Cardiopulmonary bypass surgery in a patient with paroxysmal nocturnal haemoglobinuria

A Safety Management Case of Laparoscopic Colectomy in a Patient With Paroxysmal Nocturnal Hemoglobinuria

Paroxysmal nocturnal hemoglobinuria is a rare and life-threatening disorder of acquired hemolytic anemia. Surgery is one of the major clinical situations that trigger hemolytic attack. Eculizumab is a humanized monoclonal antibody that binds the complement protein C5 and prevents complement-mediated hemolysis via inhibition of the terminal complement cascade. A 76-year-old woman received a diagnosis of ascending colon cancer during the search for the cause of right lower abdominal pain. She had received a diagnosis of paroxysmal nocturnal hemoglobinuria and been followed for 26 years at our hospital. We planned to start eculizumab for perioperative management in order to reduce the risk of the patient developing hemolytic crisis as a result of surgery. We administered 600 mg of eculizumab on the 15th, 8th, and 1st preoperative days. The levels of serum complement and lactate dehydrogenase decreased with the first administration of eculizumab. Laparoscopic right hemicolectomy was performed successfully. The patient had good postoperative progress. We administered 600 mg of eculizumab on the 6th postoperative day and 900 mg of eculizumab on the 13th postoperative day. She was discharged from hospital on the 16th postoperative day. We started use of eculizumab before surgery for safety in the management of the operation and during the perioperative period. When we enforce the elective operation for patients with paroxysmal nocturnal hemoglobinuria who do not start treatment of eculizumab, we recommend the use of eculizumab for perioperative management of patients with paroxysmal nocturnal hemoglobinuria.

Eculizumab therapy in paroxysmal nocturnal haemoglobinuria patient undergoing aortic valve surgery

Paroxysmal nocturnal haemoglobinuria is a rare disorder characterized by haemolytic anaemia and pancytopaenia. The use of cardiopulmonary bypass can lead to a haemolytic crisis in patients with paroxysmal nocturnal haemoglobinuria due to activation of complement-mediated haemolysis. We report the successful management of a 69-year-old man undergoing aortic valve replacement with standard heparin-protamine protocol by using eculizumab, a monoclonal antibody of complement factor C5. The surgery was performed without triggering a haemolytic crisis, and the patient was discharged from the hospital without major complications.

Red Blood Cell Disorders: Perioperative Considerations for Patients Undergoing Cardiac Surgery

Disorders affecting red blood cells (RBCs) are uncommon yet have many important physiologic considerations for patients undergoing cardiac surgery. RBC disorders can be categorized by those that are congenital or acquired, and further by disorders affecting the RBC membrane, hemoglobin, intracellular enzymes, or excessive RBC production. A foundational understanding of the physiologic derangement for these disorders is critical when considering perioperative implications and optimization, strategies for cardiopulmonary bypass, and the rapid recognition and treatment if complications occur. This review systematically outlines the RBC disorders of frequency and relevance with an emphasis on how the disorder affects normal physiologic processes, a review of the literature related to the disorder, and the implications and recommendations for patients undergoing cardiac surgery.

Successful management of obstructive jaundice due to gallstones with eculizumab in a patient with paroxysmal nocturnal hemoglobinuria

Paroxysmal nocturnal hemoglobinuria (PNH) makes patients susceptible to intravascular hemolysis and thrombosis, and it can be life-threatening in stressful situations. Eculizumab, a humanized monoclonal antibody that inhibits the complement protein C5, has been evaluated as a novel therapy for PNH. We herein describe the case of a 59-year-old Japanese woman with classic PNH, who had been successfully treated with eculizumab, but who later developed acute cholecystitis/cholangitis from gallstones. Although the severe obstructive jaundice requiring endoscopic therapy following cholecystectomy was complicated, critical intravascular hemolysis and thrombosis were not observed. Therefore, utilizing eculizumab during the peri-operative management of PNH patients should be carefully taken into consideration.

Paroxysmal nocturnal hemoglobinuria presenting with a left intraventricular thrombus in a patient with prior thymoma and aplastic anemia

We report the case of a 37-year old man presenting with a left ventricular cardiac thrombus in the setting of subclinical paroxysmal nocturnal hemoglobinura (PNH) developing two years after immunosuppressive therapy for thymoma-associated aplastic anemia. The literature regarding the interplay between autoimmunity and immunosuppression, aplastic anemia, thymoma and the emergence of PNH is reviewed.

Worsening of the clinical-hematological picture in a patient with a rare PK-LR compound heterozygosis after mitral replacement

We report a case of a patient affected by compound heterozygosis for two PK-LR gene mutations: p.R486W (c.1456C>T) and p.M403I (c.1209G>A). Our patient suffered from an initial moderate hemolytic anemia which subsequently evolved into a severe form after mitral prosthetic valve replacement for valve regurgitation. Thereafter, the clinical features evolved into a worsening of anemia, heart failure and pulmonary hypertension, in the absence of valve dysfunction. This clinical picture improved only after an intensive transfusion regimen. This case highlights aspects concerning the intricate balance between the risks and benefits of a mechanical prosthetic valve implant in PK-deficient patients.

Cardiac surgery in a patient with paroxysmal nocturnal hemoglobinuria

A 44-year-old woman who had been diagnosed with paroxysmal nocturnal hemoglobinuria, presented with chest pain. Angiography revealed critical distal left main stenosis and proximal stenoses of the left anterior descending and circumflex arteries. Prophylactic antibiotics, infusion of blood products and mannitol intraoperatively, and antithrombotic therapy postoperatively ensured a good outcome of coronary artery bypass graft surgery under cardiopulmonary bypass.