Hemoadsorption during cardiopulmonary bypass to absorb plasma-free hemoglobin in patients with acute type a aortic dissection: A randomized controlled trial

Abstract

Aims

This study aimed to investigate the effect of hemoadsorption (HA) on plasma-free hemoglobin (pfHb) levels during cardiopulmonary bypass (CPB) and the clinical outcomes in patients with acute type A aortic dissection (ATAAD).

Methods

In this single-center randomized trial, patients were assigned to either a group using the HA380 device or a control group without it. The primary outcome was changes in pfHb levels during CPB and within the first 48 hours after surgery. The study concentrated on comparing compared the data between the two groups using analysis of variance for repeated measures. Concurrently, both correlation and linear regression analyses were employed to identify the factors influencing pfHb levels.

Results

The mean pfHb concentration was lower in the HA380 group than in the control group,but there were no significant differences between the two groups (F = 2.883, 95% confidence interval CI: −0.006 to 0.072, p = .093) using a repeated measures analysis of covariance model. Linear regression analysis identified body mass index (BMI) as the primary factor influencing the adsorption effect (B = 0.01, 95% CI: 0.36–1.24, p = .001). Additionally, the major postoperative complications within the first 48 hours did not show significant differences between the groups, including acute kidney injury (AKI) (25% HA380 group vs 36% control group, p = .261) and postoperative liver dysfunction (PLD) (5% HA380 group vs 16% control group, p = .106).

Conclusion

The use of the HA380 device in CPB during cardiac operations may contribute to reduced pfHb levels. However, the difference was statistically non-significant because pfHb adsorption was notably influenced by the patient’s BMI. Consequently, BMI should be considered when deploying HA380 in prolonged CPB procedures, including ATADD repair. Enhancing either the number of devices or the duration of HA in patients with overweight or obesity may potentially improve postoperative clinical outcomes.

Keywords

hemoadsorption cardiopulmonary bypass acute type a aortic dissection plasma-free hemoglobin randomized controlled trial

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References

Fausto

Tatu

Antonio

, et al. Current outcome after surgery for type A aortic dissection. Ann Surg; 278: 885–892.

Kevin

Christoph

Mark

, et al. Early mortality in type A AcuteAortic dissection: insights from the international Registry of acute aortic dissection. JAMA Cardiol 2022; 7: 1009–1015.

Bartosz

Oliver

Martin

. Acute aortic dissection: evidence, uncertainties,and future therapies. Eur Heart J 2023; 44: 813–821.

Eric

Ourania

James

, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American heart association/American college of cardiology joint committee on clinical PracticeGuidelines. Circulation 2022; 146: 334–482.

Masayuki

Tamaki

. Hemolytic anemia caused by aortic flap and inversion of felt strip after ascending aorta replacement. J Cardiothorac Surg 2016; 11: 117–124.

Catherine

Hϋlya

Patrick

, et al. Association between hyperoxemia and increased cell-free plasma hemoglobin during cardiopulmonary bypass in infants and children. Pediatr Crit Care Med 2022; 23: 111–119.

Iris

CVW

Norbert

CJW

Jonas

TCS

, et al. Hemolysis during cardiac surgery is associated with increased intravascular nitric oxide consumption and perioperative kidney and intestinal tissue damage. Front Physiol 2014; 8: 340–349.

David

Lorraine

. The role of red blood cells and cell-free hemoglobin in the pathogenesis of ARDS. J Intensive Care 2015; 17: 3–20.

Jamie

Julie

Lorraine

. Toxic effectsof cell-free hemoglobin on the microvascular endothelium: implications for pulmonary and nonpulmonary organ dysfunction. Am J Physiol Lung Cell Mol Physiol 2021; 321: 429–439.

10.

Kristof

Erfan

Sacha

. Mechanisms of haemolysis-induced kidney injury. Nat Rev Nephrol 2019; 15: 671–692.

11.

Leen

. Hemolysis in cardiac surgery patients undergoing cardiopulmonary bypass: a review in search of a treatment algorithm. J Extra Corpor Technol 2008; 40: 257–267.

12.

Elettra

Lorenzo

Anna

, et al. Cytokine clearance with CytoSorb during cardiac surgery: a pilot randomized controlled trial. Crit Care 2019; 23: 108–120.

