Brandon Bravo Bruinsma, G.J.

Bredée, J.J.

de Mol, B.A.J.M.

English

International Migration, Integration and Social Cohesion online publications

UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl)UvA-DARE (Digital Academic Repository)Mitral valve repair-related hemolysis: a report of two casesBrandon Bravo Bruinsma, G.J.; Bredée, J.J.; de Mol, B.A.J.M.Publication date1997Document VersionFinal published versionPublished inInternational Journal of CardiologyLink to publicationCitation for published version (APA):Brandon Bravo Bruinsma, G. J., Bredée, J. J., & de Mol, B. A. J. M. (1997). Mitral valverepair-related hemolysis: a report of two cases. International Journal of Cardiology, 60, 317-320.General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s)and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an opencontent license (like Creative Commons).Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, pleaselet the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the materialinaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letterto: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. Youwill be contacted as soon as possible.Download date:09 Mar 2023International Journal of Cardiology 60 (1997) 317–320Mitral valve repair-related hemolysis:a report of two casesa , a b* ´George J. Brandon Bravo Bruinsma , Johan J. Bredee , Bas A.J.M. de MolaHeart Lung Institute, Department of Cardiopulmonary Surgery, University Hospital Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The NetherlandsbDepartment of Cardiopulmonary Surgery, Academic Medical Center of the University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam zuidoost,The NetherlandsReceived 18 February 1997; accepted 6 May 1997AbstractTwo patients are described who suffered from progressive intravascular hemolysis following different kinds of reconstructive surgery ofthe mitral valve. Within the context of increasing numbers of operations aimed to preserve the mitral valve, the importance and difficultyof prompt recognition and adequate treatment of this very uncommon but potential lethal complication are emphasised.  1997 ElsevierScience Ireland Ltd.Keywords: Mitral valve repair; Intravascular hemolysis1. Introduction ‘‘clear-cut’’ case of early postoperative hemolysis dueto ruptured tendinous cords following supra-annularDuring the past two decades, mitral valve repair suturing of the annuloplasty ring. The second case ishas become a well-established therapeutic option for an illustration of progressive hemolysis due to atreating mitral valve disease [1,2]. In the postopera- rupture of the leafletplasty which occurred monthstive course, severe mechanical intravascular after surgery. Hemolysis was treated by mitral valvehemolysis is a very uncommon cause of morbidity replacement in both cases.[3]. In a report reviewing the first decade (1969–1978) of mitral valve reconstruction, 59% (22/37) ofthe reoperations were due to surgical technical factors 2. Case 1[2]. Hemolysis as a cause for reoperation within thefirst two years after the initial reconstruction con- A 70 year old male was referred to the Academictributed 11% (2/18). In the report reviewing the Medical Center of the University of Amsterdam forsecond decade (1978–1988), hemolysis was no treatment of dyspnea, New York Heart Associationlonger a cause for reoperation [4]. Nevertheless, (NYHA) class III, combined with angina, NYHAseveral case reports have dealt with this complication class I. Echocardiography showed prolapse of thewhich may cause multiple organ failure. [3,5]. We posterior mitral leaflet due to chordal rupture anddescribe two patients. The first patient represents a annulus dilation. Cardiac catheterization revealedcoexistence of a significant stenosis of the left*Corresponding author: Tel.: 31 30 2506179; Fax: 31 30 2542155. anterior descending (LAD) coronary artery. During0167-5273/97/$17.00  1997 Elsevier Science Ireland Ltd. All rights reservedPII S0167-5273( 97 )00108-3318 G.J. Brandon Bravo Bruinsma et al. / International Journal of Cardiology 60 (1997) 317 –320surgery, quadrangular resection of the posterior leaf- mammary artery and two saphenous vein grafts,let was performed, followed by annuloplasty by using respectively. Intraoperatively performed TEE showeda flexible 35 mm Duran ring. A saphenous vein graft no residual regurgitation. The postoperative coursewas used for revascularization of the LAD. Weaning was uneventful and the patient was discharged fromthfrom extracorporeal circulation was uneventful. On hospital on the 10 postoperative day. Three monthsthe seventh postoperative day, slight urine darkening later, the patient complained of fatigue and urinewas noted, followed by jaundice. Diuresis remained darkening. The abnormal laboratory data showed thatsatisfactory and stools showed no abnormality. On Hb had dropped from 7.9, at the day of discharge, tophysical examination, a grade II /VI holosystolic 6.3 mmol / l and Ht from 0.37 to 0.31 l / l. Serummurmur was heard at the apex cordis. The abnormal haptoglobin had decreased to 0.1 g/ l, and serumlaboratory results comprised hemoglobin (Hb) 4.5 LDH had increased to 2500 U/ l. However, TEEmmol / l and hematocrit (Ht) 0.21 l / l; normal values showed no changes compared with the intraoperative8.6–10.7 mmol / l and 0.41–0.55 l / l, respectively. TEE. An immunological or toxic cause was excluded.Total serum bilirubin had risen to 35 mmol / l (normal The same applied for endocarditis and hemoglo-value ,17 mmol / l) and serum haptoglobin had binopathy. Finally, a bone marrow specimen revealeddropped to 0.0 g/ l (normal value 0.3–1.8 g/ l). marked erythroid hyperplasia.Vitamin B , folic acid,12Lactate dehydrogenase (LDH) was 2475 U/ l (normal and ferrous fumarate were administered. However,value 300–620 U/ l) and the reticulocyte count was after six weeks of therapy, the patient had to beelevated. Myocardial infarction, hepatitis, infection, admitted to hospital due to progressive dyspnea andand rhabdomyolysis