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Removal of Ticagrelor | Stephan Geidel | EACTS 2019 | French Subtitles

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Update on CytoSorb blood purification therapy: Clinical and economical effects in cardiac surgery | EACTS 2019 | French Subtitles

Ladies and gentlemen mr chairman first of all i want to thank for the kind invitation and congratulate all the speakers before me for the excellent presentations it’s really an honor for me to be part of this group this afternoon i’m from hamburg and i work at st george hospital which is one of the oldest hospital institutions in europe and we are located directly

In the center of the city of hamburg at the water and we’re getting a lot of emergency cases from that whole metropolitan region that comprises about five million inhabitants now last year our group has published a paper on bleeding complications after use of novel oral anticoagulants in patients undergoing cardiac surgery and from that retrospective analysis

We concluded that despite official recommendations patients should not whenever possible be considered for elective cardiac operations within 10 days of noaa withdrawal during that research it was the first time for me that i really longed for a method to remove or extract drugs that cause major bleeding from the human blood during open-heart surgery and i want to

Show you that with the cytosorb we have such a method since the time of the first stent implantation stent thrombosis has been a serious problem in pci patients so the evolution of pci and here you see the data from germany the evolution of pci is still going on over the years has also been an evolution of anti-platelet therapy after pci i think you know this

Figure and there was one very important try the play to try that showed us how effective tiger grille is compared to clopidogrel both drugs showed major bleedings okay and i was really surprised that the recent investigation antigua grillo showed that it is inferior to prasa grill for reducing ischemic events anyway chicago is a very frequently given p2 epsilon

12 receptor antagonist it has a direct acting does not require metabolic activation as a rapid onset and it shows something very useful a high degree of protein binding now the 2017 esc guidelines for stimi patients they recommend to give such a potent p2 epsilon 12 receptor antagonist at latest at the time of pci so what happens when such a patient goes to the

Ur in the end he or she has a high incidence of major bleeding complications with this almost 40 percent on the first day and 25 or more in the second or third day so whenever it’s non-emergent then time is a really good antidote like these authors recommend just wait three or four days but what shall we do when it’s real emergency i think it was in april or

May 2017 that this experimental research was published that showed that the cytosorb is able to remove ticagrelor from the human blood what cytosorb is what it can we have heard this it uses a high-tech polymer technology it has a big surface and it is able to remove medium-sized molecules now the first time we used it was in june 2017 and i had to operate on

It was a friday evening on the type aortic dissection and was a young patient and he was freshly loaded with tiger griloa after pci for the circumflex artery and still remember it as if it was yesterday we we had a short time to talk to that patient said man this is really high risk surgery and it’s even more risky because you have taken that drug and we have

To do something and this is what a perfusionists of us made a drawing and said we take that cytosorb and put it into the hot lung machine between the venous reservoir and the oxygenator in that small circulate and try to remove the ticagrill off from the blood patient agreed and this is the setting now we used and we published in when you are interested in the

Details of everything you would like to invite you to have a look at our paper that we published on this this is another image after cardi pulmonary bypass it’s from from from the local journal we published this in hamburg now let’s look at these 43 patients all patients underwent emergency cardiac surgery at our institution between june 2016 and june 2018 it

Was a retrospective single center analysis and 32 of these cases had that cytosol absorption that we first used in june 2017 in other words we had a very small control group of only 11 patients done the year before but same surgeons same procedures now is there a blood test to validate effectiveness of such a meth method now there is that multi-plate analyzer

That offers the possibility of a rapid determination of platelet function the point in the sense of a point-to-care investigation is that small machine and upon activation platelets aggregate on metal sensors at us as you see it here so when the method works we see a nice increase of that levels now during that period we didn’t have that multiplate so we will

Have it in the future but during that time we we took the blood from only five patients and gave it to another institution so this is really a small data set but i think it’s interesting enough to give the information to you today and maybe discuss it later now let’s first look at the baseline characteristics of these patients now we have that cytosol group

32 we have a small control group 11 patients all were true emergency cases and all had an underlying coronary artery disease and the first thing we realized in that retrospective analyzes was that we had saved operation time with the cytosol more than an hour and we had saved red blood cell transfusions seventy eight percent did not need any blood cell transfer

Transfusion and the reason is they bleeded less here you see the drainage volume of that patients over 24 hours and you see aggressive bleeding without adsorption and you see more or less normal blood loss in that cytosol group the mean value was 350 milliliters and we all know this is normal after cabbage and there was no rhetorical to me in that group compared

To four of eleven in the other where the short icu you stay and with a shorter total length of stay now patients done with adsorption did not need any platelet transfusion in half of the cases and when they needed they only needed one compared to all of the patients done without adsorption and half of them needed two or more platelet transfusion now let’s look

At that very small data set of the multi-plate patients here you see something very familiar the platelet counts pre and post cardiopulmonary bypass you see a decrease of the values which is normal but you see when you look at patient number four that he had a decrease below 100 000 and that was the only one who did not show a nice increase of the values in the

Multiplate he showed a decrease and this was the only one of this group who had a really high drainage volume afterwards and the truth is we don’t know why he was old okay he had low platelet numbers okay but maybe albumin was loaded with other drugs or the adsorption came upon against limiting factors we don’t know this is only one of the open questions the

Other is the duration time of absorption to fully eliminate the drug from the body is unclear and what about the effectiveness in norwalk patients some noaak have protein binding too now this is a figure from our or graphical abstract from our publication and here you see in number 55 we included 12 patients who were operated under rivaroxaban and when we now

Look at that figure of the drainage volumes you see here tikka grilloy you see here rivaroxaban almost the identical figures so the rivaroxaban patients showed less bleeding recently removal of dabikatran has been shown an experimental study some weeks ago and another interesting paper is that a reversal agent for tiger griloa has been tested in a phase one trial

I think in a few years we can use it but i guess it will be expensive so let’s talk about costs if bg impact analysis was done of that small data set we saw improvements we saw decreases is it cost relevant statistical analysis was done including a bootstrap analysis for calculations of costs and two things we identified the cost of icus they had the highest

Impact on level of cost savings as you can see it here and the other was that adsorption generated savings calculated as about 3 700 euro without reimbursement so when you reimburse the absorber is maybe 5000 or something like this so we saw both medical and economic benefits of the cytosol by reduced operation time faster discharge generally improved patient

Blood management of course there are a lot of limitations it was a non-randomized observational study of a single center what really limits the breadth of conclusions we had only 55 patients and the control groups were small as i mentioned so definitely prospective investigations are required and this is what we are going to do with the support of experienced

Other centers and the protocols are written we just have to give it to the ethics committee and hopefully we can answer more of these questions in the near future for now for today the adsorption method has become our standard procedure in patients loaded with ticker galore and also rivaroxaban and finally i want to show you one more case i think you see on one

Glimpse what had happened it was a young woman with a coronary artery disease of that big right coronary artery and what happened was a desection during pci and the patient was loaded under ticker grille but in that case that i operated on i felt so much more comfortable and confident because i knew that we now overlook 61 patients done with the absorber and we

Had only one rhetoric to me among them and that was a real surgical bleeding a detached clip and the icu’s daytime was so short so i can only encourage you to make your own experience with this i think you will really like this method thank you very much for your attention

Transcribed from video
Removal of Ticagrelor | Stephan Geidel | EACTS 2019 | French Subtitles By CytoSorb