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International Society For Minimally Invasive Cardiothoracic Surgery

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Intraoperative Removal Of Ticagrelor And Rivaroxaban During Emergency Cardiac Operations Using A Cytokine Adsorber
Michael Schmoeckel, Kambiz Hassan, Jochen Kannmacher, Peter Wohlmuth, Stefan Geidel.
AK St. Georg, Hamburg, Germany.

OBJECTIVE: The number of cardiac patients being treated with novel anticoagulants and/or ticagrelor preoperatively is increasing. Antidots are expensive or unavailable up to date. In order to reduce bleeding complications we therefore used a cytokine adsorber containing polymer beads during emergency cardiac surgery in patients with anti-platelet/ coagulant medication.
METHODS: We investigated 55 consecutive patients (median age 70 years) who underwent emergency cardiac surgery at our institution between 06/2016 and 06/2018. All patients were on preoperative therapy with either Ticagrelor (n=43) or Rivaroxaban (n=12). Since 04/2017 we routinely installed a standardized cytokine adsorber into the heart-lung-machine circuit in 39 cases. Bleeding complications during and after surgery were analyzed in detail and compared to the 16 patients treated before without adsorption.
RESULTS: After adsorption chest drainage volumes over 24-hours were reduced from 890 to 350 ml after Ticagrelor administration and 600 to 390 ml after Rivaroxaban therapy (p=0.004). Therefore the majority of patients in the adsorber group did not receive transfusions of blood products. In patients without adsorption, multiple bleeding complications occurred. These were associated with extended operation times (p=0.004), more transfusions of red blood cells (p=0.01) and platelets (p=0.047), a significantly higher re-thoracotomy rate (36% and 40% vs. none; p=0.0003), prolonged ICU stay (p=0.01) and a longer hospital stay (p=0.02).
CONCLUSIONS: Intra-operative use of a cytokine adsorber containing polymer beads for removal of Ticagrelor and Rivaroxaban during emergency open-heart surgery is a safe and effective method to reduce bleeding complications. We recommend the routine use as long as appropriate antidots are not available.


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