Con: Exchange transfusion is not required for sickle cell trait patients undergoing cardiopulmonary bypass

Single-center experience of LVAD implantation in patients with sickle-cell trait: A retrospective analysis

BACKGROUND

The most worrisome complications in patients supported by left ventricular assist device (LVAD) are pump thrombosis, embolism, and bleeding. The actual rate of these events in patients with sickle-cell disease (SCD) has not well investigated. The aim of our study is to evaluate the outcomes of LVAD implantation in patients with sickle-cell hemoglobinopathy at our institution.

METHODS

This retrospective, observational, single-center study was conducted on patients with sickle-cell trait (SCT), who underwent LVAD implantation using the HeartMate3 LVAD.

RESULTS

LVAD devices were implanted in four patients with SCT. All procedures were performed successfully. All patients had uneventful post-implant course. Overall, the mean follow-up time was 25 months (range 21-28 months) and showed an unremarkable post-implant course. There was a significant improvement in hematological markers over the follow-up period.

CONCLUSIONS

Despite the limited numbers of patients enrolled in this study, our findings indicate that LVAD surgery is safe in SCD patients and offers remarkable clinical improvement. Further studies are needed to provide more evidence regarding this type of patients undergoing LVAD implantation.

Simple open-heart surgery protocol for sickle-cell disease patients: a retrospective cohort study comparing patients undergoing mitral valve surgery

OBJECTIVES

Sickle-cell disease (SCD) patients are considered to be at high risk from open-heart surgery. This study assessed the role of a simple sickling-prevention protocol.

METHODS

Perioperative non-specific and SCD-specific morbidity and 30-day mortality are investigated in a retrospective cohort study on patients undergoing isolated mitral valve surgery. Patients with and without SCD were compared. In the SCD cohort, a bundle of interventions was applied to limit the risk of sickling: 'on-demand' transfusions to keep haemoglobin levels of around 7-8 g/dl, cardiopulmonary bypass (CPB) with higher blood flow and perfusion temperature, close monitoring of acid-base balance and oxygenation.

RESULTS

Twenty patients with and 40 patients without SCD were included. At baseline, only preoperative haemoglobin levels differed between cohorts (8.1 vs 11.8 g/dl, P < 0.001). Solely SCD patients received preoperative transfusions (45.0%). Intraoperative transfusions were significantly larger in SCD patients during CPB (priming: 300 vs 200 ml; entire length: 600 vs 300 ml and 20 vs 10 ml/kg). SCD patients had higher perfusion temperatures during CPB (34.7 vs 33.0°C, P = 0.01) with consequently higher pharyngeal temperature, both during cooling (34.1 vs 32.3°C, P = 0.02) and rewarming (36.5 vs 36.2°C, P = 0.02). No mortality occurred, and non-SCD-specific complications were comparable between groups, but one SCD patient suffered from perioperative cerebrovascular accident with seizures, and another had evident haemolysis.

CONCLUSIONS

SCD patients may undergo open-heart surgery for mitral valve procedures with an acceptable risk profile. Simple but thoughtful perioperative management, embracing 'on-demand' transfusions and less-aggressive CPB cooling is feasible and probably efficacious.

First Experience in Living Liver Donation From Donors With Sickle Cell Trait

Living donor liver transplantation is the main source of organs in the Middle East. Therefore, well balanced criteria are needed to avoid unnecessary exclusion of potential donors, while prioritizing donor safety. We face a high incidence of sickle cell trait (SCT; and disease). Therefore, there is vast experience in general and cardiac surgeries in SCT carriers at our center. After studying their management in detail, we considered accepting SCT carriers as living liver donors, on an exceptional basis. This the first single-center case series of living donor liver transplantation with SCT.

Aortic valve replacement in a patient with sickle cell disease-Are we justified to perform surgery in the TAVI era?

Not all variants of SCD need the same management and this should be decided on a case-by-case basis. Heterozygous SCD patients can undergo cardiac surgery without the need for intraoperative exchange transfusions with good clinical outcomes.

Heart valve surgery in patients with homozygous sickle cell disease: A management strategy

Background:

Patients with the homozygous sickle cell disease have increased perioperative mortality. Some indications like heart valve surgery, may justify an exchange blood transfusion to reduce the proportion of hemoglobin S (HbS) and complications.

