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Zientara A, Salmasi MY, Milan-Chhatrisha B, Kapadia S, Bashir R, Cummings I, Quarto C, Asimakopoulos G. Thrombocytopenia after sutureless and standard stented aortic valve replacement: a retrospective analysis of risk factors, clinical course, and early outcome. J Cardiothorac Surg 2024; 19:219. [PMID: 38627820 PMCID: PMC11020882 DOI: 10.1186/s13019-024-02755-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 03/29/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVES Thrombocytopenia following Perceval aortic valve replacement has been described previously with variable outcome. Studies have lacked a robust analysis of platelet fluctuation and factors affecting it. We aimed to statistically describe the trend in thrombocyte variability as compared with conventional aortic valve replacement, and to assess predictors as well as impact on associated outcomes. METHODS One hundred consecutive patients with first-time Perceval were retrospectively compared to 219 patients after Perimount Magna Ease valve replacement. The primary outcome was the serial thrombocyte count on day 0-6. Generalized estimating equations were used to analyse the data using fixed-effect models: for the effect of the post-operative day on platelet count, and random-effect models estimating both time-variant (platelets) and time in-variant variables (valve type, age, LV function, pre-op platelet level). RESULTS Perceval patients were older (72 ± 1 vs 68 ± 1 years, p < 0.01) with higher NYHA status (3(2-3) vs 2(1-2), p < 0.001). Mean platelet count in the sutureless group was lowest on day 2 (91.9 ± 31.6 vs 121.7 ± 53.8 × 103 µl-1), and lower on day 4 (97.9 ± 44) and 6 (110.6 ± 61) compared to the conventional group (157.2 ± 60 and 181.7 ± 79) but did not result in a higher number of transfusions, bleeding or longer hospital stay (p > 0.05). Reduced platelet count was a strong predictor of red cell transfusion in the conventional (p = 0.016), but not in the sutureless group (p = 0.457). Age (Coef -1.025, 95%CI-1.649--0.401, p < 0.001) and CPB-time (Coef 0.186, 95%CI-0.371--0.001, p = 0.048) were predictors for lower platelet levels. CONCLUSION Considering the older patient profile treated with Perceval, postoperative thrombocytopenia does not impact on outcome in terms of transfusions, complications or hospital stay.
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Affiliation(s)
- Alicja Zientara
- University Hospital Freiburg, Heart Centre, Hugstetter Strasse 55, 79106, Freiburg, Germany.
| | - Mohammad Yousuf Salmasi
- Department of Surgery, Imperial College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital, Hill End Road, Uxbridge, UB9 6JH, UK
| | | | - Sharan Kapadia
- Department of Surgery, Imperial College London, London, UK
| | - Ryan Bashir
- Guy's and St Thomas' NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
| | - Ian Cummings
- Guy's and St Thomas' NHS Foundation Trust, St Thomas Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Cesare Quarto
- Guy's and St Thomas' NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
| | - George Asimakopoulos
- Guy's and St Thomas' NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
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Nakayama T, Nakamura Y, Shikata F, Ushijima M, Yasumoto Y, Yoshiyama D, Kuroda M, Sawa S, Tsuruta R, Furutachi A, Narita T, Ito Y. Thrombocytopenia Following Perceval Sutureless Aortic Valve Replacement in Asian Patients. Circ J 2024; 88:549-558. [PMID: 36709983 DOI: 10.1253/circj.cj-22-0587] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND This study analyzed the safety and performance of the Perceval valve for aortic valve replacement (AVR) in patients at 1 year after undergoing aortic stenosis (AS) treatment, and its effect on significant declines in the platelet count during the immediate postoperative period.Methods and Results: Data were collected retrospectively for the initial 121 patients (median age 77 years; 47.1% females) who underwent Perceval sutureless AVR between May 2019 and July 2022. Implantation was successful in all (100%), with median cross-clamp and CPB times of 59 and 100 min, respectively. Postoperative thrombocytopenia (platelet count <50×103/μL) was noted in 80 (66.1%) patients. Multivariate analysis showed advanced age (>80 years), preoperative low platelet count (<200×103/μL), and a sternotomy approach as significant risk factors for postoperative thrombocytopenia. One (0.8%) patient died within 30 days after the procedure. The 2-year site-reported event rate was 14% (n=17) for all-cause mortality, 0.8% (n=1) for cardiac mortality, 4.1% (n=5) for stroke, and 1.7% (n=2) for endocarditis and valve-related reoperation; there were no instances of paravalvular leakage or structural valve deterioration. CONCLUSIONS Thrombocytopenia was common after Perceval sutureless AVR, although its impact was not significant. Although Perceval sutureless AVR was found to be a safe and effective option, preoperative assessment of potential bleeding should be performed and the Perceval valve should not be used for patients with a high bleeding risk.
