Intraoperative antithrombotic drug removal during urgent CABG: early German experience with a novel hemoadsorption device
U Zeymer, M Thielmann, K Hassan, A Meyer, T Eberle, B Panholzer, M Diekmann, T Donovan, H Mair, A Liebold, W Fan, D Wendt, E Deliargyris, M SchmoeckelAbstract
Background
Severe bleeding is very frequent when patients on antithrombotics require urgent coronary artery bypass grafting (CABG) before completing the recommended washout period. A novel hemoadsorption device is CE mark approved for intraoperative ticagrelor and rivaroxaban removal and may reduce this bleeding risk, which is reported to be 30-35%. The International Safe and Timely Antithrombotic Removal (STAR) registry captures real-world use and outcomes with this novel intervention.
Methods
The current analysis from 13 German heart centers includes 233 patients on ticagrelor or direct oral anticoagulants (DOAC) undergoing CABG before completing the recommended washout periods. The device was incorporated into the cardiopulmonary bypass (CPB) circuit and active for the duration of the pump run. Bleeding was assessed according to the Bleeding Academic Research Consortium (BARC-4) definition.
Results
Mean age was 66.6±10.1 years, 81.1% were male, and 75.5% were also on aspirin (n=233: 143 ticagrelor, 19 clopidogrel, 12 prasugrel, 22 apixaban, 10 rivaroxaban, 6 edoxaban, 3 dabigatran and 18 on multiple drugs). CABG was performed at an average time of 26.5±22.2 hours from the last antithrombotic dose. Preoperative EuroSCORE II was 5.9%±10.4%, while CPB duration (equal to device exposure) and aortic cross clamp time were 108.3±43.8 min. and 61.9±24.7 min., respectively. BARC-4 bleeding occurred in 7.5% while reoperation for bleeding control occurred in 3.0% of patients. Mean 24-hour chest tube drainage was 696±432 mL. No device-related adverse events occured and device integration into CPB was reported as feasible by all participating centers. The 30-day mortality rate was 5.6%.
Conclusions
The results of this German experience from the STAR registry suggest that intraoperative antithrombotic drug removal is a simple and safe procedure that can potentially reduce the high risk of bleeding in patients on antithrombotic drugs requiring urgent CABG.