Use of CytoSorb therapy to treat critically ill coronavirus disease 2019 patients: a case series.

BACKGROUND: Acute respiratory distress syndrome is an important clinical presentation of respiratory complications caused by severe acute respiratory syndrome coronavirus 2, a novel coronavirus responsible for the ongoing pandemic. The disease is poorly understood, and immunopathogenesis is constantly evolving. Cytokine release syndrome remains central to pathology of coronavirus disease 2019. Antivirals, anticytokine treatment, and other pharmacological approaches have failed to treat it. CytoSorb, an extracorporeal cytokine adsorber that reduces the cytokine storm and other inflammatory mediators in the blood, seems promising in treating severely ill patients with coronavirus disease 2019. CASE PRESENTATION: This article presents three cases of Asian ethnicity of severely ill adult patients with coronavirus disease 2019 admitted to intensive care unit who were treated with CytoSorb therapy. All patients used single CytoSorb device. During their clinical course, all patients were prescribed tocilizumab (an interleukin-6 receptor blocker), antivirals, hydroxychloroquine, azithromycin, and other antibiotics and general antipyretic drugs. No vasopressor treatment was required. The patients' average duration of stay in intensive care unit was 30 days; the average duration of stay in hospital was 31 days. All three patients showed significant improvement in biochemical parameters and clinical outcomes post CytoSorb therapy. C-reactive protein levels decreased by 91.5%, 97.4%, and 55.75 %, and mean arterial pressure improved by 18%, 23%, and 17 % in patient 1, 2, and 3, respectively, on day 7 post-therapy. CONCLUSIONS: All three patients improved clinically and survived.

Ruptured abdominal aortic aneurysm with aortocaval fistula and embolic IVC thrombus-a rare clinical scenario detected on CT angiography.

Rupture with fistulization of an abdominal aortic aneurysm with the vena cava is a rare complication and typically presents with congestive cardiac failure. Embolization of a thrombus from the aneurysm into the vena cava can however present in the absence of failure symptoms which can make it difficult to diagnose clinically without cross sectional imaging.

Experience with hemoadsorption (CytoSorb®) in the management of septic shock patients.

BACKGROUND: Cytokines and inflammatory mediators are the hallmarks of sepsis. Extracorporeal cytokine hemoadsorption devices are the newer clinical support system to overcome the cytokine storm during sepsis. AIM: To retrospectively evaluate the clinical outcomes of patients admitted in intensive care unit with septic shock with different etiologies. METHODS: The laboratory parameters including biomarkers such as procalcitonin, serum lactate and C-reactive protein; and the hemodynamic parameters; mean arterial pressure, vasopressor doses, sepsis scores, cytokine levels and other vital parameters were evaluated. We evaluated these outcomes among survivors and non-survivors. RESULTS: Of 100 patients evaluated, 40 patients survived. Post treatment, the vasopressors dosage remarkably decreased though it was not statistically different; 34.15% (P = 0.0816) for epinephrine, 20.5 % for norepinephrine (P = 0.3099) and 51% (P = 0.0678) for vasopressin. In the survivor group, a remarkable reduction of biomarkers levels; procalcitonin (65%, P = 0.5859), C-reactive protein (27%, P = 0.659), serum lactate (27%, P = 0.0159) and bilirubin (43.11%; P = 0.0565) were observed from baseline after CytoSorb® therapy. A significant reduction in inflammatory markers; interleukin 6 and interleukin 10; (87% and 92%, P < 0.0001) and in tumour necrosis factor (24%, P = 0.0003) was also seen. Overall, 28 (28%) patients who were given CytoSorb® therapy less than 48 h after onset of septic shock survived and the maximum duration of stay for 70% of these patients in intensive care unit was less than 15 d. CONCLUSION: CytoSorb® is a safe and well tolerated rescue therapy option in patients with septic shock. However, early (preferably within < 48 h after onset of septic shock) initiation could result in better clinical outcomes. Further randomized trials are needed to define the potential benefits of this new treatment modality.

Impaired substrate-mediated cardiac mitochondrial complex I respiration with unaltered regulation of fatty acid metabolism and oxidative stress status in type 2 diabetic Asian Indians.

BACKGROUND: The cardiovascular complications associated with type 2 diabetes mellitus could be attributed to changes in myocardial mitochondrial metabolism. Though it is a known fact that permeabilized cardiac muscle fibers and isolated mitochondria are metabolically compromised in the Caucasian population, studies of Asian Indian myocardial mitochondrial function are lacking. Thus, the objective of the present study is to analyze if there is altered cardiac mitochondrial substrate utilization in diabetic Asian Indians. METHODS: Mitochondrial substrate utilization was measured using high-resolution respirometry in isolated mitochondria prepared from right atrial appendage tissues of diabetic and nondiabetic subjects undergoing coronary artery bypass graft surgery. Western blotting and densitometric analysis were also done to compare the levels of proteins involved in fatty acid metabolism and regulation. RESULTS: The mitochondrial oxygen consumption rate for fatty acid substrate was shown to be decreased in diabetic subjects compared to nondiabetic subjects along with an unvaried mitochondrial DNA copy number and uniform levels of electron transport chain complex proteins and proteins involved in fatty acid metabolism and regulation. Decreased glutamate but unchanged pyruvate-mediated state 3 respiration were also observed in diabetic subjects. CONCLUSION: The current study reports deranged cardiac mitochondrial fatty acid-mediated complex I respiration in type 2 diabetic Asian Indians with comparable levels of regulators of fatty acid oxidation to that of nondiabetic myocardium. Altered glutamate-mediated mitochondrial respiration also points toward possible alterations in mitochondrial complex I activity. When compared with previous reports on other ethnic populations, the current study suggests that Asian Indian population too have altered cardiac mitochondrial substrate utilization.

Distortion of aortic valve from mechanical traction imposed by the mitral valve prosthesis: The three-dimensional transesophageal echocardiographic perception.

Iatrogenic injury to the aortic valve is a rare but frequently reported complication during mitral valve surgeries. Intraoperative 2-dimensional transesophageal echocardiography (2D TEE) has a major impact in diagnosing these injuries, so that timely intervention is possible. However, 2D TEE has lot of limitations during the perioperative period, which can be overcome by the three dimensional echocardiography (3D-TEE). We report a case where 3D TEE has undoubtedly delineated the cause for distortion of aortic sinus after mitral valve replacement and helped in the successful outcome.