Multiple cardiac surgical procedures in a case of an octogenarian with essential thrombocythemia

An 85-year-old woman was referred to our hospital for the surgical management of aortic valve stenosis, angina pectoris, and paroxysmal atrial fibrillation with New York Heart Association class III heart failure.

A decade ago, the patient was diagnosed with essential thrombocythemia (ET). She had consulted a hematologist at another facility and was treated with low-dose aspirin (100 mg/day) and hydroxycarbamide (hydroxyurea, HU) (500 mg/day).

Patient’s left ventricular ejection function reduced to 35%, as determined using transthoracic echography. The aortic valve was calcified and its area was 0.30 cm2; the peak pressure gradient across the aortic valve was 70 mmHg. Coronary angiography revealed triple vessel lesions involving critical stenosis of the right coronary artery (RCA #2; 90%) and the left anterior descending coronary artery (LAD #7; 75%). The patient was also diagnosed with chronic kidney disease and peripheral arterial disease.

Preoperatively, the low-dose aspirin was replaced by heparin, which increased the activated partial thromboplastin time from 40 to 50 s. A known side effect of HU is delayed wound healing. Therefore, as her hematologist suggested, we planned to maintain the platelet count at < 100,000/µL and discontinued HU 1 day before surgery. However, 3 days preoperatively, HU had to be stopped, because the patient’s platelet count markedly decreased from 300,000 to 87,000/µL, following which, the platelet count increased to 150,000/µL just before surgery.

The surgical procedure involved aortic valve replacement, coronary artery bypass grafting (CABG), and pulmonary vein isolation (PVI). The aortic valve was replaced with a 19 mm bioprosthetic prosthesis (Carpentier Edwards Perimount Magna Ease, Edwards Life science, Irvine, CA, US). The bypass design was from the left internal mammary artery to the LAD and from the saphenous vein (SV) to the RCA. CABG and PVI were performed on pump beating. Proximal anastomosis of the SV was achieved using the HEARTSTRING III Proximal Sealing System (MAQUET Holding B.V. & Co. KG, Rastatt, Germany). Activated clotting time was maintained over 450 s during cardiopulmonary bypass (CPB). The reservoir did not need to be changed, and no clots were captured during CPB. The CPB, aorta clamping, and operation times were, respectively, 178 min, 88 min, and 384 min. Intraoperative blood transfusion included 2240 mL of erythrocytes, 840 mL of fresh frozen plasma, and 500 mL of platelets.

Postoperatively, low-dose aspirin (100 mg/day) was resumed as little or no postoperative bleeding was observed, and coumadin was initiated as anticoagulant therapy for valve replacement. Four days after the surgery, the platelet count increased enough for HU to be resumed at the same dose as that preoperatively (Fig. 1).

Fig. 1figure 1

Preoperative and postoperative platelet count with the treatment course. HU hydroxyurea, PLT platelet, POD postoperative day

During treatment, the patient experienced no complications, such as hemorrhage or thrombosis. However, prolonged hospitalization was required for protracted wound healing, a side effect of HU (Fig. 2).

Fig. 2figure 2

Surgical wound of median sternotomy

The patient did not experience heart failure throughout the postoperative course and was discharged from the hospital on the 22nd day postoperatively.

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