13.

Kuhne

Binczyk

Rieβ

. Comparison of intraoperative versus intraperative plus postoperative hemoadsorption therapy in cardiac surgery patients with endocarditis. Int J Artif Organs 2019; 42: 194–200.

14.

Bernardi

Rinoesl

Dragosits

, et al. Effect of hemoadsorption during cardiopulmonary bypass surgery - a blinded, randomized, controlled pilot study using a novel adsorbent. Crit Care 2016; 20: 96–109.

15.

Nierhaus

Morales

Wendt

, et al. Comparison of the CytoSorb ^® 300 mL and Jafron HA380 hemoadsorption devices: an in vitro study. Minim Invasive Ther Allied Technol 2022; 31: 1058–1065.

16.

Sheng

Guiyu

Lijing

, et al. Using machine learning to predict postoperative liver dysfunction after aortic arch surgery. J Cardiothorac Vasc Anesth 2021; 35: 2330–2335.

17.

Christina

Alexander

. Diagnosis of cardiac surgery-associated acute kidney injury. J Clin Med 2021; 10: 3664–3672.

18.

John

Norbert

KDIGO AKI Guideline Work Group . Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Crit Care 2013; 17: 204–219.

19.

Montin

Ankawi

Lorenzin

, et al. Biocompatibility and cytotoxic evaluation of new sorbent cartridges for blood hemoperfusion. Blood Purif 2018; 46: 187–195.

20.

Poli

Rimmelé

Schneider

. Hemoadsorption with CytoSorb®. Intensive Care Med 2019; 45: 236–239.

21.

Zijian

Hongyu

Xuhua

, et al. The efficacy of resin hemoperfusion cartridge on inflammatory responses during adult cardiopulmonary bypass. Blood Purif 2022; 51: 31–37.

22.

Yang

Zhu

, 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: 954–964.

23.

Thomas

Michael

Joseph

, et al. Hemoadsorption to reduce plasma-free hemoglobin during cardiac surgery: results of REFRESH I pilot study. Semin Thorac Cardiovasc Surg 2019; 31: 783–793.

24.

Mark

Tamir

Daniel

BKS

. Hemolysis and cell-free hemoglobin drive an intrinsic mechanism for human disease. J Clin Invest 2012; 122: 1205–1208.

25.

Iris

CVW

Maarten

Sebastiaan

, et al. Hemolysis is associated with acute kidney injury during major aortic surgery. Kidney Int 2010; 77: 913–920.

26.

Emanuele

Fumito

Sabrina

, et al. Pulmonary and systemic vascular resistances after cardiopulmonary bypass: role of hemolysis. J Cardiothorac Vasc Anesth 2017; 31: 505–515.

27.

Rosemary

Apayne

Geoffrey

. Higher donor body mass index is associated with increased hemolysis of red blood cells at 42-days of storage: a retrospective analysis of routine quality control data. Transfusion 2021; 61: 449–463.

28.

Kelsey

Fang

Marjorie

, et al. Blood donor obesity is associated with changes in red blood cell metabolism and susceptibility to hemolysis in cold storage and in response to osmotic and oxidative stress. Transfusion 2021; 61: 435–448.

29.

Roberta

Mariangela

Samantha

, et al. Decreased membrane fluidity and altered susceptibility to peroxidation and lipid composition in overweight and obese female erythrocytes. J Lipid Res 2004; 45: 1846–1851.

30.

Jill

Anthony

Kelly

, et al. Elevated free hemoglobin and decreased haptoglobin levels are associated with adverse clinical outcomes, unfavorable physiologic measures, and altered inflammatory markers in pediatric cardiac surgery patients. Transfusion 2018; 58: 1631–1639.

31.

Keyvan

Jeannie

Jason

, et al. Red cell transfusion-associated hemolysis in cardiac surgery: an observational cohort study. Anesth Analg 2017; 124: 1986–1991.

32.

Diab

Lehmann

Bothe

, et al. Cytokine hemoadsorption during cardiac surgery versus standard surgical care for infective endocarditis (REMOVE): results from a multicenter randomized controlled trial. Circulation 2022; 145: 959–968.