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Azarfarin R, Ziyaeifard M, Alizadehasl A, Roudini K, Hadipourzadeh F, Jamalian J. Anesthesia Management in Redo Mitral Valve Replacement Surgery in a Patient with a Rare Blood Group: A Case Report. Anesth Pain Med 2022; 12:e124213. [PMID: 36818485 PMCID: PMC9923330 DOI: 10.5812/aapm-124213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 04/16/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction One of the conditions leading to hemolysis in patients with artificial metallic heart valves is valvular dysfunction. In case of symptomatic hemolysis, a blood transfusion may be needed along with standard treatments. Inattention to the differential diagnosis of hemolysis and making decisions based on causes that are more obvious can lead to incorrect approaches. Case Presentation In this case report, we presented a case with a previously undiagnosed rare blood group (positive antibody anti-E, anti-c, anti-Kell), undergoing reoperation of mitral valve replacement (MVR), who developed severe hemolysis and subsequent acute renal failure secondary to incompatible blood transfusion and required hemodialysis. Conclusions In this patient, hemolysis was solely attributed to mitral valve dysfunction. By timely diagnosis of the subtype of her blood group and appropriate decision-making during surgery, adverse blood transfusion outcomes were prevented.
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Affiliation(s)
- Rasoul Azarfarin
- Cardio-Oncology Research Center, Rajaie Cardiovascular Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohsen Ziyaeifard
- Cardio-Oncology Research Center, Rajaie Cardiovascular Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azin Alizadehasl
- Cardio-Oncology Research Center, Rajaie Cardiovascular Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Kamran Roudini
- Department of Internal Medicine, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Javad Jamalian
- Rajaie Cardiovascular Research Center, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Rajaie Cardiovascular Research Center, Iran University of Medical Sciences, Tehran, Iran.
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Sarraj A, Calle Valda CM, Muñoz DE, Reyes G. New Presentation of Hemolysis After Papillary Muscles Approximation for Mitral Valve Repair. Ann Thorac Surg 2017; 103:e321-e322. [DOI: 10.1016/j.athoracsur.2016.09.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 08/16/2016] [Accepted: 09/07/2016] [Indexed: 10/19/2022]
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Ishida R, Adachi T, Shiotsu Y, Ishida M, Mori Y, Doi K, Tamagaki K. Reoperation after mitral valve repair in viewpoints of kidney injury as well as hemolytic anemia. CEN Case Rep 2015; 4:119-125. [PMID: 28509086 DOI: 10.1007/s13730-014-0152-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 09/30/2014] [Indexed: 11/25/2022] Open
Abstract
A 70-year-old woman developed anemia and kidney injury 10 months after mitral valve (MV) repair. Serological findings and Doppler echocardiography suggested hemolytic anemia due to mitral regurgitation jet collision with an annuloplasty ring (MRCR). Since kidney injury persisted even without exacerbation of anemia over 10 months, we performed an MV replacement. The anemia improved rapidly after the surgery; however, the renal function remained chronic kidney disease (CKD) after reoperation. Kidney injury was thought to be due to iron deposition and decreased renal perfusion that caused tubular injury. A comprehensive literature review shows that hemolysis due to MRCR in the early postoperative phase (within 3 postoperative months) can be often ameliorated with endothelialization without the need for reoperation; however, hemolysis in the late postoperative phase can persist even for a long period without reoperation. Chronic hemolysis can lead to kidney injury and progress to CKD even without clinical evidence of exacerbation of anemia. Therefore, in cases of late postoperative phase hemolysis, reoperation should be considered for better management of kidney injury and hemolytic anemia.
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Affiliation(s)
- Ryo Ishida
- Division of Nephrology, Kyoto Prefecture University of Medicine, 465 Kajii-cho, Kamigyou-ku, Kyoto, Japan.
