Hematologic Effects of Heart Valve Prostheses and Vascular Grafts after Aortic Root Replacement

Abstract

Background Heart valve prosthesis as well as vascular grafts cause changes in blood parameters. This may correlate with valve-related complications, less frequently observed after repair surgery. We thus studied changes in rheology after Bentall, Ross, or Tirone David (TD) procedure.

Methods Seventeen patients underwent a TD, 17 patients underwent a Ross, and 16 patients underwent a Bentall procedure. Venous blood samples were collected 4 ± 3 (TD), 4 ± 3 (Ross), and 6 ± 3 years mean (Bentall) postoperatively. Concentrations of fibrinogen, leucocytes, platelets, haptoglobin, hemoglobin, lactate dehydrogenase (LDH), bilirubin, hematocrit, and β-thromboglobulin were determined. Platelet function and activity were analyzed. Results were compared with those of healthy control subjects.

Results Level of fibrinogen was higher in the Bentall than in the other two groups (338 ± 63 vs. 298 ± 43 Ross and 308 ± 48 mg/dL TD, p > 0.05). LDH was also elevated in the Bentall group (311 ± 45 vs. 205 ± 30 Ross, p < 0.01 and 203 ± 34 U/l TD, p < 0.01). Platelet count and haptoglobin levels were significantly reduced in the Bentall (190 ± 43/nL, 2.4 ± 1 mg/dL) and TD groups (183 ± 52/nL, 89 ± 57 mg/dL) in comparison to the control group (250 ± 86/nL, 140 ± 53 mg/dL) with p < 0.05, whereas there were no significant differences in the Ross group (214 ± 47/nL and 129 ± 54 mg/dL) in comparison to the control group. Leucocyte count and platelet function showed no significant differences between the groups.

Conclusion Polyester ascending aortic prostheses and more pronounced when combined with a prosthetic aortic valve cause hematologic changes compared with minimal deviations in Ross patients. We observed mild hemolysis, a decreased platelet count, and an increase in fibrinogen level in patients after conduit root replacement compared with procedures retaining an autologous aortic valve at midterm follow-up.

