The use of CytoSorb hemoadsorption to manage anticoagulation during cardiopulmonary bypass (CPB) has emerged as a promising strategy in high-risk cardiac surgery patients. This short communication from the Journal of Heart and Lung Transplantation Open presents a case study that underscores the clinical feasibility and potential effectiveness of intraoperative apixaban removal using the CytoSorb device during emergency heart transplantation.
The article details the case of a 61-year-old male patient with end-stage heart failure, who had been anticoagulated with apixaban prior to undergoing orthotopic heart transplantation. As the surgery could not be delayed and apixaban has a half-life incompatible with the tight scheduling demands of heart transplantation, a novel approach was employed: integrating the CytoSorb hemoadsorption cartridge into the CPB circuit to remove the anticoagulant in real time.
The patient’s anticoagulation profile was closely monitored through serial measurements of Anti-Factor Xa Activity (AFXaA). Initial levels were 330 ng/mL at anesthesia induction, reducing significantly during the CPB to 137 ng/mL, and further down to 57 ng/mL at the conclusion of bypass and protamine administration. Notably, the patient experienced no bleeding complications or need for reintervention during the critical postoperative period, and no evidence of primary graft dysfunction (PGD) was observed despite the extended ischemic time of the donor heart.
CytoSorb works through a hemoperfusion process using a cartridge filled with biocompatible polymer beads that remove hydrophobic small and medium-sized molecules from the bloodstream. Originally designed for use with cytokines, this approach has shown promise in removing direct oral anticoagulants (DOACs) such as apixaban, especially in emergency settings where standard reversal agents like Andexanet alfa may not be suitable due to cost, interaction with heparin, or unproven efficacy in cardiac surgery.
The authors highlight that the CytoSorb cartridge’s integration into the CPB system was seamless and allowed continuous drug clearance without disrupting surgical workflow. Compared to prothrombin complex concentrates or other pharmacologic strategies, hemoadsorption offers a mechanical solution that is not dependent on patient-specific drug metabolism or renal function, which is particularly relevant in this patient who had chronic kidney disease.
While AFXaA levels remained above the “safe” threshold of 30 ng/mL postoperatively, there were no adverse bleeding events, indicating that the substantial reduction in apixaban levels achieved intraoperatively may be clinically sufficient. The authors point to earlier research supporting the use of hemoadsorption for DOAC removal and reference ongoing studies like the STAR-D trial, which aim to validate the broader efficacy of this approach.
In this patient, the use of CytoSorb may also have contributed to the prevention of PGD through the removal of inflammatory mediators, suggesting a dual benefit in high-risk cardiac transplant cases. However, the authors caution that hemoadsorption could potentially interact with anesthetic or vasoactive medications, requiring careful perioperative monitoring.
Ultimately, this study supports the feasibility and safety of using CytoSorb hemoadsorption in emergent cardiac surgeries involving patients on apixaban. While larger trials are necessary to confirm these findings and develop standardized protocols, this case adds to the growing body of evidence advocating for innovative anticoagulation management techniques in cardiac transplantation and other urgent surgeries.
This paper also touches on broader implications for anticoagulation strategies in transplant candidates. Traditionally, such patients are switched from DOACs to vitamin K antagonists (VKAs) to manage bleeding risk; however, this study implies that with tools like CytoSorb, such a switch may not be necessary, simplifying patient management and improving quality of care.
Study ranking = 2 (case report with limited generalizability; promising but requires validation through larger controlled studies)
