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Thrombocytopenia after rapid deployment/sutureless aortic valve implantation : analysis and comparison between Intuity, Perceval and Conventional bioprosthesis
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A cirurgia de Substituição Valvular Aórtica (SVA) convencional permanece o gold standard para pacientes com estenose aórtica2, no entanto, existe um interesse crescente nas válvulas aórticas rapid reployment e sutureless. O objectivo deste trabalho foi analisar a resposta plaquetária pós-operatória com o uso de válvulas aórticas Convencionais e rapid deployment – Perceval e Intuity – e verificar se existe alguma relação entre este fenómeno e complicações pós operatórias como hemorragia significativa e/ou necessidade de transfusão sanguínea. Os dados de 382 pacientes submetidos a SVA isolada na nossa instituição, com o uso de válvulas aórticas Convencionais (242 pacientes), Perceval S (51 pacientes) e Intuity (89 patientes), foram revistos retrospectivamente. O grupo da válvula Perceval apresentou uma contagem plaquetária média mais baixa que os grupos de válvulas Convencionais e Intuity, com uma diminuição marcada de cerca de 50% da contagem plaquetária pré-operatória no dia 2, seguida de um aumento significativo após a alta. Este fenómeno parece estar relacionado com o uso específico da válvula Perceval. Adicionalmente, comparando com as válvuas convencionais, os grupos Intuity e Perceval permitiram uma redução média do tempo de clampagem da aorta de 20,5% e 22,2%, respectivamente. Os gradientes valvulares médios pósoperatórios foram baixos e semelhantes entre os grupos Intuity e Perceval (8 vs 9 mmHg) e não foram observados leaks paravalvulares. Neste contexto, a trombocitopenia relacionada com a implantação da válvula Perceval não foi associada a consequências clínicas negativas, tais como maiores necessidades transfusionais e aumento do número de casos de hemorragia significativa, revisão de hemostase, acidente vascular cerebral ou disfunção renal. Por outro lado, a válvula Perceval foi relacionada com uma maior necessidade de implantação de pacemaker que a válvula Intuity (20% vs 9%). Finalmente, a explicação para a trombocitopenia ainda não foi confirmada, apesar de terem sido sugeridas várias hipóteses, particularmente um efeito tóxico directo da solução de armazenamento das válvulas.
Conventional Aortic Valve Replacement (AVR) surgery remains the gold standard for patients with aortic stenosis2, however there is a growing interest in rapid deployment aortic valves and sutureless valves. The objective of this study was to analyse the postoperative platelet response to aortic valve replacement with the use of Conventional Aortic Valves and Rapid deployment valves - Perceval and Intuity - and verify if there is any relation between this phenomenon and postoperative complications such as bleeding and/or blood transfusion. Data of 382 patients who underwent isolated AVR in our institution, using Conventional Aortic valves (242 patients), Perceval S (51 patients) and Intuity (89 patients) were retrospectively reviewed. The Perceval S valve group presented a lower postoperative mean PLT count than Conventional and Intuity valves, with a marked decrease of about 50% of the preoperative PLT on day 2, followed by a mild improvement after discharge. This transient thrombocytopenia appears to be related to the use of this specific valve. Additionally, the Intuity and Perceval valves implantation allowed a median reduction of the cross clamping time of 20,5% and 22,2%, respectively (vs Conventional valves). The postoperative mean gradients were low and similar between Intuity and Perceval groups (8 vs 9 mmHg) and no paravalvular leakage was reported. In this setting, the platelet reduction with the implantation of Perceval S wasn’t associated with negative clinical outcomes, such as more significant bleeding, higher packed red blood cells transfusion requirements, re-exploration for bleeding, stroke or renal disfunction. However, the Perceval valve was related to a higher need of pacemaker implantation than Intuity valves (20% vs 9%). The thrombocytopenia’s explanation is yet to be confirmed, and several hypothesis have been suggested, particularly a direct toxic effect of the storage solution of the valves.
Conventional Aortic Valve Replacement (AVR) surgery remains the gold standard for patients with aortic stenosis2, however there is a growing interest in rapid deployment aortic valves and sutureless valves. The objective of this study was to analyse the postoperative platelet response to aortic valve replacement with the use of Conventional Aortic Valves and Rapid deployment valves - Perceval and Intuity - and verify if there is any relation between this phenomenon and postoperative complications such as bleeding and/or blood transfusion. Data of 382 patients who underwent isolated AVR in our institution, using Conventional Aortic valves (242 patients), Perceval S (51 patients) and Intuity (89 patients) were retrospectively reviewed. The Perceval S valve group presented a lower postoperative mean PLT count than Conventional and Intuity valves, with a marked decrease of about 50% of the preoperative PLT on day 2, followed by a mild improvement after discharge. This transient thrombocytopenia appears to be related to the use of this specific valve. Additionally, the Intuity and Perceval valves implantation allowed a median reduction of the cross clamping time of 20,5% and 22,2%, respectively (vs Conventional valves). The postoperative mean gradients were low and similar between Intuity and Perceval groups (8 vs 9 mmHg) and no paravalvular leakage was reported. In this setting, the platelet reduction with the implantation of Perceval S wasn’t associated with negative clinical outcomes, such as more significant bleeding, higher packed red blood cells transfusion requirements, re-exploration for bleeding, stroke or renal disfunction. However, the Perceval valve was related to a higher need of pacemaker implantation than Intuity valves (20% vs 9%). The thrombocytopenia’s explanation is yet to be confirmed, and several hypothesis have been suggested, particularly a direct toxic effect of the storage solution of the valves.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2018
Palavras-chave
Cirurgia de substituição valvular aórtica Trombocitopenia Válvulas sutureless Cirurgia cardiotorácica