 Good afternoon from Athens, Greece. My name is Victoria Vasiliadou, and I'm a cardiovascular perfusionist at 4-1 General Military Hospital of Athens at the Joint Corps Armed Forces Cardio-Surgery Department. I'm honored today to be invited to present in this exceptional perfusion conference that we are celebrating the 50th anniversary of the HCI School of Perfusion Technology. I want to express for one more time my gratitude to Mr. Crane and all my instructors during my education. Today, I'm going to present to you a case report of mitral valve replacement for infective endocarditis with the use of cytokine absorption filter during cardiopulmonary bypass. Infective endocarditis, also called bacterial endocarditis, is an infection caused by bacteria that enter the bloodstream and settle in the heart lining, a heart valve, or a blood vessel. It's an uncommon disease with a yearly incidence three to 10 per 100,000 people. The causes and epidemiology of the disease have evolved in recent decades with the doubling of the average patient aid and an increased prevalence in patients within dwelling cardiac devices. The microbiology of the disease has also changed and staphylocal key most often associated with health care conduct and invasive procedures have overtaken streptococcy as the most common cause of the disease. Although novel diagnostic and therapeutic strategies have emerged, one year mortality has not improved and remains at 30%, which is worse than for men cancers. There are two forms of infective endocarditis. They are acute with zebralobs abruptly and progresses suddenly in a few days with high fever, fast heart rate, fatigue, rapid and extensive heart valve damage. And the subacute which develops slowly with fatigue, mild fever, weight loss, sweating and low red blood count. There are local consequences, myocardial abscesses with tissue distraction and sometimes conduction system abnormalities, usually with low septal abscesses. The sudden severe valve or regurgitation will cause heart failure and death and now it is due to contiguous spread of infection. The systemic consequences are due to embolization of infected material from the heart valve. They're immune mediated phenomena primarily in chronic infection. The right-sided lesions typically produce septic pulmonary emboli and then left-sided lesions may embolize to any tissue, particularly kidney, spleen and central nervous system. These patients are at high risk for developing systemic inflammatory response and septic shock as a result of the bacteria spread out from valve vegetations. The surgery of valve repair or valve replacement is indicated in patients with heart failure, particularly those with prosthetic valve, pulmonary edema, cardiogenic shock with uncontrolled infection at risk of embolism from large vegetation or recurrent emboli. The timing of surgery requires experienced clinical judgment. If heart failure caused by a correctable lesion is worsening, particularly when the organism is staphylococcus aureus or a fungus, surgery may be required after only 24 to 72 hours of antimicrobial therapy. The surgical procedure, together with cardiopulmonary bypass in a patient with an underlying infective endocrinitis disease represent an intervention with increased risks. The combination of surgical trauma, the bacteria spread out and artificial cardiopulmonary bypass surface results in a release of key inflammatory mediators such as tumor necrosis factor A, interleukin 6, 8 and 10. This may finally lead to an overshooting of the systemic hyperinflammatory state frequently resulting in hemodynamic instability and induced organ dysfunction such as respiratory failure, acute kidney injury and cognitive dysfunction. Another factor that may increase the risk of developing severe serious postoperatively is the prolonged CPB surgery. Postoperative therapeutic management of these patients includes an appropriate and effective therapy in combination with therapeutic approaches maintaining vital organ function. Since inflammatory mediators are the key triggers of inflammation and post cardiopulmonary bypass series intra or postoperative removal of such mediators with a cytokine absorber has previously been described as a useful approach to control these hyperinflammatory processes to restore immune homeostasis and potentially prevent post CPB series and multiple organ dysfunction syndrome. Currently their devices use as an adaptive treatment to standard therapy in subjects suffering from serious severe sepsis or septic shock to support the removal of cytokines as well as other inflammatory mediators via direct whole blood hem absorption. This is a polymer bead-based cytokine hem absorption cartridge approved in Europe. It can be used in combination with conventional hemodialysis machines or with cardiopulmonary bypass systems. Our case report now a 49 year old Greek previously healthy female mother of two was presented in the emergency unit of a peripheral hospital with fever temperature 37.8 degrees Celsius and shortness of breath for one day. On admission, her vital parameters were respiratory rate at 10 per minute temperature 37.8 degrees Celsius, heart rate 105 per minute, blood pressures 95 to 50. Her systemic physical examination revealed no significant abnormalities. The two-dimension echocardiography that was performed found normal left ventricular function with ejection fraction 60%, severe pulmonary artery hypertension with severe mitral ergurgitation with posterior leaflet vegetations. The blood cultures revealed proteus mirabilis and a triple antibiotic therapy with vancomycin, seftrioxone, and gundamysin were started. At that time, the patient already required moderate nor epic support for hemodynamic stabilization. In the following days, it was intubated due to development of severe non-conversated pulmonary edema while her temperature range between 39 to 40 degrees Celsius. After her hemodynamic stabilization, the patient was transferred to our hospital. For the consultant meeting, the surgical treatment was decided. The patient was scheduled for coronary angiography. However, in the meantime, she had suffered an acute myocardial infarction. The coronary angiography revealed an obstructed small abuse marginal brands without other abnormalities. Due to progressive hemodynamic instability, no rapid support was supplemented by vasopressin and the butamine administration, under which blood pressure could be kept stable. Additionally, an introverted ballon palm was inserted to support and improve preoperative hemodynamic condition. The routine blood evaluation