Cardiac Surgery in a Patient With Antiphospholipid Syndrome and Heparin-Induced Thrombocytopenia

Abstract

ANTIPHOSPHOLIPID SYNDROME (APS) and heparin-induced thrombocytopenia (HIT) are separate disease processes that are both characterized by a prothrombotic state and an increased risk of perioperative complications. APS is a rare, noninflammatory, autoimmune disease, resulting in arterial and/or venous thrombosis, thrombocytopenia, fetal loss, and the presence of antiphospholipid (APL) antibodies. 1 Mishra PK Khazi FM You P et al. Severe antiphospholipid syndrome and cardiac surgery: Perioperative management. Asian Cardiovasc Thorac Ann. 2016; 24: 473-476 Crossref PubMed Scopus (4) Google Scholar The incidence of APS is approximately 2% in the general population. 2 Koniari I Siminelakis SN Baikoussis NG et al. Antiphospholipid syndrome: Its implication in cardiovascular diseases: A review. J Cardiothorac Surg. 2010; 5: 101 Crossref PubMed Scopus (72) Google Scholar Irregular thickening of heart valves from immune-complex deposition leads to valvular disease in 35% to 82% of patients with APS, and 4% to 6% of these patients require surgical intervention. 3 Berkun Y Elami A Meir K et al. Increased morbidity and mortality in patients with antiphospholipid syndrome undergoing valve replacement surgery. J Thorac Cardiovasc Surg. 2004; 127: 414-420 Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar The mitral valve is the most commonly affected, followed by the aortic valve. 1 Mishra PK Khazi FM You P et al. Severe antiphospholipid syndrome and cardiac surgery: Perioperative management. Asian Cardiovasc Thorac Ann. 2016; 24: 473-476 Crossref PubMed Scopus (4) Google Scholar Due to the prothrombotic state, valve surgery mortality rates are as high as 10% to 20%, 4 Nakajima T Enomoto Y Ishigaki M et al. Perioperative anticoagulation management during aortic valve replacement complicated by antiphospholipid syndrome. J Card Surg. 2017; 32: 633-635 Crossref PubMed Scopus (4) Google Scholar and surgical intervention usually is deferred to medical management if possible. 5 Erkan D Yazici Y Sobel R et al. Primary antiphospholipid syndrome: Functional outcome after 10 years. J Rheumatol. 2000; 27: 2817-2821 PubMed Google Scholar