Coronary artery bypass grafting in immune thrombocytopenic purpura

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.

Aggressive Perioperative Management for Immune Thrombocytopenic Purpura in a Patient Undergoing Open Heart Surgery: A Correct Strategy in an Emergent Patient?

Immune thrombocytopenic purpura (ITP) is an autoimmune pathology that causes thrombocytopenia. This can become extremely troublesome when dealing with the rare clinical scenario of having to operate a highly invasive procedure on patients with thrombocytopenia. We report a case of a 66-year-old male with multiple comorbidities, including ITP, who underwent coronary artery bypass grafting (CABG) with an aortic valve replacement (AVR). He deteriorated rapidly, prompting urgent procedures. Little to no literature exists on the treatment plan for a critical patient with ITP who is about to undergo an open heart surgery. Our goal was to aggressively treat the patient with prednisolone, azathioprine, and platelets in the short preoperative time in order to maximize the prognosis. Our patient remained stable postoperatively, developed no complications, and was discharged successfully.

Revascularization for patients with idiopathic thrombocytopenic purpura and coronary artery disease

Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder with a low platelet count characterized by premature platelet destruction and suppression of platelet production mediated by autoantibodies, which may predispose to bleeding. Although the prevalence of coronary artery disease (CAD) in ITP seems to be rare, their co-occurrence is not unusual. Patients with ITP have increased risks for thrombosis and atherosclerosis associated with hemostatic factors, endothelial damage, and the negative effects of steroid and immunoglobulin therapies. Thus, the coexistence of ITP and CAD presents complex problems requiring a balance between hemorrhagic risk and prevention of thrombosis. Here, the authors present two patients with ITP, who were revascularized in different ways for CAD. Although the optimal management of thrombocytopenic patients with CAD is uncertain, individualized treatment modalities can be useful in patients with ITP and CAD.

Endobronchial hemorrhage after intubation with double-lumen endotracheal tube in a patient with idiopathic thrombocytopenic purpura for minimally invasive cardiac surgery: a case report

Minimally invasive cardiac surgery (MICS) requires lung isolation. Lung isolation is usually achieved with double-lumen endotracheal tube (DLT). Patients with idiopathic thrombocytopenic purpura (ITP) have an increased risk of bleeding events. We suspected endobronchial hemorrhage after exchange of DLT during induction of anesthesia for replacement of mitral valve in a 62-year-old man with a known ITP. The MICS was stopped and bronchial artery embolization was performed in the angiographic room. In the present case, in order to reduce the risk of bronchial arterial injury in ITP patient we intubated with single lumen endotracheal tube. Lung isolation led to achievement of intermittent total lung deflation. Based on the results, we recommend a high-dose intravenous immunoglobulin therapy and platelet transfusion prior to cardiac surgery in patients with ITP to increase platelet count. Moreover, it is proposed that in order to clear the vision during the operation, ventilation can be held or made intermittent both prior to cardiopulmonary bypass or at its conclusion to permit exposure.

A surgical case of mitral regurgitation due to active infective endocarditis with idiopathic thrombocytopenic purpura

A 71-year-old woman with idiopathic thrombocytopenic purpura (ITP), who had been treated with steroid and cyclosporine, was admitted in an emergency with fever and dyspnea. The diagnosis was mitral regurgitation due ton infective endocarditis. Although she received treatments for infection and cardiac failure, the cardiac failure could not be controlled. After high-dose γ-globulin therapy, an emergency operation was performed during the active phase of infective endocarditis. Rapid platelet transfusion was administered after weaning from extracorporeal circulation. She recovered and was discharged without postoperative bleeding and re-infection.The treatment course of elective cardiac surgery complicated with ITP has been established, but the course of emergency surgery has not been established because of the small number of cases reported. Since few patients have undergone emergency surgery for active infective endocarditis, we had difficulty in deciding the time of surgery and treatment for increasing the number of platelets before surgery, it was considered that the case provided us with useful suggestion for the future treatment for urgent surgery complicated with ITP.

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.