revealed anemia, leukocytosis, as well as elevated bilirubin presepsin and the troponin T was high to 27,000 nanograms per liter. During the following days, the antibiotic regimen was changed to a six-plis seam 16 of six antibiotics. The serum creatinine levels were increased to 2.5 milligrams per deal, confirming the diagnosis of acute kidney injury that was treated with continuous intravenous infusion of furosamide and not continuous renal replacement therapy. The blood cultures were negative, but temperature remained at 39 degrees Celsius. For surgeries, troponin levels were required to be below 5,000 nanograms per liter. The surgery was performed on the 13th day of hospitalization and on the seventh day post-myocardial infarction, a mitral valve replacement procedure using a heart lung machine that was run in conjunction with hemoabsorption therapy was decided by the surgery team. The reason for using a cytokine absorption filter, it was that she was a highly septic post-infarction patient at risk of an additional episode of cytokine storm as a result of the surgical procedure. The cytokine absorber was used intraoperatively in conjunction with the carrier of pulmonary bypass circuit. The duration of hemoabsorption therapy was 120 minutes during the whole CPB time. The duration of surgery was three hours. We used hyperein of 22,000 units and the activated clotted time remained over 513 seconds with no additional peppering. We transfused three units of red blood cells. The results of the interop treatment was hemodynamic stability during cardiopulmonary bypass with mean arterial pressure over 60. The lactate level remained under 3.1 millimoles per liter and the urine output was over 50 ml per hour. The patient needed low inotropic support immediately after bypass. Immediately after the successful mitral valve replacement the hemodynamic condition of the patient was stable. However, in the ICU she gradually developed a fever of 39.5 to 40.5 degrees of Celsius in the early post-op period. And again required increasing of hemodynamic support including norepi, epinephrine, vasopressin, debutamine, methane blue, along with the intraortive balloon pump. Despite this, the urine output and lactate levels were within their normal range. In this near-disaster condition continuous renal replacement therapy was started which however proved ineffective. And a cytokine absorber was additionally integrated into the CRT circuit one day later on the third post-op day. That was treatment two that lasted for 40 hours. For a discontinuation of the combined CRT and hem absorption therapy on the fifth post-op day the hemodynamic condition of the patient again deteriorated dramatically with metabolic acidosis and increasing requirements of inotropic and vasopressor support. Consequently, she was reconnected to the CRT with hem absorption therapy a few hours later. The third treatment lasted 48 hours. The result of post-op treatment with a cytokine filter was a stabilization in the hemodynamics of the patient. A drastic decrease in inotropic and vasopressor support during both treatment cycles. A decrease in inflammatory mediator levels. A cessation of fever as a result of combined dialysis and cytokine hem absorption therapy. And the plasma lactate concentrations improved and stabilized the level lower of two millimole per liter. The introverted balloon pump was removed on the third post-op day. The combined CRT with hem absorption therapy was finally stopped on post-operative day seven. The patient still required minimum inotropic support until day 11 while the lactate level was already within the normal range from post-operative day seven. Total post-operative transfusion volume was eight units of packed red blood cells, 10 units of platelet concentrates and four fresh frozen plasma. Aterechiaostomy was performed on the seventh post-op day. The cultures of the valve or tissue revealed that the responsible microbial specimen was coxialoburneti. The patient developed a critical illness polyneuropathy. Following a prolonged post-operative course, it was finally discharged from hospital on the 50th post-operative day in a good clinical condition. Due to the findings reported in literature, this was the first case where the cytokine absorption filter was used in a case of infective endocarditis along with septic shock and myocardial infarction. The treatment resulted in hemodynamic stabilization, control of the inflammatory response and normalization of metabolic parameters. Generally, the acute surgical treatment of infective endocarditis carries a high risk of post-op mortality. Most complications are linked to uncontrolled sepsis and inflammatory processes. The cytokine hemorrhagic absorption is an exocorporeal technique which has benefits reported in hemorrhagic stability and reduction of inflammatory response. After a systematic literature review that was conducted on PubMed with the keyword cytokine absorption, cardiac surgery, infective endocarditis, we found six articles, a randomized control trial, a case series comparative study, a retrospective single standard study, a prospective multi-sender RCT and a case report, except from the retrospective study by Center that found no significant difference in hemodynamic stability and outcomes for the hem absorption group. The rest of the studies presented positive pace and outcomes with the use of a cytokine absorber filter during bypass and post-op when integrated in the CRT in an ECMO or a CPB circuit. Based on limit evidence, the use of a cytokine absorption filter during cardiopulmonary bypass and in conjunction with CRT in the ICU is a safe technique and well-tolerated by the patient with no device-related adverse events during or after the treatment sessions. It helps with the reduction of cytokine levels contributing to better patient outcomes when a cytokine storm is released. Of course, more randomized trials are needed to prove the efficacy of cytokine absorption filters used in reducing cytokines in the bloodstream of the patients. Many studies are already running in Europe right now, especially in COVID patients require a ECMO, but also in cases where emergent cardiac surgery is required for the reduction of the anticoagulant concentration. The results of these trials are needed to confirm that the use of the filter can reduce the length of stay in the ICU and total hospital stay. Although the filter has an initial upfront cost, this was proven to be cost-effective due to the potential health resource savings on both short and long-term projections. Thank you for your attention.