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Restivo GA, Scalzo S, Di Palermo A. Mechanical Hemolytic Anemia Associated With Mitral Valve Repair: A Case Report With Literature Review. J Pediatr Hematol Oncol 2023; 45:e993-e995. [PMID: 37526400 DOI: 10.1097/mph.0000000000002734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/05/2023] [Indexed: 08/02/2023]
Abstract
Hemolytic anemia could be caused by several conditions, depending on intrinsic or extrinsic defects of the erythrocyte. The latter group includes mechanical intravascular hemolysis, generally related to malfunctioning prosthetic heart valves or, rarely, heart valves repair. We describe a case of a child with Down syndrome, who developed hemolytic anemia after mitral valve repair. We observed that this condition is a rare complication in pediatrics, with only 7 cases reported in literature. Mechanical hemolysis should always be considered in the differential diagnosis of a new-onset hemolytic anemia, especially in patients with valvular heart disease, undergoing cardiac surgery.
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Affiliation(s)
| | - Simona Scalzo
- Emergency Department, ARNAS Ospedali Civico, Di Cristina e Benfratelli
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2
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Weill O, Peyre M, Vergnat M, Cazavet A, Stos B, Belli E, Hascoet S, Acar P. Repeat mitral valve repair for haemolysis in children. Arch Cardiovasc Dis 2015; 108:118-21. [PMID: 25662003 DOI: 10.1016/j.acvd.2014.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/10/2014] [Accepted: 09/17/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Severe haemolysis is a rare complication after mitral valve repair in congenital heart disease. AIM We describe four children with severe mitral regurgitation who underwent valve repair and subsequently developed profound haemolytic anaemia. METHODS Clinical, echocardiographic and surgical data were collected retrospectively from a surgical centre in France during a 5-year period. RESULTS Two patients had atrioventricular septal defects, one patient had congenital mitral dysplasia and one had anomalous left coronary artery from the pulmonary artery with mitral regurgitation. Haemolysis was diagnosed 20 to 75 days after surgery, as a result of clinical and biological examination; it was severe, and blood transfusion support was necessary in all cases. Haemolysis was always associated with eccentric mitral regurgitation with a variable degree of severity (from low to severe). After exclusion of other haemolysis aetiology, redo mitral repair surgery was performed successfully in all cases. The haemolysis was considered to be mechanical in origin, caused by regurgitation of blood through the residual mitral regurgitation and stitches. CONCLUSION Severe haemolysis is a rare complication that can occur after mitral valve repair in congenital heart disease. All patients underwent successful redo repair and had resolution of haemolysis after surgery. Even if redo surgery is required, iterative mitral repair is possible.
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Affiliation(s)
- Olivia Weill
- Toulouse University Hospital, M3C, Paediatric Cardiology Unit, Toulouse, France.
| | - Marianne Peyre
- Toulouse University Hospital, M3C, Paediatric Cardiology Unit, Toulouse, France
| | - Mathieu Vergnat
- Centre Chirurgical Marie-Lannelongue-M3C, Department of Paediatric and Congenital Heart Disease, Paris-Sud University, France
| | - Alexandre Cazavet
- Toulouse University Hospital, M3C, Paediatric Cardiology Unit, Toulouse, France
| | - Bertrand Stos
- Centre Chirurgical Marie-Lannelongue-M3C, Department of Paediatric and Congenital Heart Disease, Paris-Sud University, France
| | - Emre Belli
- Centre Chirurgical Marie-Lannelongue-M3C, Department of Paediatric and Congenital Heart Disease, Paris-Sud University, France
| | - Sébastien Hascoet
- Toulouse University Hospital, M3C, Paediatric Cardiology Unit, Toulouse, France
| | - Philippe Acar
- Toulouse University Hospital, M3C, Paediatric Cardiology Unit, Toulouse, France
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3
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DANNA PAOLO, PROIETTI RICCARDO, SAGONE ANTONIO, ARENSI ANDREA, VIECCA MAURIZIO, RAGO ANNA, RUSSO VINCENZO. Does Left Atrial Appendage Closure with a Cardiac Plug System Reduce the Stroke Risk in Nonvalvular Atrial Fibrillation Patients? A Single-Center Case Series. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 36:347-53. [PMID: 23252940 DOI: 10.1111/pace.12058] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 09/23/2012] [Accepted: 10/23/2012] [Indexed: 11/28/2022]
Affiliation(s)
- PAOLO DANNA
- Cardiology Department; Luigi Sacco Hospital; Milan; Italy
| | | | - ANTONIO SAGONE
- Cardiology Department; Luigi Sacco Hospital; Milan; Italy
| | - ANDREA ARENSI