Treatment of immune-mediated thrombocytopenia purpura with concurrent intravenous immunoglobulin and platelet transfusion: a retrospective review of 40 patients

We performed a retrospective review of patients with immune-mediated thrombocytopenia (ITP) treated with prolonged infusions of intravenous immunoglobulin (IVIg) (1 g/kg by continuous infusion over 24 hr) and concurrent platelets (1 pheresis unit every 8 hr), to determine the response rate of this therapy. Patient inclusion criteria included clinically significant thrombocytopenia, with either active bleeding, need for anticoagulation, or a needed surgical procedure. The average pretreatment platelet count was 10,000/microl, which increased to 55,000/microl after 24 hr and 69,000/microl after 48 hr. After 24 hr, 62.7% of patients had a platelet count >50,000/microl. Bleeding was controlled initially in all patients, and those requiring a procedure experienced no bleeding complications. Over half of the patients (52.5%) required additional treatments for recurrent or refractory ITP. Six of the 21 patients requiring retreatment (29%) received IVIg and platelets again in a similar fashion, with similar results. No side effects of the combined treatment were noted. There is limited literature on the optimal dose and schedule for administration of IVIg and platelets. Our approach for administration of IVIg and platelets concurrently was associated with minimal side effects, resolution of bleeding, ability to safely undergo procedures, and rapid restoration of adequate platelet counts.

Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline

BACKGROUND

A minority of patients having cardiac procedures (15% to 20%) consume more than 80% of the blood products transfused at operation. Blood must be viewed as a scarce resource that carries risks and benefits. A careful review of available evidence can provide guidelines to allocate this valuable resource and improve patient outcomes.

METHODS

We reviewed all available published evidence related to blood conservation during cardiac operations, including randomized controlled trials, published observational information, and case reports. Conventional methods identified the level of evidence available for each of the blood conservation interventions. After considering the level of evidence, recommendations were made regarding each intervention using the American Heart Association/American College of Cardiology classification scheme.

RESULTS

Review of published reports identified a high-risk profile associated with increased postoperative blood transfusion. Six variables stand out as important indicators of risk: (1) advanced age, (2) low preoperative red blood cell volume (preoperative anemia or small body size), (3) preoperative antiplatelet or antithrombotic drugs, (4) reoperative or complex procedures, (5) emergency operations, and (6) noncardiac patient comorbidities. Careful review revealed preoperative and perioperative interventions that are likely to reduce bleeding and postoperative blood transfusion. Preoperative interventions that are likely to reduce blood transfusion include identification of high-risk patients who should receive all available preoperative and perioperative blood conservation interventions and limitation of antithrombotic drugs. Perioperative blood conservation interventions include use of antifibrinolytic drugs, selective use of off-pump coronary artery bypass graft surgery, routine use of a cell-saving device, and implementation of appropriate transfusion indications. An important intervention is application of a multimodality blood conservation program that is institution based, accepted by all health care providers, and that involves well thought out transfusion algorithms to guide transfusion decisions.

CONCLUSIONS

Based on available evidence, institution-specific protocols should screen for high-risk patients, as blood conservation interventions are likely to be most productive for this high-risk subset. Available evidence-based blood conservation techniques include (1) drugs that increase preoperative blood volume (eg, erythropoietin) or decrease postoperative bleeding (eg, antifibrinolytics), (2) devices that conserve blood (eg, intraoperative blood salvage and blood sparing interventions), (3) interventions that protect the patient's own blood from the stress of operation (eg, autologous predonation and normovolemic hemodilution), (4) consensus, institution-specific blood transfusion algorithms supplemented with point-of-care testing, and most importantly, (5) a multimodality approach to blood conservation combining all of the above.

A surgical case of aortic valve replacement in patient with chronic idiopathic thrombocytopenic purpura

A 64-year-old man was presented to another hospital with bleeding from the upper jaw with a platelet count of 0.1 x 10(4)/microl one year ago, and idiopathic thrombocytopenic purpura complicated with aortic stenosis and regurgitation was diagnosed. Corticosteroid administration was initiated and the patient was admitted to our hospital for surgery two months after confirmation of symptoms associated with cerebral ischemia. Corticosteroid was administered for one year until the day of surgery, and aortic valve replacement was performed with a platelet count of 8.4 x 10(4)/microl. During surgery, bleeding tendency with decreased platelets was confirmed, which was corrected with intraoperative platelet transfusion, postoperative gamma-globulin administration, and postoperative oral corticosteroid administration. Caution must be exercised against perioperative bleeding tendency in open heart surgery, even when platelet count is maintained using small amounts of preoperative corticosteroid.