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Affiliation(s)
- Taisuke Nakayama
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital
| | | | - Fumiaki Shikata
- Department of Cardiovascular Surgery, Kitasato University School of Medicine
| | - Masaki Ushijima
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital
| | - Yuto Yasumoto
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital
| | - Daiki Yoshiyama
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital
| | - Miho Kuroda
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital
| | - Shintaro Sawa
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital
| | - Ryo Tsuruta
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital
| | - Akira Furutachi
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital
| | - Takuya Narita
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital
| | - Yujiro Ito
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital
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Jayet A, Lu H, Monney P, Verdugo-Marchese M, Gunga Z, Rancati V, Ltaief Z, Kirsch M. Thrombocytopenia among Patients Undergoing Aortic Valve Replacement Using the Sutureless Perceval S Bioprosthesis: A Retrospective Study. J Clin Med 2024; 13:1083. [PMID: 38398396 PMCID: PMC10888618 DOI: 10.3390/jcm13041083] [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: 01/08/2024] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The sutureless Perceval S bioprosthesis is associated with postoperative thrombocytopenia. Our objectives were to compare the incidence, severity, and clinical implications of thrombocytopenia after aortic valve replacement (AVR) using the Perceval S or the Trifecta bioprosthesis. METHODS Patients who underwent AVR between March 2016 and August 2019 using the Perceval or Trifecta were retrospectively included. The primary endpoint was the nadir in platelet counts within 15 days after surgery. Secondary endpoints included postoperative hemolysis and inflammatory parameters, as well as clinical and echocardiographic outcomes. RESULTS Overall, 156 patients were included (Perceval, n = 103; Trifecta, n = 53). Preoperatively, there was no difference in platelet counts between the two groups. Postoperatively, the Perceval S bioprosthesis was associated with a greater decrease in platelet counts. The nadir was reached at Day 3 for both groups, but thrombocytopenia was more severe for the Perceval S (Perceval S vs. Trifecta, 89.2 ± 37.7 × 109/L vs. 106.5 ± 34.1 × 109/L, p = 0.01). No difference regarding lactate dehydrogenase, C-reactive protein, and white blood cells count was found. All-cause 30-day mortality rates (both valves, 2%, p = 0.98), hospital lengths of stay, and re-operation rates were similar. CONCLUSION The Perceval S bioprosthesis was associated with more severe postoperative thrombocytopenia. This did not translate into higher short-term morbidity or mortality.
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Affiliation(s)
- Adrien Jayet
- Division of Cardiovascular Surgery, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (A.J.); (M.V.-M.); (Z.G.)
| | - Henri Lu
- Division of Cardiology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (H.L.)
| | - Pierre Monney
- Division of Cardiology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (H.L.)
| | - Mario Verdugo-Marchese
- Division of Cardiovascular Surgery, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (A.J.); (M.V.-M.); (Z.G.)
| | - Ziyad Gunga
- Division of Cardiovascular Surgery, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (A.J.); (M.V.-M.); (Z.G.)
| | - Valentina Rancati
- Department of Anaesthesiology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland;
| | - Zied Ltaief
- Adult Intensive Care Unit, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland;
| | - Matthias Kirsch
- Division of Cardiovascular Surgery, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland; (A.J.); (M.V.-M.); (Z.G.)
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Tang Z, Shao Y. Postoperative thrombocytopenia and subsequent consequences in acute type A aortic dissection. Ann Med 2023; 55:2281653. [PMID: 38071662 PMCID: PMC10880570 DOI: 10.1080/07853890.2023.2281653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 11/06/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES To ascertain if postoperative thrombocytopenia following open aortic surgery with a median sternotomy can predict early- and intermediate-term morbidity and mortality. METHODS From January 2018 to December 2022, a comparison was made between patients who had and didn't have postoperative thrombocytopenia (defined as a nadir < 75 × 103/μL after 72 h of open aortic surgery with median sternotomy). Intermediate-term mortality during follow-up was the main result, with cerebrovascular accident and acute renal injury requiring dialysis as secondary events. Inverse probability treatment weighting (IPTW) was used to account for selection bias between groups. The Kaplan-Meier method with the log-rank test was used to assess intermediate-term survivals following IPTW modification. To identify the nonlinear link between platelet nadir and mortality probability, a generalized additive mix model was applied. To help increase power in testing for the overall effect of platelet nadir on outcomes in the generalized additive mix model, the hazard ratios and 95% CIs for each subgroup and their interactions were examined. RESULTS The study included 457 patients, 347 male (75.9%), with mean age of 54 ± 12 years. The last follow-up was done on April 14th, 2023 and the median follow-up time was 16 (6-31) months. Following IPTW, patient characteristics were balanced among cohorts. Platelet nadir was found to be significantly inversely related to early-term mortality (IPTW-adjusted hazard ratio = 0.968 (0.960, 0.977), p < 0.001), and AKI requiring dialysis (IPTW-adjusted hazard ratio = 0.979 (0.971, 0.986), p < 0.001). A nonlinear relationship between platelet nadir and mortality risk probability during follow-up visually showed that the likelihood of mortality decreased with platelet nadir increased. In confounder-adjusted survival ('postoperative thrombocytopenia not acquired' vs 'postoperative thrombocytopenia'; HR: 0.086 [95% CI: 0.045-0.163]; p < 0.01) analysis, non-acquired postoperative thrombocytopenia was associated with a lower risk of mortality, and the treatment benefit was validated in IPTW-adjusted analysis, which showed an HR of 0.067. CONCLUSIONS Early postoperative thrombocytopenia following type A aortic dissection surgery is a risk factor for morbidity and mortality. Because postoperative thrombocytopenia can indicate a poor prognosis, monitoring early postoperative platelets helps identify individuals who may develop late postoperative problems, which is performed by this affordable biomarker.