- Cardiology Department; Luigi Sacco Hospital; Milan; Italy
| | | | - ANNA RAGO
- Chair of Cardiology; Second University of Naples-Monaldi Hospital; Naples; Italy
| | - VINCENZO RUSSO
- Chair of Cardiology; Second University of Naples-Monaldi Hospital; Naples; Italy
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4
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Inoue M, Kaku B, Kanaya H, Ohka T, Ueda M, Masahiro S, Shimizu M, Mabuchi H. Reduction of hemolysis without reoperation following mitral valve repair. Circ J 2003; 67:799-801. [PMID: 12939559 DOI: 10.1253/circj.67.799] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Hemolytic anemia following mitral valve repair and annular ring placement is uncommon compared with mitral valve replacement. A 60-year-old man, who had undergone mitral valve repair with a Duran ring, developed hemolytic anemia and needed a blood transfusion. Transesophageal echocardiography revealed a paravalvular mitral regurgitation jet colliding with the Duran ring. Most cases of severe hemolysis after mitral valve repair have undergone reoperation, but in the present case study, the hemolysis after mitral valve repair reduced without the need for reoperation, although the paravalvular mitral regurgitation jet continued to collide with the Duran ring.
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Affiliation(s)
- Masaru Inoue
- Molecular Genetics of Cardiovascular Disorders, Division of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan.
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5
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Tsang JC, Shum-Tim D, Tchervenkov CI, Jutras L, Sinclair B. Hemolytic anemia after atrioventricular septal defect repair without synthetic material. Ann Thorac Surg 1999; 68:1838-40. [PMID: 10585070 DOI: 10.1016/s0003-4975(99)00752-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We report a rare case of severe hemolytic anemia following repair of a congenital heart defect without the use of prosthetic material. A review of the literature, diagnosis, and management are described. Although this is an unusual complication following congenital heart surgery, a high index of suspicion must be maintained and a possible mechanical cause should be sought and corrected.
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Affiliation(s)
- J C Tsang
- Department of Cardiovascular Surgery, The Montreal Children's Hospital, McGill University, Quebec, Canada
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6
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Yeo TC, Freeman WK, Schaff HV, Orszulak TA. Mechanisms of hemolysis after mitral valve repair: assessment by serial echocardiography. J Am Coll Cardiol 1998; 32:717-23. [PMID: 9741517 DOI: 10.1016/s0735-1097(98)00294-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We sought to determine, using serial echocardiography, the hydrodynamic mechanisms involved in the occurrence of hemolysis after mitral valve repair. BACKGROUND Recently, fluid dynamic simulation models have identified distinct patterns of mitral regurgitant flow disturbances in patients with mitral prosthetic hemolysis that were associated with high shear stress and may therefore produce clinical hemolysis. Rapid acceleration, fragmentation, and collision jets were associated with high shear stress and hemolysis whereas slow deceleration and free jets were not. METHODS We reviewed serial echocardiographic studies of 13 consecutive patients with hemolytic anemia after mitral valve repair who were referred for mitral reoperation between January 1985 and December 1996 (group 1). Thirteen patients undergoing reoperation for mitral regurgitation after mitral valve repair but without hemolysis served as controls (group 2). RESULTS The mitral regurgitant jet was central in origin in 12 group 1 patients and 9 group 2 patients (Fisher exact test, p= 0.3). The other patients had para-ring regurgitation. Group 1 patients had collision (n=11), rapid acceleration (n=2) or fragmentation (n=1) jets whereas group 2 patients had slow deceleration (n=11) or free jets (n=2) (Fisher exact test, p < 0.0001). One patient with hemolysis had both collision and rapid acceleration jets. The "culprit" jet could be identified on the postbypass transesophageal echocardiography (TEE) study in only 1 patient at the time of initial mitral repair. Twelve group 1 patients underwent reoperation, with subsequent resolution of hemolysis in all patients. At reoperation, the initial repair was found to be intact in 8 (67%) patients. CONCLUSION Distinct patterns of flow disturbance associated with high shear stress were identified by color Doppler imaging in patients with hemolysis after mitral valve repair. The majority (92%) of these color flow disturbances were not present during intraoperative postbypass TEE study after initial mitral repair and subsequently developed in the early postoperative period.
