Coronary artery bypass in idiopathic thrombocytopenia without splenectomy

Concurrent coronary artery disease and immune thrombocytopenia: a systematic review

Introduction

Coronary artery disease (CAD) management in the setting of immune thrombocytopenia (ITP) remains very challenging to clinicians as a reasonable balance between bleeding and thrombosis risks needs to be achieved, and the evidence guiding such management is scarce.

Methods

We conducted a systematic review following the PRISMA guidelines to summarize the available literature on the management and outcomes of CAD coexisting with ITP. We searched PubMed and Embase for studies published in English exploring CAD and ITP management until 05 October 2022. Two independent reviewers screened and assessed the articles for inclusion. Patients' characteristics, CAD treatment modalities, ITP treatment, and complications were reported.

Results

We identified 32 CAD cases, among which 18 cases were revascularized with percutaneous coronary intervention (PCI), 12 cases underwent coronary artery bypass graft surgery (CABG), and two cases were managed conservatively. More than 50% were men, with a mean age of 61 ± 13 years and a mean baseline platelet count of 52 ± 59 × 109/L. Irrespective of the revascularization modality, most patients were treated with either corticosteroids alone, intravenous immunoglobulins (IVIG) alone, or in combination. Among those who underwent PCI, two patients had bleeding events, and one patient died. Similarly, among those with CABG, one patient developed bleeding, and one patient died.

Conclusion

We found that revascularization with either PCI or CABG with the concurrent use of corticosteroids and/or IVIG for ITP was feasible, with an existing non-negligible risk of bleeding and mortality.

Coronary artery stenting in a patient with chronic immune thrombocytopenic purpura: a clinical conundrum

A patient with long-standing immune thrombocytopenic purpura (ITP) would logically contradict antiplatelet use due to increased bleeding risk during coronary stenting. Coronary stenting using an endothelial progenitor cells (EPC) capture stents (Genous™) was used to successfully revascularise our patient using a transradial approach. The only complication was extensive superficial ecchymosis on the patient's forearm from antiplatelet use, which resolved spontaneously. To the best of our knowledge, this is the first case report of EPC capture stents in a chronic ITP patient.

Primary PCI for acute myocardial infarction in a patient with idiopathic thrombocytopenic purpura. A case report and review of the literature

BACKGROUND AND PURPOSE

The occurrence of acute myocardial infarction (AMI) in patients with idiopathic thrombocytopenic purpura (ITP) is rare, especially when the platelet count is low. Since only few case reports have been published, there are no recommendations for the management of thrombocytopenic patients with AMI. The aim of the present study is to discuss different aspects of this challenging issue and to review limited data available in the literature.

CASE STUDY

An 80-year-old patient with ITP (platelet count 5 . 10(9)/l) is presented who developed an AMI (ST segment elevation myocardial infarction) and was successfully treated by primary percutaneous coronary intervention (PCI).

CONCLUSION

Considering the high bleeding risk in patients with ITP and AMI, careful balance between usual anticoagulation and antiplatelet therapy on the one hand, and efforts to raise platelet count on the other hand are needed.

Are patients with Werlhof's disease at increased risk for bleeding complications when undergoing cardiac surgery?

BACKGROUND

It is generally assumed, that patients with Werlhof's disease (WD) are at increased risk for bleeding complications when undergoing cardiac surgery with extracorporeal circulation. Therefore we performed this case control study to estimate the real risk for bleeding complications of these patients.

METHODS

Between 05/95 and 07/98, ten patients with WD (eight males, two females) underwent cardiac surgery employing extracorporeal circulation (WD-group). Five of these patients with platelet counts below 80/nl were treated by immunoglobulins preoperatively. Each patient with WD was matched to five patients without WD (no-WD-group) using diagnosis, age, gender, ejection fraction, number of distal anastomosis and body-mass-index as matching criteria.

RESULTS

Mean number of platelet counts were significant lower in the WD-group than in the no-WD-group despite a significant increase of platelet counts after immunoglobulin treatment (54/nl-->112/nl, P=0.018). On the day before, directly after and on the first day after surgery they were 141/nl vs. 215/nl (P=0.012), 75/nl vs. 147/nl (P=0.001) and 93/nl vs. 136/nl (P=0.009). Accordingly, patients of the WD-group received significantly more platelet concentrates than patients of the no-WD-group (mean number of platelet concentrates: 2.3 versus 0.7, P=0.007). Total drainage loss via the mediastinal chest tubes was almost identical (1197 ml in the no-WD-group and 1140 ml in the WD-group). One patient of each group suffered from a bleeding complication requiring reexploration. Three patients of the no-WD-group (6%) and one patient of the WD-group (10%) expired postoperatively unrelated to WD.

CONCLUSIONS

Patients with WD may possibly undergo cardiac surgery without a markedly enhanced risk for bleeding complications despite a more than usual transfusion requirement and significantly lower platelet counts perioperatively.

