonary function in cardiopulmonary bypass patients. Am J Ther, 2016, 23(6): e1680-e1689.
15. Dinarello CA. Historical insights into cytokines. Eur J Immunol, 2007, 37(Suppl 1): S34-S45.
16. Kumar V. Toll-like receptors in sepsis-associated cytokine storm and their endogenous negative regulators as future immunomodulatory targets. Int Immunopharmacol, 2020, 89(Pt B): 107087.
17. Nebelsiek T, Beiras-Fernandez A, Kilger E, et al. Routine use of corticosteroids to prevent inflammation response in cardiac surgery. Recent Pat Cardiovasc Drug Discov, 2012, 7(3): 170-174.
18. De Iuliis V, Dadorante V, Marino A, et al. Cytokine expression profile and blood parameter evaluation of patients undergoing cardiac surgery. J Biol Regul Homeost Agents, 2017, 31(4): 1109-1113.
19. Bernardi MH, Rinoesl H, Ristl R, et al. Hemoadsorption does not have influence on hemolysis during cardiopulmonary bypass. Asaio J, 2019, 65(7): 738-743.
20. Carbonell R, Moreno G, Martín-Loeches I, et al. Prognostic value of procalcitonin and C-reactive protein in 1608 critically ill patients with severe influenza pneumonia. Antibiotics (Basel), 2021, 10(4): 350.
21. Napp LC, Ziegeler S, Kindgen-Milles D. Rationale of Hemoadsorption during extracorporeal membrane oxygenation support. Blood Purif, 2019, 48(3): 203-214.
22. Sun S, He L, Bai M, et al. High-volume hemofiltration plus hemoperfusion for hyperlipidemic severe acute pancreatitis: A control led pilot study. Ann Saudi Med, 2015, 35(5): 352-358.
23. Kuebler WM, Goetz AE. The marginated pool. Eur Surg Res, 2002, 34(1-2): 92-100.
24. Engels M, Bilgic E, Pinto A, et al. A cardiopulmonary bypass with deep hypothermic circulatory arrest rat model for the investigation of the systemic inflammation response and induced organ damage. J Inflamm (Lond), 2014, 11: 26.
25. Morimoto K, Nishimura K, Miyasaka S, et al. The effect of sivelestat sodium hydrate on severe respiratory failure after thoracic aortic surgery with deep hypothermia. Ann Thorac Cardiovasc Surg, 2011, 17(4): 369-375.
26. Hong B, Ling Z, Songmin H, et al. Continuous venovenous hemofiltration and hemoperfusion in successful treatment of a patient with crush syndrome and acute pancreatitis. Ren Fail, 2012, 34(3): 383.
27. Scharf C, Liebchen U, Paal M, et al. Blood purification with a cytokine adsorber for the elimination of myoglobin in critically ill patients with severe rhabdomyolysis. Crit Care, 2021, 25(1): 41.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Safety and efficacy of hemoperfusion in cardiopulmonary bypass for postoperative inflammatory response in patients with acute Stanford type A aortic dissection: A randomized controlled trial

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