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Affiliation(s)
- T C Yeo
- Division of Cardiovascular Diseases, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Cerfolio RJ, Orszulak TA, Daly RC, Schaff HV. Reoperation for hemolytic, anaemia complicating mitral valve repair. Eur J Cardiothorac Surg 1997; 11:479-84. [PMID: 9105812 DOI: 10.1016/s1010-7940(96)01091-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To identify the possible cause(s) of hemolysis after mitral valve repair for mitral regurgitation (MR) and to evaluate the late outcome of surgical treatment. METHODS We reviewed all patients who had reoperation after valve repair for mitral regurgitation. Ten patients had reoperation because of hemolytic anaemia. The diagnosis of hemolysis was made by decreased serum haptoglobin, elevation of serum lactate dehydrogenase (LDH), and schistocytosis. No other causes of anaemia or hemolysis were identified in these six men and four women (ages 35-84 years; median 59 years). Interval between initial mitral valve repair and reoperation ranged from 40 to 165 days (median 87 days), and prior to reoperation, red cell transfusions (range 2-12 units; median 5 units) were required in all patients. Seven patients were symptomatic: two complained of easy fatigability and five were severely limited. Transesophageal echocardiogram during hemolytic evaluation showed only mild MR in two patients, moderate in five, moderately severe in two and severe in one. RESULTS Etiology of hemolysis was suggested from echocardiography and confirmed at reoperation. In one patient, an eccentric MR jet struck a pledget of a commissural annuloplasty. In the remaining nine patients, the regurgitant jet struck a non-endothelialized portion of the annuloplasty ring (Carpentier-Edwards n = 5; Duran n = 2; Cosgrove-Edwards n = 2). Seven patients had prosthetic replacement and three patients had re-repair. There were no operative deaths and all patients had resolution of hemolytic anaemia. CONCLUSIONS Relatively minor degrees of regurgitation after mitral valve repair can produce hemolytic anaemia which is manifested within the first few postoperative months. Most patients are highly symptomatic because of anaemia. The mechanism of red cell destruction is a high velocity eccentric stream of blood impacting on a small area of a prosthetic ring or pledget. This process retards endothelialization of the ring. Reoperation with re-repair or mitral valve replacement is safe and effectively relieves the hemolysis.
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Affiliation(s)
- R J Cerfolio
- Section of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Abstract
We report 2 cases of severe intravascular hemolysis after mitral valve repair using a Duran annuloplasty ring. In both patients residual mitral regurgitation was present, hemolysis was severe enough to warrant a second operation, and hemolysis ceased immediately after the second operation. We believe that a high-velocity regurgitant jet directed toward the cloth-covered annuloplasty ring was responsible for the hemolysis in both patients.
