Preoperative platelet count correction could directly impact the outcome of patients with immune thrombocytopenia (ITP) who are undergoing surgery, according to a study recently published in the American Journal of Case Reports.
“A poor prognosis may be indicated by thrombocytopenia, which may also indicate more severe right-sided heart failure, aberrant hemodynamics (due to hepatic congestion and the ensuing hypersplenism), and abnormal hemodynamics,” the authors wrote.
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This case report describes a 42-year-old female with a history of ITP diagnosed over 20 years ago. She received routine transfusions of thrombocyte concentrate. Her chief complaint at the time of presentation was breathing difficulties after daily activities over the previous 4 years.
Transthoracic echocardiography revealed severe mitral stenosis and moderate mitral regurgitation secondary to rheumatic heart disease. The test also showcased mild tricuspid regurgitation and signs suggestive of pulmonary hypertension. The healthcare team decided to perform a mitral valve replacement.
Preoperative blood work reported thrombocytopenia with a platelet count of 49,000/µL. The patient received 500 mg of methylprednisolone 3 times daily for 5 days and 10 units of thrombocyte concentrate 1 day before surgery. The platelet count increased to 107,000/µL, meeting the threshold to allow the procedure.
The intraoperative findings correlated with those of echocardiography, and a left atrial thrombus was identified. The total bleeding was 1000 cc, and the patient received thrombocyte concentrate and fresh frozen plasma postoperatively. New laboratory results revealed a platelet count of 53,000/µL, which increased to 87,000/µL and 147,000/µL on the second and third days, respectively.
Although left atrial thrombus can be a side effect of this management, the benefits likely outweigh the risks.
“The shear stress causes the primary mechanism of hemostatic dysfunction through an artificial device, which is accompanied by conflicting mechanisms such as platelet activation, aggregation, and generation of procoagulant microparticles, platelet dysfunction, loss of surface receptors, and bleeding complications,“ the authors explained.
Reference
Soetisna TW, Parna DR, Damayanti NMAS, et al. Initial thrombocyte concentrate transfusion in woman with chronic immune thrombocytopenia purpura (ITP) who underwent mitral valve replacement surgery: a case report. Am J Case Rep. Published online April 19, 2023. doi:10.12659/AJCR.938752