Preoperative immunoglobulin treatment in patients with Werlhof's disease undergoing cardiac operation

BACKGROUND

Patients with Werlhof's disease and undergoing a cardiac surgical procedure with cardiopulmonary bypass are at increased risk for bleeding complications. We report the usefulness of preoperative immunoglobulin treatment in selected patients.

METHODS

Between May 1995 and July 1998, 10 patients with Werlhof's disease underwent a cardiac surgical procedure with cardiopulmonary bypass in our department. Five patients with mean platelet counts of less than 80x10(9)/L received immunoglobulin therapy preoperatively (group 1). The other 5 patients with mean platelet counts higher than 80x10(9)/L were not so treated (group 2).

RESULTS

In group 1, mean platelet count increased from 54x10(9)/L 5 days before operation to 112x10(9)/L after immunoglobulin treatment (p = 0.018) and did not fall to less than 60x10(9)/L postoperatively. Patients in group 1 received 16 units of packed red blood cells and 5 units of platelet concentrate. Patients in group 2 required 24 units of packed red blood cells, 5 units of platelet concentrate, and 23 units of fresh frozen plasma. Only 1 patient (group 2) had a surgical bleeding complication that required reexploration. Mean drainage loss was 1,100 mL in group 1 and 1,210 mL in group 2.

CONCLUSIONS

Our data demonstrate that immunoglobulin treatment of patients with Werlhof's disease and mean platelet counts of less than 80x10(9)/L significantly augments platelet counts preoperatively. It may be useful in selected patients.

Refractoriness to platelet transfusion following double valve replacement in an ITP patient who had undergone splenectomy

Reports of patients with idiopathic thrombocytopenic purpura (ITP) undergoing cardiac surgery are rare, and almost all of the reported cases required platelet transfusion. ITP patients, especially those having a history of splenectomy or a history of heavy bleeding, may have to undergo multiple platelet transfusions. Such transfusions may induce alloimmunization against the human leukocyte antigen (HLA) and result in refractoriness to subsequent platelet transfusions. We report a case of a 63-year-old female with ITP, with a history of splenectomy and multiple platelet transfusions, who underwent aortic and mitral valve replacement. Although corticosteroid administration, high-dose immunoglobulin therapy, and repeated platelet transfusion led to a temporary increase in platelet count and successful hemostasis, refractoriness to platelet transfusion occurred postoperatively because of the presence of the anti-HLA antibody. In addition, the patient showed complications of pyothorax. Corticosteroids might have exerted an inhibitory influence on the occurrence of pyothorax.

Aortic valve replacement in a patient with idiopathic thrombocytopenic purpura

A patient with aortic regurgitation and idiopathic thrombocytopenic purpura underwent a successful valve replacement. Cardiac surgery requiring a cardiopulmonary bypass in idiopathic thrombocytopenic purpura can be safely carried out with the preoperative intravenous administration of high-dose gammaglobulin, which may thereby reduce the need for either perioperative transfusion or prophylactic splenectomy.

Coronary artery bypass grafting in immune thrombocytopenic purpura

BACKGROUND

Reports of patients with idiopathic thrombocytopenic purpura undergoing cardiac operations are scarce and no recommendations exist regarding their management. We report 3 patients with idiopathic thrombocytopenic purpura and severe coronary artery disease who underwent uncomplicated coronary bypass grafting.

METHODS

The case history of each patient with idiopathic thrombocytopenic purpura who underwent coronary artery bypass grafting and the literature were reviewed.

RESULTS

All 3 patients underwent uncomplicated coronary artery bypass grafting after preoperative treatment with intravenous immunoglobulin and intraoperative platelet transfusions if needed. Prophylactic splenectomy was not performed. There was no increased incidence of bleeding complications.

CONCLUSIONS

Coronary artery bypass grafting can be safely performed in patients with idiopathic thrombocytopenic purpura using conventional conduits after pretreating with immunoglobulin G and avoiding splenectomy.

Emergency aortic arch replacement in a patient with idiopathic thrombocytopenic purpura

We herein report the case of a 56-year-old man with idiopathic thrombocytopenic purpura who required an emergency aortic arch replacement. Intraoperatively, hemostasis was achieved using platelet transfusions. Postoperatively, the use of high-dose gamma-globulin therapy was able to maintain an adequate platelet count and good hemostasis.

Aortic valve replacement and splenectomy in a patient with chronic idiopathic thrombocytopenic purpura--preoperative management with high-dose gamma-globulin

We report the management of a patient with chronic idiopathic thrombocytopenic purpura and severe aortic valvular disease. Preoperative intravenous high-dose gamma-globulin administration was employed, and aortic valve replacement combined with splenectomy were performed during the same operation. The platelet count at admission was 34,000/mm3 and increased to 146,000/mm3 after the gamma-globulin therapy. Platelet transfusion at the end of the cardiopulmonary bypass was considered no longer necessary in the postoperative period, because the platelet count increased quickly after the procedure. The postoperative course was uneventful. We believe that open heart surgery and splenectomy can successfully be performed simultaneously in a patient with chronic idiopathic thrombocytopenic purpura treated with high-dose gamma-globulin therapy.