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Affiliation(s)
- Zhiwei Tang
- Department of Cardiovascular Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yongfeng Shao
- Department of Cardiovascular Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
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Haeussler A, Ntinopoulos V, Rings L, Papadopoulos N, Hoti G, Fleckenstein P, Dzemali O. Thrombocytopenia after Implantation of the Perceval, Intuity, and Sapien Aortic Valve Prostheses. Thorac Cardiovasc Surg 2023; 71:550-556. [PMID: 36462753 DOI: 10.1055/s-0042-1757893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND An increased incidence of thrombocytopenia was reported after implantation of the LivaNova Perceval and the Edwards Sapien aortic valve bioprostheses. Aim of this study is to assess the perioperative platelet count and bleeding complications in three different types of aortic valve bioprostheses intended for high-risk patients, the sutureless LivaNova Perceval, the rapid deployment Edwards Intuity, and the transcatheter Edwards Sapien. METHODS We performed a retrospective analysis of the perioperative data of patients receiving the Perceval, Intuity, and Sapien aortic valve bioprosthesis. The platelet count was collected preoperatively, at nadir postoperatively, and at discharge. The bioprostheses were compared for between-group differences in platelet count and postoperative bleeding complications. RESULTS Overall, 37 patients received the Perceval, 42 the Intuity, and 58 the Sapien bioprosthesis. There was no significant between-group difference in the preoperative platelet count [Perceval 203(178-246)G/l, Intuity 214(190-232)G/l, Sapien 201(178-275)G/l, p = 0.800]. There was a significant between-group difference in the postoperative platelet count, both at nadir value [Perceval 57(37-80)G/l, Intuity 91(73-109)G/l, Sapien 126(105-170)G/l, p < 0.0001] and at discharge [Perceval 150(83-257)G/l, Intuity 239(200-343)G/l, Sapien 232(179-284)G/l, p = 0.001]. There was no significant between-group difference regarding red blood cell transfusions (p = 0.242), platelet transfusions (p = 0.656), and rethoracotomy for bleeding (p = 0.847). CONCLUSION We found a significant platelet count reduction in all three bioprostheses which was more marked in the Perceval group. The platelet count reduction was transient and fully recovered in the Intuity and Sapien groups, whereas the Perceval group showed only a partial platelet count recovery. However, bleeding complications were not different between the three bioprostheses.
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Affiliation(s)
- Achim Haeussler
- Department of Cardiac Surgery, City Hospital of Zurich - Triemli, Zurich, Switzerland
| | - Vasileios Ntinopoulos
- Department of Cardiac Surgery, City Hospital of Zurich - Triemli, Zurich, Switzerland
| | - Laura Rings
- Department of Cardiac Surgery, City Hospital of Zurich - Triemli, Zurich, Switzerland
| | - Nestoras Papadopoulos
- Department of Cardiac Surgery, City Hospital of Zurich - Triemli, Zurich, Switzerland
| | - Gojart Hoti
- Department of Cardiac Surgery, City Hospital of Zurich - Triemli, Zurich, Switzerland
| | - Philine Fleckenstein
- Department of Cardiac Surgery, City Hospital of Zurich - Triemli, Zurich, Switzerland
| | - Omer Dzemali
- Department of Cardiac Surgery, City Hospital of Zurich - Triemli, Zurich, Switzerland
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Panagiotopoulos I, Kotsopoulos N, Verras GI, Mulita F, Katinioti A, Koletsis E, Triantafyllou K, Yfantopoulos J. Perceval S, sutureless aortic valve: cost-consequence analysis. KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2022; 19:22-27. [PMID: 35414814 PMCID: PMC8981134 DOI: 10.5114/kitp.2022.114551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/28/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Sutureless aortic valve prostheses have the potential of shortening ischemic time. AIM We conducted the present study to assess the clinical and economic impact of the biological, sutureless, self-expanding Perceval S valve since the effect of shortened operative times on hospital costs remains unclear. MATERIAL AND METHODS This is a retrospective analysis. From January 2018 to January 2019, 29 patients underwent isolated aortic valve replacement with the Crown PRT bioprosthetic Aortic Valve, whereas 35 patients underwent aortic valve replacement with Perceval S (auto-expanded, sutureless, bioprosthesis). Preoperative data, hospital outcome, and health care resource consumption were compared, using χ2 and t-test. RESULTS Aortic cross-clamp, cardiopulmonary bypass, and operation times were significantly shorter in the Perceval S group (p < 0.001). Patients in the sutureless group required blood transfusion less frequently (p = 0.03) and had a shorter intensive care unit (ICU) stay (p = 0.01). Hospital stay (p = 0.57) and pacemaker implantation were similar between groups. The reduction of aortic cross-clamp, extracorporeal circulation times, and ICU stay resulted in reduced resource consumption in the sutureless group. CONCLUSIONS The use of the Perceval S valve is clinically safe and effective. A shorter procedural time in the sutureless group is associated with better clinical outcomes and reduced hospital costs.
