Takami Yoshiyuki, Hoshino Naoki, Ishikawa Hiroshi, Akita Kiyotoshi, Sakurai Yusuke, Amano Kentaro, Izawa Hideo, Takagi Yasushi
Department of Cardiovascular Surgery, Fujita Health University School of Medicine, Toyoake, Japan.
Department of Cardiology, Fujita Health University School of Medicine, Toyoake, Japan.
J Cardiol Cases. 2021 Dec 16;25(5):282-284. doi: 10.1016/j.jccase.2021.11.004. eCollection 2022 May.
We report a case of mechanical prosthetic mitral valve thrombosis in a 52-year-old woman with previous diagnosis of dilated cardiomyopathy, who was supported with advanced mechanical circulatory support after urgent mechanical mitral valve replacement (MVR) and tricuspid annuloplasty. Difficult weaning from cardiopulmonary bypass needed support with veno-arterial extracorporeal membranous oxygenation and Impella (Abiomed Inc, Danvers, MA, USA), so-called ECPELLA. Temporary discontinuation of heparin and massive blood transfusion were necessary due to four times of reoperation for bleeding during ECPELLA support. Poor recovery of cardiac function needed escalation from ECPELLA to extracorporeal biventricular assist device (ex-BiVAD) using two centrifugal pumps on Day 12. After gradual decrease in the left ventricular assist device flow, transesophageal echocardiography and fluoroscopic images revealed the stuck leaflets of the mitral prosthesis. Therefore, the patient underwent re-MVR with a bioprosthesis on Day 18, followed by continued assistance with ex-BiVAD. The patient was finally weaned from ex-BiVAD on Day 28 and was transferred to the referral hospital for rehabilitation. She was alive in good general condition at 2-year follow-up. It is important to balance the effects of anticoagulation on advanced mechanical circulatory support with ECPELLA, against the side effects of bleeding, especially in post-cardiotomy patients with bleeding tendency. < We should recognize the fatal risks of bleeding and thrombosis during advanced mechanical support, including Impella, VA-ECMO, ECPELLA, and ex-BiVAD, especially in the post-cardiotomy setting. We should also understand the choice of mechanical circulatory support, timely escalation to ex-BiVAD to avoid multiorgan failure, the diagnosis of mechanical mitral prosthetic thrombosed valve using echocardiography and fluoroscopy, and mitral valve replacement in the patient supported with ex-BiVAD.>.
我们报告了一例52岁女性机械性人工二尖瓣血栓形成的病例，该患者既往诊断为扩张型心肌病，在紧急进行机械二尖瓣置换术（MVR）和三尖瓣环成形术后接受了高级机械循环支持。体外循环脱机困难，需要静脉-动脉体外膜肺氧合（ECMO）和Impella（美国马萨诸塞州丹弗斯市Abiomed公司）支持，即所谓的ECPELLA。由于在ECPELLA支持期间因出血进行了4次再次手术，因此需要暂时停用肝素并大量输血。心脏功能恢复不佳，在第12天需要从ECPELLA升级为使用两个离心泵的体外双心室辅助装置（ex-BiVAD）。在左心室辅助装置流量逐渐减少后，经食管超声心动图和荧光透视图像显示二尖瓣人工瓣膜叶粘连。因此，患者在第18天接受了生物瓣膜再次MVR，随后继续接受ex-BiVAD辅助。患者最终在第28天脱离ex-BiVAD，并被转至转诊医院进行康复治疗。在2年的随访中，她存活且总体状况良好。重要的是要平衡抗凝对使用ECPELLA的高级机械循环支持的影响与出血的副作用，尤其是在有出血倾向的心脏术后患者中。<我们应该认识到在包括Impella、VA-ECMO、ECPELLA和ex-BiVAD在内的高级机械支持期间出血和血栓形成的致命风险，尤其是在心脏术后环境中。我们还应该了解机械循环支持的选择、及时升级为ex-BiVAD以避免多器官功能衰竭、使用超声心动图和荧光透视诊断机械性二尖瓣人工瓣膜血栓形成以及在接受ex-BiVAD支持的患者中进行二尖瓣置换。>