Subjects and Methods:

We report two female cases aged 20 and 27, of African origin with homozygous sickle cell anemia who underwent heart valve surgery to treat mitral valve regurgitation. This presentation describes the perioperative considerations including anesthesia and postoperative care.

Results:

A partial exchange blood transfusion decreased HbS levels from respectively, 90% and 84%, 9% to 27% and 34%, and simultaneously treated the anemia. Neither sickling crisis nor acidosis occurred in any patient, and no special postoperative complication occurred. Average hospital stay was 10 days. Currently, the two patients remain alive and free of cardiac symptoms.

Discussion:

Although the presence of sickle cell disorders is associated with increased risk of sickling and thus vaso-occlusive complications, they should not be taken as a contraindication for heart valve surgery. Nevertheless, monitoring of certain parameters such as venous, arterial oxygen content, pH, and body temperature is mandatory for a better outcome. Furthermore, preoperative exchange transfusion has a positive influence on the outcome of surgery and on the survival of patients undergoing heart valves surgery. Avoiding intraoperative hypoxia, hypothermia, and vaso-constrictive agents, minimizing HbS levels with preoperative exchange transfusion, and ensuring a stress-free environment with the judicious use of sedatives made surgery relatively safe in these cases.

[Treatment of a female patient with sickle-cell anemia during cardiac surgery with cardiopulmonary bypass]

A 17-year-old girl with drepanocytic (sickle-cell) anemia who was being treated with hydroxyurea and periodic blood transfusions through a Hickman-type catheter was admitted for periodic episodes of fever. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Massive right atrial thrombosis with pulmonary embolism and bacterial endocarditis were detected by computed tomography. Surgery with a beating heart and cardiopulmonary bypass was undertaken. Drepanocytic anemia in individuals homozygous for hemoglobin S is a rare condition in Spain but we are beginning to see a few cases, in which management during anesthesia will be more complicated. High-risk surgery can be carried out in these patients without adverse events if the anesthesiologist is guided by a complete blood workup and takes precautions during and after surgery to control hydration, oxygenation, temperature, and the acid-base balance.

Open heart surgery in patients with sickle cell hemoglobinopathy

BACKGROUND

In patients with sickle cell trait or disease, reduced life expectancy and a tendency for complications are believed to negatively affect likelihood of survival after open heart surgery. The aim of this study was to review retrospectively the perioperative results of patients undergoing cardiac surgery at our institution.

METHODS AND RESULTS

Between January 1995 and December 2006, 47 patients with either sickle cell disease or sickle cell trait underwent open heart surgery at our institution. The average age of the 29 male and 18 female patients was 20 years. Patient outcomes were analyzed through the use of the institutional database. Clinical and echocardiographic follow-up was complete in all patients except 3, with a mean follow-up period of 46 months. Current status could be confirmed in 32 patients. The most common operations included the treatment of congenital and valvular heart diseases. There were no coronary artery bypass grafting procedures. Average weight of the patients was 45 kg. Exchange transfusion was performed both preoperatively and during surgery. Mean preoperative hemoglobin S concentration was 30.4 + or - 3.2% and decreased to 8.1 + or - 2.6% while on pump. Average on-pump hematocrit value was 25.4 + or - 3.7%; in the postoperative period, it increased to 32.7 + or - 4.9%. Mean cardiopulmonary bypass and cross-clamp times were 95 and 69 minutes, respectively. None of the patients had sickling crisis or acidosis. Postoperative complications included exploration for hemorrhage in 3 patients (6.4%), stroke in 2 patients (4.3%), renal failure in 2 patients (4.3%), and prolonged ventilation in 1 patient (2.1%). Average hospital stay was 8.3 days (range, 4 to 27 days). Early in-hospital death occurred in 1 patient (2.1%); currently, 31 patients (66%) remain alive and free of cardiac symptoms.

CONCLUSIONS

Heart valve surgery and surgery for congenital heart diseases can be performed safely in patients with sickle cell disease or sickle cell trait with acceptable outcome and survival rates.