Hemophilia C in a Patient Undergoing Cardiac Surgery: Perioperative Considerations

Intraoperative thromboelastography-guided transfusion in a patient with factor XI deficiency: A case report

BACKGROUND

Factor XI (FXI) deficiency, also known as hemophilia C, is a rare bleeding disorder of unpredictable severity that correlates poorly with FXI coagulation activity. This often poses great challenges in perioperative hemostatic management. Thromboelastography (TEG) is a method for testing blood coagulation using a viscoelastic hemostatic assay of whole blood to assess the overall coagulation status. Here, we present the successful application of intraoperative TEG monitoring in an FXI-deficient patient as an individualized blood transfusion strategy.

CASE SUMMARY

A 21-year-old male patient with FXI deficiency was scheduled to undergo reconstructive surgery for macrodactyly of the left foot under general anesthesia. To minimize his bleeding risk, he was scheduled to receive fresh frozen plasma (FFP) as an empirical prophylactic FXI replacement at a dose of 15-20 mL/kg body weight (900-1200 mL) before surgery. Subsequent FFP transfusion was to be adjusted according to surgical need. Instead, TEG assessment was used at the beginning and toward the end of his surgery. According to intraoperative TEG results, the normalization of coagulation function was achieved with an infusion of only 800 mL FFP, and blood loss was minimal. The patient showed an uneventful postoperative course and was discharged on postoperative day 8.

CONCLUSION

TEG can be readily applied in the intraoperative period to individualize transfusion needs in patients with rare inherited coagulopathy.

Perioperative anesthetic management in a patient with factor XI deficiency undergoing coronary artery bypass graft surgery

Spontaneous bleeding is rare in patients with factor XI deficiency and significant bleeding usually occurs after a trauma or a surgical procedure. It is difficult to maintain hemostatic balance in these patients. In the present case report, a 68-year-old male patient with no chronic disease was scheduled for elective cardiopulmonary bypass surgery. Eight units of fresh-frozen plasma (FFP) were slowly infused and the operation was initiated with the activated partial thromboplastin time (aPTT) of 34.5, which was 108.7 in the preoperative period. Tranexamic acid bolus was administered before the skin incision and continued throughout the operation. Intraoperative aPTT was measured intermittently and a total of six units of FFP were administered. After 76 minutes of cross-clamp time, the patient was separated from cardiopulmonary bypass without any problem. There is no consensus regarding the management of bleeding during cardiac surgery in patients with factor XI deficiency. The common approach includes normalizing the factor levels via FFP infusion or factor concentrates in the preoperative period, proceeding with surgery following the replacement, and close monitoring of perioperative factor levels and aPTT values.