Late bleeding complication in a patient with Idiopathic Thrombocytopenic Purpura (ITP) after aortic valve replacement

Introduction: Patients with idiopathic thrombocytopenic purpura (ITP) can safely undergo cardiac surgery when certain pre-and postoperative precautions are considered. We report on a severe bleeding complication one week after aortic valve replacement(AVR) in a female patient with ITP. Aims: A 60 year old woman suffering from aortic valve stenosis underwent AVR. Her medical history revealed longstanding ITP and a history of splenectomy, lymphocytosis of unknown origin and chronic Hepatitis C, her platelet count was 70000/nl. Intraoperatively steroids were administered and platelets substituted. Initially the patient tolerated the procedure well;Platelet count increased over the next 7 days to 221/nl. On postoperative day(POD)8 hemoglobin level dropped to 8.1g/dl while platelet count remained normal(193/nl), INR was 1.39. A right hemothorax was diagnosed by chest-x-ray. In the OR no surgical bleeding was identified but 4 units of platelets, 6 fresh frozen plasma and 8 red cell concentrates had to be transfused;1000 IE of prothrombin complex and 1000 IE of antithrombin III were given. Prednisolon was applied for the treatment of ITP. During the next 8 hours bleeding continued while the platelet count remained low (60/nl). A second rethoracotomy again revealed no surgical bleeding. Further transfusions were followed by factor VII concentrate (NovoSeven ® ). The chest was left open. For the following days the patient received 30mg of IV immunoglobulins and steroids. The chest was closed on POD2, extubation followed on POD5, with an increased platelet count to 403/nl. On POD28 the patient was discharged. Discussion: To our knowledge this is the first reported case of a patient with ITP, who experienced a severe bleeding complication one week after AVR. Due to regular coagulation parameters a sudden dramatic drop in her platelet count due to ITP might have been responsible for that fatal complication. Different treatment options have been discussed for ITP in patients undergoing surgery. Most commonly the combination of steroids and IV immunoglobulins is recommended. Splenectomy can be performed to eliminate the production of antiplatelet antibodies either before cardiac surgery or – less common – during the same session. Despite these well known pre-, intra- and postoperative diagnostic and treatment modalities ITP remains an unpredictable disease in the surgical setting and thorough postoperative monitoring is needed to prevent devastating late bleeding complications.