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Affiliation(s)
- Ioannis Panagiotopoulos
- Department of Cardiothoracic Surgery, General University, Hospital of Patras, Patras, Greece
| | - Nikolaos Kotsopoulos
- Division of Health Economics, Global Market Access Solutions, St-Prex, Switzerland
| | | | - Francesk Mulita
- Department of Surgery, General University, Hospital of Patras, Patras, Greece
| | - Anastasia Katinioti
- Cardiology Unit, Hippokration Hospital, Athens University Medical School, Athens, Greece
| | - Efstratios Koletsis
- Department of Cardiothoracic Surgery, General University, Hospital of Patras, Patras, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, 2nd Department of Internal Medicine-Propaedeutic, National and Kapodistrian University of Athens, “Attikon” University General Hospital, Athens, Greece
| | - John Yfantopoulos
- MBA – Health Department of Economics, National and Kapodistrian University of Athens, Athens, Greece
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Tirado-Conte G, Salazar CH, McInerney A, Cruz-Utrilla A, Jiménez-Quevedo P, Cobiella J, Gonzalo N, Carnero M, Núñez-Gil I, Mejía-Rentería H, Salinas P, Macaya F, Maroto LC, Vilacosta I, Fernández-Ortiz A, Escaned J, Macaya C, Nombela-Franco L. Incidence, clinical impact and predictors of thrombocytopenia after transcatheter aortic valve replacement. Int J Cardiol 2022; 352:21-26. [DOI: 10.1016/j.ijcard.2022.01.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 11/20/2021] [Accepted: 01/31/2022] [Indexed: 11/17/2022]
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Aljalloud A, Spetsotaki K, Tewarie L, Rossato L, Steinseifer U, Autschbach R, Menne M. Stent deformation in a sutureless aortic valve bioprosthesis: a pilot observational analysis using imaging and three-dimensional modelling. Eur J Cardiothorac Surg 2021; 62:6427438. [PMID: 34791144 DOI: 10.1093/ejcts/ezab485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 09/21/2021] [Accepted: 09/26/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The goal of this analysis of the Perceval aortic bioprosthesis was to investigate the ovalization/deformation of the Perceval prosthesis stent after implantation and its propensity for cusp dysfunction, fluttering, fibrosis and blockage. METHODS Between August 2014 and May 2019, a total of 134 patients (52% female) underwent aortic valve replacement with the Perceval bioprosthesis. We reconstructed three-dimensional models of the Perceval stent using thorax computed tomography scans for 16 patients employing the software Mimics (Materialise NV, Leuven, Belgium) and analysed the ovality of the stents. Radial force (RF) measurements were performed to compare the stiffness of the Perceval bioprosthesis to that of other valves. RESULTS The three-dimensional reconstructions showed that all Perceval stents exhibited some degree of deformation and ovalization. Ovality in the annulus and commissure section of the Perceval stents ranged from 6.8% to 45% with mean values of 13.6% and 21.9%, respectively. The RF of the Perceval prosthesis was noticeably lower than that of the Edwards Intuity and several transcatheter aortic valve implantation devices. The stent adopted the preoperative shape of the aorta in the 2 patients for whom pre- and postoperative computed tomography data existed. CONCLUSIONS The Perceval bioprostheses were deformed to different degrees in all analysed cases. The comparably low RFs might be an explanation for the propensity towards this deformation, which can lead to fluttering, a reduction of the cusps' mobility. This condition could potentially result in fibrosis as well as increased transvalvular pressure gradients and might be the cause for the increase in lactate dehydrogenase and the decrease in platelet count.
