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J Thorac Cardiovasc Surg 2007;133:801-803
© 2007 The American Association for Thoracic Surgery
Brief Communication |
a Intensive Care Unit, Critical Care and Emergencies Department, Medico-Surgical University Hospital, Jaén Hospital Complex, Jaén, Spain
b Departamento Ciencias de la Salud, Universidad de Jaén, Jaén, Spain
c Surgery Department, Poniente Hospital, El Ejido, Almería, Spain
d Intensive Care Unit, Critical Care and Emergency Department, Torrecárdenas Hospital, Almería, Spain
e Intensive Care Unit, Critical Care and Emergency Department, Poniente Hospital, El Ejido, Almería, Spain
f Medicine Department, University of Granada, Granada, Spain.
Received for publication September 17, 2006; accepted for publication October 24, 2006. * Address for reprints: Dr. Manuel Ruiz-Bailén, C/. Las Torres 57, 23650 Torredonjimeno. Jaén, Spain. (Email: mrb1604{at}teleline.es).
Thrombosis of a prosthetic valve is usually a cause for emergency cardiac surgery, particularly in the presence of a major contraindication for systemic thrombolysis. Recent surgery is a major contraindication for the administration of thrombolysis. Our objective is to describe the administration of thrombolysis in a valve prosthesis after major surgery.
A 61-year-old male patient was admitted for lower intestinal obstruction. Sigmoidoscopy was performed and a tumor (moderately differentiated adenocarcinoma) of the upper rectum, 12 cm from the anal margin, was diagnosed. The patient had a metallic cardiac valve prosthesis (St Jude Medical, Inc, St Paul, Minn) in the mitral position and was being treated with acenocumarol. After reversal of the anticoagulation, the patient underwent surgery, a subtotal proctocolectomy with ileorectal anastomosis. The patient was admitted to the intensive care unit (ICU) because of hemodynamic instability in the first 24 hours, requiring high doses of dopamine and norepinephrine, with an initial diagnosis of distributive shock. Forty-eight hours after the operation, a transesophageal echocardiogram with hemodynamic assessment was performed, revealing prosthetic valve thrombosis with obstruction and abnormal disc motion of the medial hemidisc. A mean transmitral pressure gradient of 19.6 mm Hg was observed (Figure 1). The Doppler echocardiographic hemodynamic study was compatible with severe cardiogenic shock, with a left atrial pressure of 27 mm Hg using the Kuecherer formula.1
The patient remained in hemodynamically unstable condition, with acute pulmonary edema and prerenal renal failure. Transfer to the reference hospital for surgery in the reference cardiac surgery department was rejected. Because of the persistence of cardiogenic shock, systemic thrombolysis (100 mg of alteplase over 120 minutes) was administered on the sixth postoperative day. A repeat transthoracic and transesophageal echocardiogram, performed at the end of the alteplase infusion, demonstrated disappearance of the prosthetic valve thrombosis and normalization of the transmitral gradient (Figure 2). The patient’s hemodynamic situation normalized; extubation was possible 48 hours after administration of the alteplase, and the patient was discharged from the ICU. A later complication occurred in the form of an upper gastrointestinal hemorrhage resulting from an acute, self-limiting lesion of the gastric mucosa, which did not require blood transfusion. After transfer to the surgery ward, the remainder of the postoperative course was within normal limits. Follow-up at 6 months was normal.
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In the context of major abdominal surgery with a high risk of hemorrhage and the long-term administration of anticoagulant drugs, an option undertaken on occasion is the normalization of the prothrombin activity for the duration of surgery, while simultaneously administering prophylactic doses of enoxaparin. However, although the period the patient is without anticoagulation is relatively short, in patients with a high risk of thrombosis, as in the present case, in which the diagnosis was of adenocarcinoma, this period may be sufficient for a thrombotic event, such as prosthetic valve thrombosis, to develop.2
A further interesting problem in this discussion concerns reaching the correct diagnosis; the most frequent diagnosis, distributive shock resulting from cytokine release, was initially assumed. However, although the possibility of this situation existed, there was a clear cardiologic cause in this patient: prosthetic valve thrombosis. This case is a prime example of the benefit of echocardiography carried out in the ICU, being performed to assess the hemodynamic situation without suspecting the cardiologic cause a priori. This might encourage intensive care physicians to consider the need to use this technique routinely in hemodynamically unstable patients, as it is a diagnostic technique that has proven very effective and may change the therapeutic approach.3
Another problem consists in the therapeutic approach to be followed after the diagnosis of prosthetic valve thrombosis has been made in a patient in cardiogenic shock with multiorgan dysfunction. Thrombolysis may have a hemorrhagic effect and increase the emboligenic risk; however, it has been shown to be effective and efficient in the treatment of prosthetic valve thrombosis and has been proposed as the initial treatment.4,5
In patients with a high hemorrhagic risk (an absolute contraindication to systemic thrombolysis), as in the present case, the most straightforward option would be surgery. Our patient also was not a candidate for surgery, however, owing to an unacceptable surgical risk. In this case, and in similar cases, systemic thrombolysis may be administered as a final, desperate measure. Despite the absolute contraindication for thrombolysis in the immediate postoperative period, it has been administered at this time, and even during surgery itself, in many cases, in case series of surgical patients with pulmonary thromboembolism, and even in high-risk situations such as pregnancy.6 For this reason, despite an absolute contraindication for systemic thrombolysis, in specific cases such as this one, the risk of its use should be evaluated and compared with the natural course of the pathologic condition without its use.
References
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