Intravascular hemolysis after mitral valve repair: a word of caution

Mestres, Carlos A.; Soo, Choi Sung; Sim, Eugene K.W.; Adebo, O A; Yan, Peter; Lee, Chuen Neng

doi:10.1016/1010-7940(92)90084-b

Cited by 16 publications

(10 citation statements)

References 6 publications

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“…Of these, the reports we chose fulfilled the following three conditions: a clear degree of MR jet as seen on Doppler echocardiography; a clear interval from initial operation to the appearance of hemolysis, and a clear oneto-one relation between the MR grade and the interval in the case series; and an absence of causes other than MR jet collision, including partial annuloplasty dehiscence, protruding paravalvular suture material, the whiplash motion of tendinous chords, or regurgitant jet collision with the pledget or atrial wall. We evaluated nine case reports and two case series of hemolysis caused by unendothelialization of the annuloplasty ring with or without MR jet collision as measured by echocardiography or reoperation (Table 3) [4,[12][13][14][15][16][17][18][19][20][21]. The cases of reoperation include seven reports and two series.…”

Section: Discussionmentioning

confidence: 99%

Reoperation after mitral valve repair in viewpoints of kidney injury as well as hemolytic anemia

Ishida¹,

Adachi²,

Shiotsu³

et al. 2014

CEN Case Rep

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Section: Discussionmentioning

confidence: 99%

Reoperation after mitral valve repair in viewpoints of kidney injury as well as hemolytic anemia

Ishida¹,

Adachi²,

Shiotsu³

et al. 2014

CEN Case Rep

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“…Only 7 patients among 1,548 who had underwent mitral valve repair needed reoperation for hemolytic anemia. 4 The mechanisms of hemolysis following mitral valve repair have been reported to include dehisced annuloplasty rings producing para-ring regurgitant jets, 3,8,11 protruding perivalvular suture material that provided a site of impact for circulating RBCs, 7,9,13 'whiplash motion' of residual, free-floating chordae tendineae within a hyperkinetic left ventricular chamber, 10 nonendothelialization of foreign materials such as sutures or rings 6 and a small but turbulent regurgitation jet against the left atrial wall. 5 Rapid acceleration, fragmentation and collision jets are associated with high shear stress, and may cause mitral prosthetic hemolysis, whereas free and slow deceleration jets are not.…”

Section: Discussionmentioning

confidence: 99%

“…12 On the other hand, an improvement in the hemolytic anemia following reoperation has been reported in many cases. [2][3][4][5][6][7][8][9][10][11] Because of the severe hemolysis requiring a blood transfusion, we recommended that our patient undergo reoperation, but unexpectedly, the hemolysis reduced without reoperation, although a moderate mitral regurgitation jet remained. Slowed velocity caused by propranolol may reduce the shearing stress between RBCs and foreign material, 14 but in this case, the hemolysis was reduced without an apparent change in velocity or blood pressure.…”

Section: Discussionmentioning

confidence: 99%

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Reduction of Hemolysis Without Reoperation Following Mitral Valve Repair

Inoue

Kaku

Kanaya

et al. 2003

Circ J

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emolytic anemia is uncommon after mitral valve repair and only a few cases have been reported. Although it is thought that rapid acceleration, fragmentation and collision of mitral regurgitation jets may be associated with high shear stress and cause hemolysis, 1,2 the precise mechanisms are not understood. In addition, the course of severe hemolysis after mitral valve repair has not been established, although in most cases the hemolysis improves with reoperation. [2][3][4][5][6][7][8][9][10][11] We report a patient who developed a severe hemolytic anemia after mitral valve repair that was reduced without the need for reoperation. Case ReportA 60-year-old man suffered from shortness of breath because of severe mitral regurgitation secondary to the prolapse of the posterior mitral leaflet. Transthoracic echocardiography revealed severe mitral regurgitation filling the whole left atrium from the medial scallop of the posterior mitral leaflet. The dimension of the left atrium in systole phase and the left ventricle in diastole was 53 mm and 58 mm, respectively. Surgery was performed under cardiopulmonary bypass, in mild hypothermia. Myocardial protection was afforded with cold crystalloid cardioplegia. A left paraseptal atriotomy was performed. The prolapsing medial scallop of the posterior mitral leaflet was resected, and the edge of leaflet was sewn onto a mitral annulus. A Duran flexible ring was sutured and fixed along the mitral Circulation Journal Vol.67, September 2003 annulus. A water injection test confirmed no regurgitation. Transthoracic echocardiography 10 days after the mitral valve repair showed mild mitral regurgitation, reaching the deep left atrium from the posterior mitral commissure. The dimension of the left atrium in systole and the left ventricle in diastole was 34 mm and 45 mm, respectively. Three weeks after the mitral valve repair, the patient was discharged with no complaints. After 2 months, he was readmitted complaining of fatigue and shortness of breath. His palpebral conjunctivae were anemic and bulbar conjunctivae icteric, but splenomegaly was not apparent. Laboratory data were as follows: red blood cell (RBC): 206×10 4 / l; hemoglobin: 6.2 g/dl; haptoglobin: <10 mg/dl; reticulocytes: 15.6×10 4 / l; lactate dehydrogenase (LDH): 3,235 IU/L; total bilirubin: 1.6 mg/dl. All these values had been within the normal range 5 months earlier. The Donath-Landsteiner test, Coombs test, Ham test and sugar water test were all negative. Drug-induced hemolytic anemia was not apparent, because there was no reduction of hemolysis after stopping the administration of any drug without furosemide, which was administered before the mitral valve repair. The

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“…Mechanical trauma is the main cause of hemolysis and the mechanism most frequently associated with hemolysis is turbulence of outflow caused by a valve’s configuration and/or functioning [1]. With an increasing number of valve repairs, hemolytic anemia has been reported only in a few cases [3-6]. …”

Section: Introductionmentioning

confidence: 99%

Hemolytic anemia after mitral valve repair: a case report

2013

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BackgroundHemolytic 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 presentationWe 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.ConclusionThis 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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Intravascular hemolysis after mitral valve repair: a word of caution

Cited by 16 publications

References 6 publications

Reoperation after mitral valve repair in viewpoints of kidney injury as well as hemolytic anemia

Reoperation after mitral valve repair in viewpoints of kidney injury as well as hemolytic anemia

Reduction of Hemolysis Without Reoperation Following Mitral Valve Repair

Hemolytic anemia after mitral valve repair: a case report

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