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Affiliation(s)
- Ali Aljalloud
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital Aachen, Aachen, Germany.,Department of Cardiology, Rhein Maas Klinikum, Würselen, Germany
| | - Konstantina Spetsotaki
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Lachmandath Tewarie
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Leonardo Rossato
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Ulrich Steinseifer
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Ruediger Autschbach
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Matthias Menne
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, Medical Faculty, RWTH Aachen University, Aachen, Germany
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Lorusso R, Jiritano F, Roselli E, Shrestha M, Folliguet T, Meuris B, Pollari F, Fischlein T. Perioperative platelet reduction after sutureless or stented valve implantation: results from the PERSIST-AVR controlled randomized trial. Eur J Cardiothorac Surg 2021; 60:1359-1365. [PMID: 34118150 DOI: 10.1093/ejcts/ezab175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 02/19/2021] [Accepted: 02/28/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Platelet count reduction is a common but not fully understood phenomenon after aortic valve replacement (AVR) with bioprosthesis implantation. The aim of the present study was to investigate the occurrence and the clinical impact of platelet count reduction in patients receiving the Perceval bioprosthesis compared to those receiving standard sutured stented bioprosthetic aortic valve in a randomized, controlled AVR study. METHODS PERceval Sutureless Implant versus STandard Aortic Valve Replacement is a prospective, randomized, adaptive, open-label trial. Patients were randomized (March 2016-September 2018) to AVR with a sutureless or stented valve. Ad hoc analyses have been performed to evaluate the occurrence of platelet count reduction and the clinical impact of the platelet variations in the 2 groups. RESULTS The Perceval group showed a higher platelet reduction than the control group (46% vs 32%). The phenomenon was transient in both groups, with a slow recovery of the platelet count by hospital discharge. No differences were observed between groups regarding need of transfusions, blood loss, major bleeding and stroke events. CONCLUSIONS The Perceval sutureless aortic bioprosthesis implantation is associated with higher rate of transient platelet reduction as compared to stented bioprostheses for AVR. However, the platelet count reduction is transient and the decline does not affect the patient's clinical outcomes. Current explanations for this phenomenon are speculative, and further investigations are required to elucidate it. CLINICAL TRIAL REGISTRATION NUMBER NCT02673697-ClinicalTrials.gov-4 February 2016.
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Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Federica Jiritano
- Cardio-Thoracic Surgery Department, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, Netherlands.,Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Eric Roselli
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Thierry Folliguet
- Department of Cardiac Surgery, Hôpital Henri Mondor, Université Paris 12, Créteil, Paris, France
| | - Bart Meuris
- Cardiac Surgery Department, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Francesco Pollari
- Klinikum Nürnberg, Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany
| | - Theodor Fischlein
- Klinikum Nürnberg, Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany
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Squiccimarro E, Jiritano F, Serraino GF, ten Cate H, Paparella D, Lorusso R. Quantitative and Qualitative Platelet Derangements in Cardiac Surgery and Extracorporeal Life Support. J Clin Med 2021; 10:jcm10040615. [PMID: 33561947 PMCID: PMC7914426 DOI: 10.3390/jcm10040615] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/30/2021] [Accepted: 02/03/2021] [Indexed: 01/19/2023] Open
Abstract
Thrombocytopenia and impaired platelet function are known as intrinsic drawbacks of cardiac surgery and extracorporeal life supports (ECLS). A number of different factors influence platelet count and function including the inflammatory response to a cardiopulmonary bypass (CPB) or to ECLS, hemodilution, hypothermia, mechanical damage and preoperative treatment with platelet-inhibiting agents. Moreover, although underestimated, heparin-induced thrombocytopenia is still a hiccup in the perioperative management of cardiac surgical and, above all, ECLS patients. Moreover, recent investigations have highlighted how platelet disorders also affect patients undergoing biological prosthesis implantation. Though many hypotheses have been suggested, the mechanism underlying thrombocytopenia and platelet disorders is still to be cleared. This narrative review aims to offer clinicians a summary of their major causes in the cardiac surgery setting.