could be excluded. Trans- jaundice. On physical examination, a Grade III /VIesophageal echocardiography (TEE) revealed rup- holosystolic murmur could be heard at the apextured tendinous cords of the central scallop of the cordis. LDH had increased to 5190 U/ l, Hb and Htanterior mitral leaflet and supra-annular insertion of had decreased further to 5.6 mmol / l and 0.27 l / l,the annuloplasty ring. The patient’s hemodynamic respectively. Peripheral blood smear now showedcondition deteriorated and multiple blood transfusions markedly deformed micropoikilocytes, indicative ofthwere needed. On the 13 postoperative day the mitral mechanically destructed erythrocytes. TEE revealed avalve was replaced by a St. Jude no. 27 mechanical distinct prevalvular acceleration of the blood streamvalve. Postoperatively, sustained normalization of Hb at the central site of apposition of the anterior andand serum LDH were observed. posterior leaflet (Fig. 1). Although the patient re-mained hemodynamically stable, multiple bloodtransfusions were necessary. Approximately seven3. Case 2 months after the initial operation, the patient wasreoperated on. During surgery, good endothelializa-A 54-year-old male was admitted to the University tion of the bovine pericardial strip and a rupturedHospital Utrecht for treatment of dyspnea, NYHA suture at the central point of apposition of the leafletsclass II, based on mitral valve regurgitation combined were seen. The valve was replaced by a 29 mm¨with stable angina pectoris, NYHA class II. Cardiac Bjork–Shiley mechanical valve. Anemia andcatheterization showed significant triple-vessel cor- hemolysis disappeared rapidly. The patient was dis-thonary artery disease. Echocardiography revealed a charged from hospital on the 11 postoperative day.prolapse of the anterior mitral leaflet. Surgery com-prised triangular resection of the prolapsing centralscallop of the anterior leaflet. The cleft was closed 4. Discussionwith interrupted sutures. Posterior annular remodel-ling was established with a bovine pericardial strip, After open-heart surgery, intravascular hemolysissized to a 30 mm Carpentier–Edwards ring. Myocar- is mainly caused by mechanical destruction of eryth-dial revascularization comprised grafting of the LAD, rocytes in the presence of a mechanical heart valve,the second obtuse marginal branch, and the posterior primarily in the aortic position. However, paravalvu-descending coronary artery by using the left internal lar leakage, infection, and blood transfusion reaction,G.J. Brandon Bravo Bruinsma et al. / International Journal of Cardiology 60 (1997) 317 –320 319Fig. 1. Photograph showing a longitudinal view of the mitral valve, assessed by TEE. The arrow is pointed at the central site of apposition where theruptured suture of the plasty of the anterior leaflet was located and a distinct prevalvular acceleration of the blood stream was identified by color-Doppleranalysis. LA5left atrium, LV5left ventricle.have to be ruled out [6]. Causes for reoperations represented by series in which up to 81% of thewithin two years following the initial mitral valve mitral valves subjected to surgery, could be preservedrepair include, dehiscence of the prosthetic mitral [1]. Thus, a small percentage of reoperations due toring, oversizing of the ring, and residual regurgitation intravascular hemolysis might reappear in the reportin the presence of interrupted sutures on pledgets of reviewing the third decade (1989–1999) of mitralfelt [4]. Case one of this paper illustrates the impor- valve repair. Based on the two presented cases,tance of surgical accuracy. The chordal cords had prompt recognition and adequate treatment of post-probably ruptured due to the shearing-stress, induced operative mitral valve repair-related intravascularby the altered geometry of the mitral valve apparatus hemolysis are emphasised.[5]. As reported by Mestres et al. [3], detection of thecause of hemolysis can be difficult which is illus-trated by case two. Nonendothelialization of foreignAcknowledgmentsbodies and the presence of a regurgitant jet, even ofsmall hemodynamic significance, may play an im-The authors would like to express their gratitude toportant role in the origin of intravascular hemolysis.Mrs. G.L. van Gaalen for her valuable and ap-However, even in the absence of a regurgitant jet,preciated contribution.assessed by TEE with color mapping and Doppleranalysis [3], one has to consider the possibility of acardiac cause of intravascular hemolysis. Up to now,only a few case reports have dealt with this subject. ReferencesHowever, increased surgical experience has led tomodification of repair techniques and expansion of [1] Atunes MJ. Mitral valve repair into the 1990s. Eur J Cardiothoracthe indications for mitral valve repair [1,4]. This is Surg 1992;6(Suppl. 1):S13–6.320 G.J. Brandon Bravo Bruinsma et al. / International Journal of Cardiology 60 (1997) 317 –320[2] Carpentier A, Chauvaud S, Fabiani JN et al. Reconstructive [5] Seyr M, Hasibeder W, Furtwaengler W, Antretter H, Mutz NJ.surgery of mitral valve incompetence. J Thorac Cardiovasc Surg Multiple organ failure after mitral valve repair with intravascular1980;79:338–48. hemolysis and its recovery due to mitral valve replacement. Inten-[3] Mestres CA, Soo CS, Sim EK, Adebo OA, Yan P, Lee CN. sive Care Med 1993;19:358–60.Intravascular hemolysis after mitral valve repair: a word of caution. [6] Warnes C, Honey M, Brooks N, Davies J, Gorman A, Parker N.Eur J Cardiothorac Surg 1992;6:103–5. Mechanical haemolytic anaemia after valve repair operations for[4] Deloche A, Jebra VA, Relland JYM et al. Valve repair with nonrheumatic mitral regurgitation. Br Heart J 1980;44:381–5.Carpentier techniques. The second decade. J Thorac CardiovascSurg 1990;99:990–1002.

Mitral valve repair-related hemolysis: a report of two cases

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Mitral valve repair-related hemolysis: a report of two cases

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