Mitral insufficiency associated with primary antiphospholipid syndrome and chronic renal failure

Aortic Valve Replacement and Perioperative Management in Hemodialyzed Patient wth Antiphospholipid Syndrome

Antiphospholipid syndrome is characterized by the presence of antiphospholipid antibodies, hypercoagulability, and prolonged phospholipid-dependent coagulation indices such as activated clotting time (ACT). Perioperative thrombotic complications are frequent among patients with antiphospholipid syndrome submitted to cardiac surgery, therefore, in these patients, heparin-protamine titration for anticoagulation monitoring is particularly recommended. We demonstrate a case of 42-year-old hemodialyzed patient with antiphospholipid syndrome, submitted to the replacement of stenotic aortic valve. In our patient celite ACT and heparin concentration during cardiopulmonary bypass did not correspond to each other. Anticoagulation based on heparin concentration assessment resulted in safe perioperative hemostatic management.

Mitral valve surgery for mitral regurgitation caused by Libman-Sacks endocarditis: a report of four cases and a systematic review of the literature

Libman-Sacks endocarditis of the mitral valve was first described by Libman and Sacks in 1924. Currently, the sterile verrucous vegetative lesions seen in Libman-Sacks endocarditis are regarded as a cardiac manifestation of both systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS). Although typically mild and asymptomatic, complications of Libman-Sacks endocarditis may include superimposed bacterial endocarditis, thromboembolic events, and severe valvular regurgitation and/or stenosis requiring surgery. In this study we report two cases of mitral valve repair and two cases of mitral valve replacement for mitral regurgitation (MR) caused by Libman-Sacks endocarditis. In addition, we provide a systematic review of the English literature on mitral valve surgery for MR caused by Libman-Sacks endocarditis. This report shows that mitral valve repair is feasible and effective in young patients with relatively stable SLE and/or APS and only localized mitral valve abnormalities caused by Libman-Sacks endocarditis. Both clinical and echocardiographic follow-up after repair show excellent mid- and long-term results.

Cardiovascular Surgical Outcomes in Patients with the Antiphospholipid Syndrome—A Case-Series

BACKGROUND

Patients with the antiphospholipid syndrome (APLS) have severe involvement of the cardiovascular apparatus and often need surgical interventions to correct these manifestations. Few studies that have looked at the outcomes of cardiothoracic surgeries in APLS patients have reported high rates of perioperative mortality and thromboembolic events.

OBJECTIVE

Our goal was to examine the outcomes of adult APLS patients undergoing coronary artery bypass surgery (CABG) and/or valvular surgery. We also wanted to determine whether aggressive anticoagulation therapy could prevent life threatening thromboembolic complications in these patients.

METHODS

We retrospectively reviewed medical records of nine patients with primary APLS undergoing cardiothoracic surgery between 1985 and 2005 at our institution. Patient demographics, operative procedures and one-year clinical outcomes were obtained.

RESULTS

Forty-five percent of our patients had more than three cardiovascular risk factors other than APLS. There were no mortalities in our case series. However, 89% of our patients developed major complications. Despite aggressive anticoagulation, 37.5% developed thromboembolic events including cerebrovascular accidents, myocardial infarctions and vena caval thrombosis. Other complications included heparin-induced thrombocytopenia, redo of CABG surgery and sepsis.

CONCLUSION

Despite aggressive anticoagulation and lack of significant pre-operative co-morbidities, APLS patients undergoing cardiothoracic surgery appear to have high rates of post-operative clinical events.

Increased morbidity and mortality in patients with antiphospholipid syndrome undergoing valve replacement surgery

OBJECTIVE

Heart valve abnormalities are commonly found in patients with antiphospholipid syndrome but experience with valve replacement in such patients is limited. We analyzed the results of valve replacement in patients with this condition at our institution.

METHODS

Between 1989 and 2002, 10 patients with antiphospholipid syndrome (8 women, 2 men; aged 38-73 years, mean 49 years) with severe mitral valve disease (n = 7), aortic valve disease (n = 2), or combined mitral-aortic disease (n = 1) underwent valve replacement. We reviewed retrospectively their clinical data, operative and postoperative courses, and the long-term results. Pathological reassessment was performed in all cases.

RESULTS

Procedures performed included mitral valve replacement in 7 patients, aortic valve replacement in 2 patients, and combined aortic valve replacement plus mitral valve replacement in 1 patient. In addition, 2 patients underwent tricuspid annuloplasty. The immediate mortality was 20% (2 patients). Major complications occurred in 2 other cases. During a follow-up period of up to 8 years, 2 patients required repeat operation for valve-related complications (1 death). An additional patient died of cardiac causes 13 months after surgery. One patient had major thromboembolic events 3 and 10 months after the operation. The late outcome was uneventful in only 4 patients.

CONCLUSION

Valve replacement in patients with antiphospholipid syndrome may carry significant early and late mortality and morbidity, particularly when such patients are referred with advanced valvular heart disease.