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Affiliation(s)
- Enrico Squiccimarro
- Department of Cardiac Surgery, Mater Dei Hospital, 70125 Bari, Italy;
- Department of Emergency and Organ Transplant (DETO), University of Bari, 70125 Bari, Italy
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), 6229HX Maastricht, The Netherlands;
| | - Federica Jiritano
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), 6229HX Maastricht, The Netherlands;
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
- Correspondence:
| | - Giuseppe Filiberto Serraino
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
| | - Hugo ten Cate
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, D-55131 Mainz, Germany;
- Thrombosis Center Maastricht, Maastricht University Medical Center (MUMC), 6229HX Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), 6229HX Maastricht, The Netherlands
| | - Domenico Paparella
- Division of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, 70125 Bari, Italy;
- Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), 6229HX Maastricht, The Netherlands;
- Cardiovascular Research Institute Maastricht (CARIM), 6229HX Maastricht, The Netherlands
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11
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Ezelsoy M, Saracoglu KT, Oral K, Saracoglu A, Akpinar B. Positive Heparin/PF4 Antibodies and High Mortality Rate: a Retrospective Case-Series Analysis. Braz J Cardiovasc Surg 2020; 35:950-957. [PMID: 33306320 PMCID: PMC7731847 DOI: 10.21470/1678-9741-2019-0360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction Heparin-induced thrombocytopenia (HIT) is a potentially lethal complication of unfractionated or low-molecular weight heparin therapy. We aimed to determine the incidence and mortality rate of patients with positive heparin/platelet factor 4 (PF4) antibodies, which is a rapid detection test of HIT. Methods Coronary artery bypass grafting and mitral and aortic valve surgeries were evaluated. Cardiopulmonary bypass was employed in all patients. The diagnosis of HIT was based on immunological assays. Postoperative complications, mortality rates, and the causes of death were specified in patients with positive heparin/PF4 antibodies. Results Postoperative thrombocytopenia was detected in 257 patients. Twenty of these patients undergoing open heart surgery were included in the final analysis. Antibodies against heparin/PF4 complex were positive in 20 patients. The mean body mass index was 28.8±2.3 kg/m2, mean value of left ventricular ejection fraction was 48.3±6.7%, cardiopulmonary bypass time was 113.0±35.0 min, aortic cross-clamping time was 88.0±32.7 min, mean intensive care unit length of stay was 10.9±4.9 days, mean preoperative platelet count was 307.250±88528 platelets/microliter, and mean postoperative platelet count was 243.050±89.354 platelets/microliter. The mean duration of heparin exposure was 6.9±2.9 days. The mortality rate was 45% (nine patients) and 1.2% (three patients) in heparin/PF4 complex positive and negative patients, respectively. Conclusion Although the incidence of HIT was low in patients undergoing open heart surgery, an increased rate of early mortality was observed in patients with positive heparin/PF4 antibodies.
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Affiliation(s)
- Mehmet Ezelsoy
- Department of Cardiovascular Surgery, Istanbul Demiroglu Bilim University Medical School, Istanbul, Turkey
| | - Kemal Tolga Saracoglu
- Department of Anesthesiology and Intensive Care, Health Sciences University Medical School, Istanbul, Turkey
| | - Kerem Oral
- Department of Cardiovascular Surgery, Istanbul Demiroglu Bilim University Medical School, Istanbul, Turkey
| | - Ayten Saracoglu
- Department of Anesthesiology and Intensive Care, Istanbul Marmara University Medical School, Istanbul, Turkey
| | - Belhan Akpinar
- Department of Cardiovascular Surgery, Istanbul Demiroglu Bilim University Medical School, Istanbul, Turkey
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12
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Formica F, Guarracino F. Reply: Transient thrombocytopenia after Perceval S implantation: A good reason to continue with the research. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)32288-1. [PMID: 33172658 DOI: 10.1016/j.jtcvs.2020.07.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 07/17/2020] [Accepted: 07/17/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Francesco Formica
- Cardiac Surgery Unit, Department of Medicine and Surgery, Parma General Hospital, University of Parma, Parma, Italy
| | - Fabio Guarracino
- Department of Anaesthesia and Critical Care Medicine, Cardiothoracic and Vascular Anaesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
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13
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Stegmeier P, Bechtel JFM. REPLY: THROMBOCYTOPENIA AFTER IMPLANTATION OF A PERCEVAL S AORTIC BIOPROSTHESIS SHOULD BE STUDIED MORE VIGOROUSLY, NOT LESS. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)32285-6. [PMID: 33172659 DOI: 10.1016/j.jtcvs.2020.07.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 07/11/2020] [Accepted: 07/14/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Philipp Stegmeier
- Klinik für Herz- und Thoraxchirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Ruhr-Universität Bochum, Bochum, Germany
| | - J F Matthias Bechtel
- Klinik für Herz- und Thoraxchirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Ruhr-Universität Bochum, Bochum, Germany
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14
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Stegmeier P, Schlömicher M, Stiegler H, Strauch JT, Bechtel JM. Thrombocytopenia after implantation of the Perceval S aortic bioprosthesis. J Thorac Cardiovasc Surg 2020; 160:61-68.e8. [DOI: 10.1016/j.jtcvs.2019.07.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 06/25/2019] [Accepted: 07/10/2019] [Indexed: 01/07/2023]
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15
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Movileanu I, Pepa M, Cândea M, Ureche C. Heart valve mechanical prosthesis: The perfect match until it is not - A case report. Exp Ther Med 2020; 20:2481-2483. [PMID: 32765738 DOI: 10.3892/etm.2020.8959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/01/2020] [Indexed: 12/12/2022] Open
Abstract
Primary immune thrombocytopenia (ITP), formerly known as idiopathic thrombocytopenia, is defined by a reduced platelet count <50x109 and is clinically manifested through signs and symptoms such as bleeding, ecchymosis and petechiae. Its coexistence with the implantation of the mechanical valves and the necessity of anticoagulation creates an additional risk of bleeding. Although mechanical valves are indispensable in prolonging and improving the quality of life in patients with valvular heart disease, in the context of an additional bleeding risk factor, their presence could represent a threat to life exposing the patient to major complications and leading to death. The purpose of this case report is to discuss the disadvantages and possible fatal complications of the association between mechanical valves and severe thrombocytopenia. A possible solution to these downsides could be found in the future search in regenerative medicine and tissue engineering of heart valves resulting in products that do not require anticoagulation and do not pose a threat to patients with thrombocytopenia.
