Abstract 15523: Breaking Bad - Severe Mechanical Hemolytic Anemia After Failed Mitral Valve Repair

Abstract

Introduction: Hemolytic anemia is a rare complication of mitral valve repair surgery. Mechanisms include a high-velocity regurgitant jet striking the annuloplasty ring or displacement of the annuloplasty ring with para-annular leak. Case Report: A 66 year old man with a past history of coronary artery disease was found to have severe, eccentric mitral regurgitation (MR) due to anterior mitral valve leaflet prolapse/flail at the A2 segment. At another institution, he underwent surgical mitral valve repair involving chordal transfer from P2 to A2 segment, suture closure of the resulting P2 defect, and ring annuloplasty. Intra-operative transesophageal echocardiography confirmed the elimination of MR. Three weeks later the patient presented with fatigue and cola-colored urine. Physical examination revealed a murmur of MR. Lab tests were consistent with severe hemolytic anemia, including hemoglobin of 6 g/dL, indirect hyperbilirubinemia, elevated lactate dehydrogenase, and a low haptoglobin level. Peripheral blood smear showed dysmorphic red blood cells suggestive of mechanical lysis. The patient required multiple transfusions of packed red blood cells. Acute kidney injury developed and was attributed to pigment nephropathy. He was transferred to our institution. Decision-making: Recurrent MR from failure of recent mitral valve repair was suspected. Transthoracic and transesophageal echocardiography confirmed severe eccentric MR. The Heart Team recommended re-operation. In the operating room, the suture repair of the P2 defect was found to have dehisced. Re-repair was deemed infeasible, and the mitral valve was replaced with a porcine bioprosthesis. Post-operatively, hemolysis resolved and renal function recovered. Conclusion: This case illustrates the importance of suspecting hemolysis from recurrent MR in patients presenting with unexplained anemia after mitral valve surgery. Re-operation is generally required to treat this rare condition.