Coronary artery bypass grafting in an immune thrombocytopenic purpura patient using off-pump techniques

We performed an off-pump coronary artery bypass grafting (OPCABG) procedure on a 60-year-old woman with idiopathic thrombocytopenic purpura (ITP) whose platelet count was 42 x 10(3) per microliter on admission. She was treated with immunoglobulin G (IgG) (0.5 g.kg(-1).d(-1)) for 4 days, resulting in a platelet count rise to 187 x 10(3) per microliter. She subsequently underwent an uneventful OPCABG procedure without requiring any blood transfusions. The combination of OPCABG and preoperative IgG therapy appears to be an ideal strategy for ITP patients requiring coronary revascularization.

Management of the patient with coagulation disorders

Understanding normal haemostasis and the pathophysiology of its disorders is essential for providing optimal care and ensuring judicious usage of blood products, as is keeping abreast of novel therapeutic modalities in a rapidly evolving field. The growing availability of synthetic coagulation factors has (at least in the western hemisphere) helped to reduce morbidity and therapeutic complications, while expanding the indications and usage of these agents. Promising advances in gene therapy may indeed introduce a sea change in the next decade or two.

Percutaneous coronary intervention with adjunctive abciximab and clopidogrel in a patient with chronic idiopathic thrombocytopaenic purpura

The use of the antiplatelet agents abciximab and clopidogrel is now accepted therapy in percutaneous coronary intervention. We present a case in which these agents were used in a patient with idiopathic thrombocytopaenic purpura and a platelet count of 40x10(9)/l undergoing primary multivessel coronary stenting. This case shows that unstable coronary syndromes can occur in patients with thrombocytopaenia and that antiplatelet agents may be used safely in this context.

Nafamostat mesilate treatment during open heart operation in immune thrombocytopenic purpura

A 58-year old woman with idiopathic thrombocytopenic purpura underwent mitral and aortic valve replacements and tricuspid annuloplasty. Preoperative therapeutic interventions including prednisone and immunoglobulin were successful in elevating the platelet count to 93,000/ mm2. Furthermore, we used nafamostat mesilate for coagulopathy prophylaxis during cardiopulmonary bypass. Postoperative bleeding was average and clinical course was uneventful. The perioperative management for patients with idiopathic thrombocytopenic purpura requiring cardiac operation is reviewed.

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.

Redo without transfusion in a patient with idiopathic thrombocytopenic purpura

Mitral valve replacement was able to be carried out at redo operation requiring neither allogeneic platelet nor blood transfusion in a patient with idiopathic thrombocytopenic purpura, by means of preoperative high-dose intravenous gamma-globulin, autologous blood predonation, use of a centrifugal pump, heparin-coated extracorporeal circuits, and simultaneous splenectomy.

Mitral valve replacement in a patient with idiopathic thrombocytopenic purpura

Reports of a cardiac operation in a patient with idiopathic thrombocytopenic purpura are scarce. Here we present a case of successful mitral valve replacement in a patient with idiopathic thrombocytopenic purpura. Preoperative treatment with high-dosage gamma-globulin successfully increased the platelet count from 50,000/microliter to 80,000/microliter. Twenty units of platelet-rich plasma were administered during and after the operation. No other blood products were used. The postoperative convalescence was uneventful. Perioperative management for patients with idiopathic thrombocytopenic purpura undergoing open-heart surgery is discussed.

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.

Primary percutaneous transluminal coronary angioplasty performed for acute myocardial infarction in a patient with idiopathic thrombocytopenic purpura

A 72-year-old female with idiopathic thrombocytopenic purpura (ITP) complained of severe chest pain. Electrocardiography showed ST-segment depression and negative T wave in I, aVL and V4-6. Following a diagnosis of acute myocardial infarction (AMI), urgent coronary angiography revealed 99% organic stenosis with delayed flow in the proximal segment and 50% in the middle segment of the left anterior descending artery (LAD). Subsequently, percutaneous transluminal coronary angioplasty (PTCA) for the stenosis in the proximal LAD was performed. In the coronary care unit, her blood pressure dropped. Hematomas around the puncture sites were observed and the platelet count was 28,000/mm3. After transfusion, electrocardiography revealed ST-segment elevation in I, aVL and V1-6. Urgent recatheterization disclosed total occlusion in the middle segment of the LAD. Subsequently, PTCA was performed successfully. Then, intravenous immunoglobulin increased the platelet count and the bleeding tendency disappeared. A case of AMI with ITP is rare. The present case suggests that primary PTCA can be a useful therapeutic strategy, but careful attention must be paid to hemostasis and to managing the platelet count.