Keywords

aortic valve and root - aorta - anticoagulation

• References

• 1 Okumiya T, Ishikawa-Nishi M, Doi T , et al. Evaluation of intravascular hemolysis with erythrocyte creatine in patients with cardiac valve prostheses. Chest 2004; 125 (6) 2115-2120
• 2 Stratton JR, Thiele BL, Ritchie JL. Natural history of platelet deposition on Dacron aortic bifurcation grafts in the first year after implantation. Am J Cardiol 1983; 52 (3) 371-374
• 3 Magilligan Jr DJJ, Fisher E, Alam M. Hemolytic anemia with porcine xenograft aortic and mitral valves. J Thorac Cardiovasc Surg 1980; 79 (4) 628-631
• 4 Chang H, Lin FY, Hung CR, Chu SH. Chronic intravascular hemolysis after valvular surgery. J Formos Med Assoc 1990; 89 (10) 880-886
• 5 Mecozzi G, Milano AD, De Carlo M , et al. Intravascular hemolysis in patients with new-generation prosthetic heart valves: a prospective study. J Thorac Cardiovasc Surg 2002; 123 (3) 550-556
• 6 Ellis JT, Wick TM, Yoganathan AP. Prosthesis-induced hemolysis: mechanisms and quantification of shear stress. J Heart Valve Dis 1998; 7 (4) 376-386
• 7 Nygaard H, Paulsen PK, Hasenkam JM, Kromann-Hansen O, Pedersen EM, Rovsing PE. Quantitation of the turbulent stress distribution downstream of normal, diseased and artificial aortic valves in humans. Eur J Cardiothorac Surg 1992; 6 (11) 609-617
• 8 Sharefkin JB, Latker C, Smith M, Cruess D, Clagett P, Rich NM. Early normalization of platelet survival by endothelial seeding of Dacron arterial prostheses in dogs. Surgery 1982; 92 (2) 385-393
• 9 McCollum CN, Kester RC, Rajah SM, Learoyd P, Pepper M. Arterial graft maturation: the duration of thrombotic activity in Dacron aortobifemoral grafts measured by platelet and fibrinogen kinetics. Br J Surg 1981; 68 (1) 61-64
• 10 Koppensteiner R, Moritz A, Schlick W , et al. Blood rheology after cardiac valve replacement with mechanical prostheses or bioprostheses. Am J Cardiol 1991; 67 (1) 79-83
• 11 Koppensteiner R, Moritz A, Moidl R , et al. Blood rheology in patients with native heart valve disease and after valve replacement. Am J Cardiol 1998; 81 (2) 250-252
• 12 Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968; 23 (4) 338-339
• 13 Yacoub MH, Gehle P, Chandrasekaran V, Birks EJ, Child A, Radley-Smith R. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg 1998; 115 (5) 1080-1090
• 14 Kouchoukos NT, Masetti P, Nickerson NJ, Castner CF, Shannon WD, Dávila-Román VG. The Ross procedure: long-term clinical and echocardiographic follow-up. Ann Thorac Surg 2004; 78 (3) 773-781 , discussion 773–781
• 15 David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992; 103 (4) 617-621 , discussion 622
• 16 Stähli BE, Grünenfelder J, Jacobs S , et al. Assessment of inflammatory response to transfemoral transcatheter aortic valve implantation compared to transapical and surgical procedures: a pilot study. J Invasive Cardiol 2012; 24 (8) 407-411
• 17 Leguyader A, Watanabe R, Berbé J, Boumediene A, Cogné M, Laskar M. Platelet activation after aortic prosthetic valve surgery. Interact Cardiovasc Thorac Surg 2006; 5 (1) 60-64
• 18 Haven MC, Tetrault GA, Schenken JR. Laboratory Instrumentation. John Wiley and Sons; 1994
• 19 Sucker C, Zotz RB, Kurt M, Feindt P, Litmathe J. Platelet-function analyzer closure times indicate shear stress-induced hemostatic abnormalities in patients with aortic valve stenosis and correlate with perioperative transfusion requirements. Perfusion 2010; 25 (3) 153-158
• 20 McDonagh PF, Hokama JY, Gale SC , et al. Chronic expression of platelet adhesion proteins is associated with severe ischemic heart disease in type 2 diabetic patients: chronic platelet activation in diabetic heart patients. J Diabetes Complications 2003; 17 (5) 269-278
• 21 Skoularigis J, Essop MR, Skudicky D, Middlemost SJ, Sareli P. Frequency and severity of intravascular hemolysis after left-sided cardiac valve replacement with Medtronic Hall and St. Jude Medical prostheses, and influence of prosthetic type, position, size and number. Am J Cardiol 1993; 71 (7) 587-591
• 22 Ismeno G, Renzulli A, Carozza A , et al. Intravascular hemolysis after mitral and aortic valve replacement with different types of mechanical prostheses. Int J Cardiol 1999; 69 (2) 179-183
• 23 Hasenkam JM, Nygaard H, Pedersen EM, Ostergaard JH, Paulsen PK, Johannsen G. Turbulent stresses downstream of porcine and pericardial aortic valves implanted in pigs. J Card Surg 1989; 4 (1) 74-78
• 24 Tadić S, Ristić M. Comparative analysis in the use of natural and artificial vascular grafts on hematologic characteristics in patients [in Croatian]. Acta Chir Iugosl 2001; 48 (1) 53-58
• 25 Eugster M, Reinhart WH. The influence of the haematocrit on primary haemostasis in vitro. Thromb Haemost 2005; 94 (6) 1213-1218
• 26 Goldsmith IRA, Blann AD, Patel RL, Lip GYH. Effect of aortic valve replacement on plasma soluble P-selectin, von Willebrand factor, and fibrinogen. Am J Cardiol 2001; 87 (1) 107-110 , A9