Coronary bypass in a patient with hemophilia B, or Christmas disease

Continuous infusion factor replacement in haemophilia B during and after cardiac surgery: the better choice?

A 57-year-old man with mild haemophilia B was admitted for coronary artery bypass graft surgery. His factor IX (FIX) activity was 15% on admission. Our goal was to maintain his FIX activity at 80%-100% for post-op days (PODs) 0-3, and at 60%-80% for PODs 4-14. Preoperatively, the patient was given recombinant FIX (rFIX) bolus using the formula:Dosage needed=%(desired FIX level-current level of FIX)×weight (kg)×1.3.This increased his activity to 100%. One IU of rFIX increased FIX activity by 0.8%; the half-life of rFIX is 18-24 hours. The rFIX infusion was started intraoperatively and continued after surgery to maintain target FIX activity. He was discharged on POD 9 on rFIX bolus dosing of 5000 IU every 12 hours for an additional 5 days. Using continuous factor infusion, we managed to decrease the amount rFIX used by >60% while maintaining steady state FIX activity level.

Tetralogy of Fallot and Hemophilia A: Successful Management of Intracardiac Repair

A 4-year-old boy with moderately severe factor VIII deficiency underwent successful intracardiac repair of tetralogy of Fallot under cardiopulmonary bypass with the aid of factor VIII concentrates and aprotinin.

Aortic and Mitral Valve Replacement in a Patient with Hemophilia B

A 25-year-old man with factor IX deficiency had an aortic and mitral valve replacement using a 2M Starr Edwards valve in the mitral position and a 22 Medtronic valve in the aortic position under cover of factor IX concentrate. The surgical procedure and the immediate postoperative period were uneventful except for a pericardial effusion which required a pericardiostomy. He was anticoagulated with heparin in the immediate postoperative period while the factor IX concentrate was being administered. Oral anticoagulation with acenocoumarol (Acitrom®) was started, maintaining the international normalized ratio between 1.5 and 2. He was doing well at follow-up 9 months later.

Myocardial infarction, other arterial thrombosis and invasive coronary procedures, in hemaophilia B: a critical evaluation of reported cases

Myocardial infarction and other arterial thrombosis are commonly maintained to be rare in hemophilia patients. This, in general, seems true but the occurrence of a thrombotic event in hemophilia B is not exceptional. A thorough search of the literature has yielded 13 patients with myocardial infarction and 1 patient with a cerebrovascular accident. There were three fatalities. In five cases MI occurred after infusion of Prothrombin Complex Concentrates. In three additional patients the event occurred after infusion of plasma, Feiba or cryoprecipitate supernatant. Four patients had an antero-lateral infarction. Two had a non-Q infarction and one each showed a multiple or a posterior-inferior form. Several therapeutic coronary procedures (GABG and PTCA) were carried out in hemophilia B patients without undue complication providing adequate level of FIX were maintained. Heparin prophilaxis was used in all patients but one. The analysis of the literature indicates that (1) MI may occur in hemophilia B patients and (2) that invasive coronary artery therapeutic procedures may be carried out without complications.

Coronary artery bypass grafting in a patient with haemophilia B

Patients with coagulation disorders present the entire open-heart surgical team with an increased challenge. A patient with a known history of moderately severe Factor IX deficiency (2.4% activity) was evaluated for coronary artery disease. Cardiac catheterization revealed a 99% right coronary artery lesion, a long 99% circumflex lesion and normal left ventricular function. Sextuple coronary artery bypass grafting was performed with the aid of aprotinin and Factor IX transfusions. The patient's platelet count after cardiopulmonary bypass was 65,000/mm3, down from a preoperative level of 172,000/mm3, requiring the transfusion of six units of pooled platelets immediately postoperation. The patient was extubated five and a half hours after arriving in the Intensive Care Unit, and his chest-tube drainage after the first 24 hours was 373 ml. Other than a transient episode of atrial fibrillation on the third postoperative day, the patient had an uneventful postoperative course and was discharged on the sixth postoperative day. With the use of aproptinin and the newer monoclonal antibody-purified Factor IX concentrates that have been developed, many of the added risks of performing open-heart surgery on patients with haemophilia B are greatly reduced if not eliminated.

Current status of coronary artery bypass grafting for coronary artery atherosclerosis

Coronary artery bypass grafting has now undergone 18 years of proven benefit in the treatment of myocardial ischemic disease. The technique of CABG has been further extended to other situations in which myocardial blood supply is threatened, such as cardiac trauma, aneurysms of coronary arteries, and congenital lesions. The emphasis in choosing CABG over medical therapy in 1985 should be preservation of myocardium at jeopardy of infarction as well as relief of angina. Proximal stenoses in vessels subserving viable muscle that is ischemic at rest or with minimal exercise should be treated with reperfusion by angioplasty or CABG to prevent further injury. After infarction occurs and ventricular function is impaired, CABG is also necessary to preserve remaining myocardium at jeopardy. Such an aggressive approach seems warranted with today's excellent surgical results. Long-term results have also improved, as more attention has been paid to saphenous vein graft preparation, use of mammary artery grafts, complete revascularization, use of antiplatelet agents, control of spasm, and identification of hypercoagulable states that may require sodium warfarin (Coumadin). Angioplasty of vein grafts and distal anastomoses also appears promising to help extend the results of initial CABG. Figure 1 is our recommended approach for the treatment of coronary atherosclerosis.