Intraoperative Hemoadsorption Reduces Sepsis-Related Death in All-Comers Undergoing Surgery for Infective Left-Sided Endocarditis

Background: Infective endocarditis (IE) remains a deadly disease associated with an in hospital mortality of 10 to 30%. Septic multi-organ failure remains an important factor of mortality, even after curative surgery. Hemoadsorption (HA) therapy during cardiopulmonary bypass (CPB) has been shown to reduce septic-related mortality in patients with IE of the native mitral valve. The objective of this study was to assess the efficacy of intraoperative HA in patients with left-sided IE, including prosthetic valve endocarditis.

Method: A total of 197 patients with confirmed left-sided acute IE of the native valve or prosthetic valve and urgent indication for surgery were enrolled in the study. All patients underwent cardiac surgery consisting of extensive debridement and predominantly replacement of the affected valve(s) between January 2015 and March 2021. Two cohorts were generated according to the actual standard of care at the department in retrospective, sequential design. The first cohort (Control) included 101 patients who underwent surgery without intraoperative HA. The second cohort (HA) consisted of 96 patients where HA adsorber cartridge has been installed into the CPB for its entire duration. The primary end points were sepsis related death and 30-day mortality. In addition, multivariate stepwise regression analysis was performed to identify factors for sepsis-related and all-cause mortality.

Results: There were no statistically significant differences of baseline characteristics between HA and control group, except for higher proportion of gram-positive bacteria as causative pathogen in the control group (90 vs. 80.2%, p = 0.029). Patients’ operative characteristics and laboratory values were also comparable, except for more frequent application of cold crystalloid cardioplegia in HA, 35.4 versus 6.9% in control group (p ˂ 0.001).Sepsis related death was more common in control group (HA vs. control: 7.3 vs. 19%, p = 0.027). Trend toward lower 30-day mortality was observed (11.5% in HA vs. 20.8% in control, p = 0.114). Multivariate analysis identified Staphylococcus infection (p = 0.008), absence of HA (p = 0.004), and cumulative inotropes 24 hours after operation (p = 0.001) as leading factors for sepsis-related death, and preoperative CRP, cumulative inotropes 24 hours after operation (both p = 0.003), postoperative dialysis and lactate levels at 24 hours after operation (both p = 0.004) as leading factors for 30-day mortality.

Conclusion: HA treatment was well tolerated and safe. Intraoperative HA reduced sepsis related death. Our data suggest that intraoperative hemoadsorption improves surgical outcomes also in all-comers for left-sided IE.

Publication History

Article published online:
03 February 2022