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Affiliation(s)
- J H Wilson
- Department of Medicine, Good Samaritan Hospital, Cincinnati, Ohio 45220
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Khanna A, Tandon R, Basu AK, Shrivastava S. Red blood cell survival in patients with ventricular septal defect and patent ductus arteriosus. Clin Pediatr (Phila) 1981; 20:349-53. [PMID: 7226687 DOI: 10.1177/000992288102000510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Hemolysis of red blood cells (RBC) in stenotic or regurgitant cardiac valvular lesions has been felt to be due to mechanical trauma and shearing stress caused by turbulence of blood. RBC are also under a shearing stress from turbulence in high-pressure shunts, such as ventricular septal defect (VSD) and patent ductus arteriosus (PDA). The RBC survival time was measured in five patients with VSD and in 11 patients with PDA to determine if there was hemolysis of RBC. Six children without cardiac disease were also studied to obtain the control values for RBC survival times in th laboratory. Two patients with PDA were restudied one year postoperatively. Additional parameters studied were hemoglobin, packed cell volume, reticulocyte cell count, peripheral smear, and urinary hemosiderin. The hemoglobin values and the packed cell volumes were comparable in the two groups. The reticulocyte cell count was normal in all. Urinary hemosiderin was negative in all and the peripheral smear did not reveal abnormal red cell morphology. Mean red cell survival half-life in the two groups was identical. The red cell survival was abnormally low in two patients of PDA. Since one of these two patients had persistently low RBC survival postoperatively, the authors believe that the low red cell survival in this patient was unrelated to the presence of PDA. Based on findings in the small number of cases, the authors conclude that left to right shunt through a VSD or PDA is probably not associated with significant red blood cell destruction.
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Warnes C, Honey M, Brooks N, Davies J, Gorman A, Parker N. Mechanical haemolytic anaemia after valve repair operations for non-rheumatic mitral regurgitation. Heart 1980; 44:381-5. [PMID: 7426198 PMCID: PMC482414 DOI: 10.1136/hrt.44.4.381] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Two cases are described in which severe mechanical haemolytic anaemia developed shortly after operation for repair of non-rheumatic mitral regurgitation. One patient had a "floppy" valve and the other cleft mitral leaflets, and both had chordal rupture. In both there was residual regurgitation after repair though in one this was initially only trivial. Clinically manifest haemolysis ceased after replacement of the valve by a frame-mounted xenograft. There are two previously reported cases in which haemolytic anaemia followed an unsuccessful mitral valve repair operation. Subclinical haemolysis or mild haemolytic anaemia may occur with unoperated valve lesions, but hitherto frank haemolytic anaemia has been observed only when turbulent blood flow is associated with the presence of a prosthetic valve or patch of prosthetic fabric. In these four cases, however, polyester or Teflon sutures were the only foreign material, and it is suggested that when these are used for the repair of leaflets, particularly in non-rheumatic mitral valve disease, they may increase the damaging effect of turbulence on circulating red blood cells.
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Ahmad R, Manohitharajah S, Deverall P, Watson D. Chronic hemolysis following mitral valve replacement. J Thorac Cardiovasc Surg 1976. [DOI: 10.1016/s0022-5223(19)40230-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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12
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Donnelly RJ, Rahman AN, Manohitharajah SM, Deverall PB, Watson DA. Chronic hemolysis following mitral valve replacement. A comparison of the frame-mounted aortic homograft and the composite seat Starr-Edwards prosthesis. Circulation 1973; 48:823-9. [PMID: 4744788 DOI: 10.1161/01.cir.48.4.823] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The incidence and severity of chronic intravascular hemolysis was evaluated in a total of 41 patients following mitral valve replacement. Valve replacement was with a gamma-radiated frame-mounted aortic homograft in 21 patients and with a composite seat Starr-Edwards prosthesis, model 6310 or 6320, in 20 patients. The parameters used to assess hemolysis were hemoglobin, hematocrit, reticulocyte count, red cell fragment count, serum haptoglobin, LDH and HBD, hemosiderin in the urine and red cell survival. The degree of hemolysis was classified as mild, moderate or severe. In the prosthetic valve group 85% showed evidence of chronic intravascular hemolysis, of which a third were mild and the rest moderate. The homograft patients did not show any comparable evidence of hemolysis. Statistical analysis of the comparative figures of the parameters used to assess hemolysis in the two groups of patients revealed a significant difference (
P
< 0.01) in hemoglobin and hematocrit and a highly significant difference (
P
< .001) in serum haptoglobins, hemosiderin in the urine, LDH, reticulocyte count, red cell fragment count and red cell survivals.
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