| | - Takaomi Adachi
- Division of Nephrology, Kyoto Prefecture University of Medicine, 465 Kajii-cho, Kamigyou-ku, Kyoto, Japan
| | - Yayoi Shiotsu
- Division of Nephrology, Kyoto Prefecture University of Medicine, 465 Kajii-cho, Kamigyou-ku, Kyoto, Japan
| | - Mami Ishida
- Division of Nephrology, Kyoto Prefecture University of Medicine, 465 Kajii-cho, Kamigyou-ku, Kyoto, Japan
| | - Yasukiyo Mori
- Division of Nephrology, Saiseikai Izuo Hospital, 3-4-5 Kitamura, Taisyo-ku, Osaka, Japan
| | - Kiyoshi Doi
- Division of Cardiovascular Surgery, Kyoto Prefecture University of Medicine, 465 Kajii-cho, Kamigyou-ku, Kyoto, Japan
| | - Keiichi Tamagaki
- Division of Nephrology, Kyoto Prefecture University of Medicine, 465 Kajii-cho, Kamigyou-ku, Kyoto, Japan
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Sawazaki M, Tomari S, Izawa N, Zaikokuji K, Tateishi N, Imaeda Y. Interrupted Commissural Band Annuloplasty for Degenerative Mitral Valve Disease. Ann Thorac Surg 2014; 97:558-61. [DOI: 10.1016/j.athoracsur.2013.08.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 08/09/2013] [Accepted: 08/13/2013] [Indexed: 11/24/2022]
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Cardoso C, Cachado P, Garcia T. Hemolytic anemia after mitral valve repair: a case report. BMC Res Notes 2013; 6:165. [PMID: 23618497 PMCID: PMC3651723 DOI: 10.1186/1756-0500-6-165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 03/25/2013] [Indexed: 12/03/2022] Open
Abstract
Background Hemolytic anemia after mitral valve repair is still an underestimated complication because it is a rare condition and there are few described case reports in the literature. The mechanism responsible for hemolysis most commonly involves a regurgitant jet and it appears to be independent of its severity as assessed by echocardiography. Patients may experience severe symptoms with only moderate regurgitant jets. Case presentation We present a case of a 74-year-old Caucasian female who developed severe hemolytic anemia and decompensated heart failure due to a moderate mitral valve regurgitation jet, but it was not considered severe enough to explain such hemolysis. After exclusion of other causes of hemolytic anemia and the lack of clinical and laboratory improvement, the patient underwent valve replacement with a mechanical valve. Anemia and heart failure symptoms gradually resolved after surgery. Conclusion This case report indicates the importance of including the diagnosis of hemolytic anemia after mitral valve repair in patients with severe hemolysis and a surgical history of heart surgery, even if echocardiography underestimates or is unclear for showing significant alterations. The interest on mitral valve repair as suggested by the increase in the number of these procedures performed worldwide, raises the possibility that hemolytic anemia could be probably seen more frequently in the future and be a cause of major concern, especially for cardiac surgeons.
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Affiliation(s)
- Catarina Cardoso
- Department of Internal Medicine, Santa Marta Hospital, Lisbon, Portugal.
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Guillaud C, Loustau V, Michel M. Hemolytic anemia in adults: main causes and diagnostic procedures. Expert Rev Hematol 2012; 5:229-41. [PMID: 22475291 DOI: 10.1586/ehm.12.3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Hemolytic anemia is not an exceptional situation in adults. Although establishing the hemolytic mechanism of an anemia is usually rather easy, finding the etiology may be quite difficult as both hereditary (corpuscular) and acquired causes of hemolytic anemia may occur during adulthood. The diagnosis of hemolytic anemia, therefore, requires a multistep procedure taking into account both the patient's and family history, a careful analysis of the blood smear and a direct antiglobulin test. Based on these first data, the diagnostic procedure may then require more specific tests whose indications are discussed in this review.
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Affiliation(s)
- Constance Guillaud
- Department of Internal Medicine, National Referal Center for Adults' Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
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Inoue M, Kaku B, Kanaya H, Ohka T, Ueda M, Masahiro S, Shimizu M, Mabuchi H. Reduction of hemolysis without reoperation following mitral valve repair. Circ J 2003; 67:799-801. [PMID: 12939559 DOI: 10.1253/circj.67.799] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Hemolytic anemia following mitral valve repair and annular ring placement is uncommon compared with mitral valve replacement. A 60-year-old man, who had undergone mitral valve repair with a Duran ring, developed hemolytic anemia and needed a blood transfusion. Transesophageal echocardiography revealed a paravalvular mitral regurgitation jet colliding with the Duran ring. Most cases of severe hemolysis after mitral valve repair have undergone reoperation, but in the present case study, the hemolysis after mitral valve repair reduced without the need for reoperation, although the paravalvular mitral regurgitation jet continued to collide with the Duran ring.
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Affiliation(s)
- Masaru Inoue
- Molecular Genetics of Cardiovascular Disorders, Division of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan.
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Yeo TC, Freeman WK, Schaff HV, Orszulak TA. Mechanisms of hemolysis after mitral valve repair: assessment by serial echocardiography. J Am Coll Cardiol 1998; 32:717-23. [PMID: 9741517 DOI: 10.1016/s0735-1097(98)00294-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We sought to determine, using serial echocardiography, the hydrodynamic mechanisms involved in the occurrence of hemolysis after mitral valve repair. BACKGROUND Recently, fluid dynamic simulation models have identified distinct patterns of mitral regurgitant flow disturbances in patients with mitral prosthetic hemolysis that were associated with high shear stress and may therefore produce clinical hemolysis. Rapid acceleration, fragmentation, and collision jets were associated with high shear stress and hemolysis whereas slow deceleration and free jets were not. METHODS We reviewed serial echocardiographic studies of 13 consecutive patients with hemolytic anemia after mitral valve repair who were referred for mitral reoperation between January 1985 and December 1996 (group 1). Thirteen patients undergoing reoperation for mitral regurgitation after mitral valve repair but without hemolysis served as controls (group 2). RESULTS The mitral regurgitant jet was central in origin in 12 group 1 patients and 9 group 2 patients (Fisher exact test, p= 0.3). The other patients had para-ring regurgitation. Group 1 patients had collision (n=11), rapid acceleration (n=2) or fragmentation (n=1) jets whereas group 2 patients had slow deceleration (n=11) or free jets (n=2) (Fisher exact test, p < 0.0001). One patient with hemolysis had both collision and rapid acceleration jets. The "culprit" jet could be identified on the postbypass transesophageal echocardiography (TEE) study in only 1 patient at the time of initial mitral repair. Twelve group 1 patients underwent reoperation, with subsequent resolution of hemolysis in all patients. At reoperation, the initial repair was found to be intact in 8 (67%) patients. CONCLUSION Distinct patterns of flow disturbance associated with high shear stress were identified by color Doppler imaging in patients with hemolysis after mitral valve repair. The majority (92%) of these color flow disturbances were not present during intraoperative postbypass TEE study after initial mitral repair and subsequently developed in the early postoperative period.