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Affiliation(s)
- Ionela Movileanu
- First Cardiology Department, Emergency Institute of Cardiovascular Diseases and Transplant, 540136 Târgu Mure?, Romania
| | - Miruna Pepa
- First Cardiology Department, Emergency Institute of Cardiovascular Diseases and Transplant, 540136 Târgu Mure?, Romania
| | - Marcela Cândea
- First Internal Medical Department, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Târgu Mure?, Romania
| | - Corina Ureche
- First Internal Medical Department, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Târgu Mure?, Romania
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16
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Griffin BR, Bronsert M, Reece TB, Pal JD, Cleveland JC, Fullerton DA, Gist KM, Jovanovich A, Jalal D, Faubel S, Aftab M. Thrombocytopenia After Cardiopulmonary Bypass Is Associated With Increased Morbidity and Mortality. Ann Thorac Surg 2019; 110:50-57. [PMID: 31816284 DOI: 10.1016/j.athoracsur.2019.10.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 08/10/2019] [Accepted: 10/02/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Thrombocytopenia is a risk factor for morbidity and mortality in critically ill patients, and is common after cardiopulmonary bypass (CPB). In this study, we evaluate whether thrombocytopenia after CPB is an independent risk factor for postoperative morbidity and mortality. METHODS We retrospectively evaluated 1364 patients requiring CPB at the University of Colorado Hospital between January 2011 and May 2016. Platelet nadir, absolute change in platelets, and percent change in platelets were modeled as continuous variables. Patients with postoperative thrombocytopenia (defined a nadir <75 × 103/μL within 72 hours) were also compared with patients without thrombocytopenia in a propensity-matched model. The primary outcome was in-hospital mortality, and secondary outcomes included postoperative infection, postoperative acute kidney injury (AKI), postoperative stroke, and prolonged intensive care unit (ICU) and hospital lengths of stay (LOS). RESULTS Postoperative thrombocytopenia occurred in 356 (26.0%) patients. In multivariable analysis, platelet nadir was significantly inversely associated with mortality (odds ratio [OR], 0.955; 95% confidence interval [CI], 0.934-0.975; P < .001), postoperative infection (OR, 0.992; 95% CI, 0.986-0.999; P = .03), AKI (all stage) (OR, 0.993; 95% CI, 0.988-0.998; P = .01), AKI (stage 3) (OR, 0.966; 95% CI, 0.951-0.982; P < .001), postoperative stroke (OR, 0.974; 95% CI, 0.956-0.992; P = .006), prolonged ICU stay (OR, 0.986; 95% CI, 0.981-0.991; P < .001), and hospital LOS (OR, 0.998; 95% CI, 0.997-0.999; P = .001). Percent change in platelets from baseline was also significantly associated with all primary and secondary outcomes. CONCLUSIONS Postoperative thrombocytopenia is independently associated with postoperative mortality, AKI, infection, stroke, and prolonged ICU and hospital LOS. Serial platelet monitoring may help identify patients at higher risk of postoperative complications. Further studies investigating strategies to reduce postoperative thrombocytopenia, including reducing CPB time, are needed.
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Affiliation(s)
- Benjamin R Griffin
- Division of Nephrology, Department of Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Michael Bronsert
- Adult and Child Consortium for Health Outcomes Research and Delivery Science and Surgical Outcomes and Applied Research, University of Colorado, Aurora, Colorado
| | - T Brett Reece
- Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jay D Pal
- Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Joseph C Cleveland
- Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - David A Fullerton
- Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Katja M Gist
- Department of Pediatrics, Children's Hospital Colorado, The Heart Institute, Aurora, Colorado
| | - Anna Jovanovich
- Division of Nephrology, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, Rocky Mountain Regional VA Medical Center, Denver, Colorado
| | - Diana Jalal
- Division of Nephrology, Department of Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Sarah Faubel
- Division of Nephrology, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, Rocky Mountain Regional VA Medical Center, Denver, Colorado
| | - Muhammad Aftab
- Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, Rocky Mountain Regional VA Medical Center, Denver, Colorado.
