Perioperative anticoagulation management during aortic valve replacement complicated by antiphospholipid syndrome

Management of cardiovascular surgery in patients with systemic lupus erythematosus including thromboembolism and multiple organ failure prevention: A retrospective observational study

Systemic lupus erythematosus is a chronic autoimmune disease that affects most tissues. Cardiovascular events are critical, life-threatening, long-term complications of systemic lupus erythematosus (SLE). We report our single-center experience of performing cardiovascular surgery in patients with SLE while avoiding postoperative complications. We also suggest a new approach for cardiopulmonary bypass and perioperative management. We applied the antiphospholipid antibody syndrome (APS) severity classification published by the Japan Intractable Disease Information Center to patients with SLE for perioperative management. Patients with Grade III or higher severity are treated with a slightly relaxed version of catastrophic APS therapy. This treatment modality includes glucocorticoids, anticoagulation, intravenous immunoglobulin, and plasma exchange. Between April 2010 and January 2021, 26 patients (2 males, 24 females) with SLE underwent cardiovascular surgery. The mean age was 74.2 ± 13.0 years (38-84 years). The primary outcomes were in-hospital mortality and long-term results, and the secondary outcomes were related to bleeding/embolization and coagulation function/platelet count. A subset analysis was performed to examine treatment efficacy in the APS Grade III or higher group. Of the 26 patients, 17 underwent valve surgery, 4 underwent isolated coronary artery bypass grafting, and 5 underwent thoracic aortic aneurysm surgery. There were no in-hospital deaths or associated bleeding/embolic complications. Postoperative antithrombin III decreased in patients who underwent valvular and aortic surgery, and platelet counts recovered to preoperative levels within 7 to 10 days. The 5- and 10-year survival rates were 80.5% and 53.7%, respectively. In addition, there were 10 patients with APS Grade III or higher, but there was no significant difference in the frequency of complications other than platelet recovery after treatment. The surgical outcome of open-heart surgery in patients with SLE was good. Surgical treatment of cardiovascular disease in these patients is difficult and complex. We focused on blood coagulation abnormalities and treated each patient by selecting the best individual treatment protocol according to the severity of the disease, taking into account the risk of bleeding and thrombosis. Management of blood coagulation function in these patients is essential, and careful therapeutic management should be considered during open-heart surgery.

Antiphospholipid syndrome and valvular heart disease, a complex scenario of thrombotic events, a case report

BACKGROUND

Antiphospholipid syndrome (APS) is a rare coagulation disorder associated with thrombotic events, myocardial infarction, and valvular heart disease. During valvular replacement surgery, the high risk of thrombosis combined with the operative risks in these specific groups of patients poses a challenge to the medical team.

CASE PRESENTATION

We present a case of a female patient with APS and mixed aortic valve disease. During surgery, she suddenly developed complete cardiac arrest. Three months later, after she recovered, and while she was still on close follow up, a thrombotic event caused myocardial infarction. After prompt and precise treatment, the patient successfully recovered; one year after surgery patient is doing well.

CONCLUSION

Adequate surgical technique along with optimal anticoagulation strategies and long term follow up are of paramount importance to ensure an uneventful recovery. A multidisciplinary team is required to manage these complex scenarios and high-risk patients.

TEG improves anticoagulation management during cardiopulmonary bypass complicated by antiphospholipid syndrome

BACKGROUND AND AIM

Cardiopulmonary bypass (CPB) in antiphospholipid syndrome (APS) patients carries a high risk of thrombosis and hemorrhage. However, optimal anticoagulation surveillance methods have not been established and heparin optimization has not yet been totally validated as reflective of anticoagulation status.

METHODS AND RESULT

Here, a 45-year-old female with APS underwent mitral valvuloplasty due to infective endocarditis. We used a perioperative, in vitro, heparin-activated clotting time (ACT) titration line coupled with synergistic, intraoperative thromboelastography (TEG) to monitor coagulation activity. After the ACT target was reached, TEG monitored the suppression of both intrinsic and extrinsic coagulation activity throughout the surgery.

CONCLUSION

TEG thus provided valuable temporal information on both intrinsic and extrinsic coagulation suppression validating heparin-ACT titration targets.