Abstract
Cytosorb, an extracorporeal blood purification system, utilises the principles of haemoadsorption to remove low molecular weight substances from the blood, including multiple cytokines such as interleukin (IL)-1b, IL-6, IL-8, and tumour necrosis factor-α, and anti-platelet drugs aiming to improve clinical outcomes. Given the prominent role of pro-inflammatory cytokines in various inflammatory states, Cytosorb has seen growing application as a therapeutic immunomodulator including surgery. This review focuses on the effects of the use of Cytosorb in patients undergoing coronary artery bypass grafting (CABG) and the indications of removal of cytokines and anti-platelet agents such as ticagrelor. The evidence supports the feasibility and safety profile of Cytosorb, with no device-related adverse events reported in all studies. Initial studies suggest significant potential for Cytosorb in urgent or emergency CABG surgery to remove anti-platelet medication with promising benefits on clinical outcomes including fewer blood product transfusions, decreased length of intensive care unit stay, and lower re-sternotomy rates. Furthermore, a cost saving analysis indicated that intraoperative removal of ticagrelor with Cytosorb would be cost effective in the setting of emergency cardiac surgery. However, the evidence remains inconclusive when Cytosorb is used in elective CABG surgery for cytokine removal. Definite high quality clinical trials for both indications for Cytosorb in CABG surgery are needed to clarify if there is a clinically significant benefit in clinical outcomes. There is substantial trial activity for the application of Cytosorb in higher risk cardiac surgery to establish the place of Cytosorb in future treatment pathways in cardiac surgery.
Highlights
Cytosorb is an extracorporeal blood purification system characterised by a large surface area due to the special design of biocompatible absorbent polymer micro-beads
As an approved technology for multiple cytokine removal, Cytosorb has excellent adsorption rates for multiple inflammatory cytokines such as interleukin (IL)-1b, IL-6, IL-8, and tumour necrosis factor (TNF)-α, which has translated to improved clinical outcomes such as resolution of shock[2] and a significant reduction in mortality[3] when used in the context of inflammatory conditions such as sepsis
Open-heart surgery, those with long cardiopulmonary bypass (CPB) times, initiates a complex inflammatory response known as systemic inflammatory response syndrome (SIRS)[5]
Summary
Cytosorb is an extracorporeal blood purification system characterised by a large surface area due to the special design of biocompatible absorbent polymer micro-beads. Poli et al.[22] conducted a pilot RCT with 30 patients and reported no significant difference in IL-1α, IL-1b, IL-2, IL-4, IL-5, IL-6, IL-10, interferon-γ, monocyte chemoattractant protein-1, TNF-α, or any clinical outcomes including use of post-operative inotropes, duration of mechanical ventilation, acute kidney injury, length of intensive care unit (ICU) stay and ICU and hospital mortality. Taleska Stupica et al.[24] conducted a parallel 3-arm RCT of 60 patients comparing Cytosorb adsorption, intraoperative methylprednisolone and standard care (no haemoadsorption or additional drug therapy) and suggested that intraoperative glucocorticoids are superior to both Cytosorb and standard care They reported that methylprednisolone administration was associated with lower pro-inflammatory cytokines TNF-α, IL-6, and IL-8, and higher anti-inflammatory cytokines IL-10 when compared to both in the Cytosorb and control group.
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