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17
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Commentary: Perceval S bioprosthesis valve and platelets: The thrombocytopenia is behind the corner and the mystery continues. J Thorac Cardiovasc Surg 2019; 160:69-70. [PMID: 31619333 DOI: 10.1016/j.jtcvs.2019.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 02/02/2023]
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18
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Commentary: Thrombocytopenia yes…thrombocytopenia no…that is the question. J Thorac Cardiovasc Surg 2019; 160:70-71. [PMID: 31585751 DOI: 10.1016/j.jtcvs.2019.07.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 01/08/2023]
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19
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Gomes WJ. Thrombocytopenia after aortic valve procedures - A possible not so harmless finding. Int J Cardiol 2019; 296:55-56. [PMID: 31472948 DOI: 10.1016/j.ijcard.2019.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/09/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Walter J Gomes
- Cardiovascular Surgery Discipline, Escola Paulista de Medicina - Federal University of São Paulo, São Paulo, Brazil.
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20
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Peri-procedural thrombocytopenia after aortic bioprosthesis implant: A systematic review and meta-analysis comparison among conventional, stentless, rapid-deployment, and transcatheter valves. Int J Cardiol 2019; 296:43-50. [PMID: 31351790 DOI: 10.1016/j.ijcard.2019.07.056] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/14/2019] [Accepted: 07/15/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Thrombocytopenia has been shown to occur soon after surgical biological aortic valve replacement (AVR), and recently reported also after transcatheter valve implantation (TAVI). The mechanism underlying this phenomenon is still unknown, and its clinical impact on the peri-operative outcome has been poorly investigated. METHODS A systematic review and a meta-analysis of all available studies reporting data about peri-procedural thrombocytopenia on isolated bio-AVR, comparing rapid-deployment (RDV), stentless (stentless-AVR), and TAVI vs. stented (stented-AVR) valves, have been performed. RESULTS Fifteen trials (2.163 patients) were included in the meta-analysis. Perioperative platelet reduction ranged from 35% to 55% in stented-AVR, from 60% to 77% in stentless-AVR, from 53% to 60% in RDV, and from to 21% to 72% in TAVI (apparently, balloon-expandable valves more frequently associated to thrombocytopenia). Stented-AVR required more red blood cells transfusion than stentless-AVR (P < 0.0001), whereas no difference has been found between RDV and stented-AVR. Platelet transfusion rate was very low in all surgical groups. No difference has been found in RDV and stentless-AVR vs. stented-AVR, in terms of reoperation for bleeding, and length-of-intensive care unit or hospital stay. CONCLUSIONS Thrombocytopenia-related major adverse events were mainly reported in TAVI patients, whereas clinically meaningless in surgical patients. Transient peri-procedural thrombocytopenia is common after bio-AVR, regardless of prosthesis's type or implant modality. It should receive appropriate monitoring and focused investigations.
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21
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An overlooked fact: thrombocytopenia following bioprosthetic aortic valve replacement. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 16:19-26. [PMID: 31043971 PMCID: PMC6491370 DOI: 10.5114/kitp.2019.83941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 12/27/2018] [Indexed: 11/17/2022]
Abstract
Introduction Thrombocytopenia observed after bioprosthetic aortic valve replacement has remained a puzzle to solve. Aim To analyze thrombocytopenia occurring after bioprosthetic aortic valve replacement by comparison to mechanical aortic valve replacement and coronary artery bypass grafting procedures. Material and methods The study was conducted retrospectively on a total of 297 patients who underwent bioprosthetic aortic valve replacement, mechanical prosthetic aortic valve replacement and coronary artery bypass grafting at the cardiovascular surgery department of our clinical center between January 2013 and September 2017. Preoperative and postoperative first 14-day thrombocyte levels of the patients were analyzed. Results The postoperative blood thrombocyte level decrease was found to be more significant in patients who underwent bioprosthetic aortic valve replacement than in patients who underwent mechanical aortic valve replacement and coronary artery bypass grafting (p < 0.01). There was also a statistically significant difference in the time to reach the lowest postoperative platelet levels according to type of surgery (p = 0.001; p < 0.01). Conclusions When compared to the patients who underwent coronary artery bypass grafting and mechanical prosthetic aortic valve replacement, postoperative thrombocytopenia was found to be more severe in patients who underwent bioprosthetic aortic valve replacement, with a dramatic decrease in thrombocyte count being observed on the postoperative second day. It was found that the thrombocytopenia recovers without causing any problem. We think that the shear forces may play a role in this recovery through washout of chemicals responsible for thrombocytopenia from the glutaraldehyde treated bioprostheses.
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