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Affiliation(s)
- T C Yeo
- Division of Cardiovascular Diseases, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Abstract
Two patients are described who suffered from progressive intravascular hemolysis following different kinds of reconstructive surgery of the mitral valve. Within the context of increasing numbers of operations aimed to preserve the mitral valve, the importance and difficulty of prompt recognition and adequate treatment of this very uncommon but potential lethal complication are emphasised.
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Cerfolio RJ, Orszulak TA, Daly RC, Schaff HV. Reoperation for hemolytic, anaemia complicating mitral valve repair. Eur J Cardiothorac Surg 1997; 11:479-84. [PMID: 9105812 DOI: 10.1016/s1010-7940(96)01091-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To identify the possible cause(s) of hemolysis after mitral valve repair for mitral regurgitation (MR) and to evaluate the late outcome of surgical treatment. METHODS We reviewed all patients who had reoperation after valve repair for mitral regurgitation. Ten patients had reoperation because of hemolytic anaemia. The diagnosis of hemolysis was made by decreased serum haptoglobin, elevation of serum lactate dehydrogenase (LDH), and schistocytosis. No other causes of anaemia or hemolysis were identified in these six men and four women (ages 35-84 years; median 59 years). Interval between initial mitral valve repair and reoperation ranged from 40 to 165 days (median 87 days), and prior to reoperation, red cell transfusions (range 2-12 units; median 5 units) were required in all patients. Seven patients were symptomatic: two complained of easy fatigability and five were severely limited. Transesophageal echocardiogram during hemolytic evaluation showed only mild MR in two patients, moderate in five, moderately severe in two and severe in one. RESULTS Etiology of hemolysis was suggested from echocardiography and confirmed at reoperation. In one patient, an eccentric MR jet struck a pledget of a commissural annuloplasty. In the remaining nine patients, the regurgitant jet struck a non-endothelialized portion of the annuloplasty ring (Carpentier-Edwards n = 5; Duran n = 2; Cosgrove-Edwards n = 2). Seven patients had prosthetic replacement and three patients had re-repair. There were no operative deaths and all patients had resolution of hemolytic anaemia. CONCLUSIONS Relatively minor degrees of regurgitation after mitral valve repair can produce hemolytic anaemia which is manifested within the first few postoperative months. Most patients are highly symptomatic because of anaemia. The mechanism of red cell destruction is a high velocity eccentric stream of blood impacting on a small area of a prosthetic ring or pledget. This process retards endothelialization of the ring. Reoperation with re-repair or mitral valve replacement is safe and effectively relieves the hemolysis.
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Affiliation(s)
- R J Cerfolio
- Section of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55905, USA
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OSMAN KHIDIR, WILLMAN BERT, NANDA NAVINC, KIM KEESIK, PACIFICO ALBERTD. Transesophageal Echocardiographic Findings of a Dehisced Duran Mitral Annuloplasty Ring. Echocardiography 1995. [DOI: 10.1111/j.1540-8175.1995.tb00569.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Seyr M, Hasibeder W, Furtwaegler W, Antretter H, Mutz NJ. Multiple organ failure after mitral valve repair with intravascular hemolysis and its recovery due to mitral valve replacement. Intensive Care Med 1993; 19:358-60. [PMID: 8227730 DOI: 10.1007/bf01694714] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We present a patient with evidence of severe intravascular hemolysis after mitral valve repair, an established method for the surgical treatment of mitral valve disease to avoid prosthesis related complications. The coincidence of this uncommon complication with hemodynamic instability due to pre-existing myocardial dysfunction and Gram-negative pneumonia promoted the development of simultaneous dysfunction of liver, kidney and the cardio-respiratory system. Elimination of the source of hemolysis by re-operation with mitral valve replacement on the ninth postoperative day allowed prompt recovery from severe organ dysfunction. Free hemoglobin may have perpetuated progressive organ failure in our patient.
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Affiliation(s)
- M Seyr
- Clinic for Anesthesia and General Intensive Care Medicine, University of Innsbruck, Austria
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