Thrombocytopenia After Aortic Valve Replacement: Comparison Between Sutureless Perceval S Valve and Perimount Magna Ease Bioprosthesis

Mujtaba, Syed Saleem; Ledingham, Simon; Shah, Asif Raza; Schueler, Stephan; Clark, Stephen; Pillay, Thasee

doi:10.21470/1678-9741-2017-0157

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Brazilian Journal of Cardiovascular Surgery

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ORIGINAL ARTICLE • Braz. J. Cardiovasc. Surg. 33 (2) • Mar-Apr 2018 • https://doi.org/10.21470/1678-9741-2017-0157 copy

Thrombocytopenia After Aortic Valve Replacement: Comparison Between Sutureless Perceval S Valve and Perimount Magna Ease Bioprosthesis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction:

The incidence of postoperative thrombocytopenia after aortic valve replacement (AVR) with the Perceval S Sutureless bioprosthesis remains unclear. The aim of this study was to report thrombocytopenia associated with the use of sutureless AVR.

Methods:

The data was collected retrospectively for patients who had isolated AVR with sutureless Perceval S valve (Group A: 72 patients) and was compared with patients who underwent isolated sutured AVR with Perimount Magna Ease Bioprosthesis (Group B: 101 patients) in our institution between June 2014 and January 2017.

Results:

Cardiopulmonary bypass and cross-clamp time were significantly shorter in group A. Maximum drop in platelet count was 58% mean (day 2.3) in group A versus 44% mean (day 1.7) in group B (P=0.0001). Absolute platelet count on postoperative day 1-6 in group A was significantly less than in group B (P≤0.05). Platelet count recovered to preoperative value in 44% patients in group B versus only in 26% patients in group A at discharge (P=0.018). Moderate thrombocytopenia occurs more often in group A (41% vs. 26%) (P=0.008) while severe thrombocytopenia (<50 x 10⁹) was observed in 6% in group A but never in group B. Platelets (P=0.007) and packed red blood cells (P=0.009) transfusion was significantly higher in the group A.

Conclusion:

The implantation of sutureless Perceval aortic valves was associated with a significant drop in platelet count postoperatively with slow recovery and higher platelets and packed red blood cells transfusion requirements. A prospective randomised trial is needed to confirm our findings.

Keywords:
Aortic Valve/Surgery; Thrombocytopenia; Bioprosthesis/ Adverse Effects; Heart Valve Prosthesis Implantation/Adverse Effects

Abbreviations, acronyms & symbols
AVR	= Aortic valve replacement
CPB	= Cardiopulmonary bypass
ECC	= Extracorporeal circulation
POD	= Postoperative day
TAVI	= Transcatheter aortic valve implantation

	Perceval		Perimount		Chi-squared Test
Total	n=72	%	n=101	%	P
Gender (male/female)	34/38	47/52%	69/31	69/31%	0.004
Cigarette smoking history	3	4%	11	11%	0.106
History of hypertension	57	79%	60	60%	0.01
Renal disease at time of surgery	__	__	1	1%	0.40
History of pulmonary disease (i.e: COPD, asthma)	16	22%	19	19%	0.61
History of neurological disease (i.e.: TIA, CVA)	12	17%	7	7%	0.05
Angina Status pre-surgery	39	54%	37	37%	0.03
0. No angina	33	46%	63	88%
1. No limitation of physical activity	16	22%	18	25%
2. Slight limitation of ordinary activity	11	15%	11	15%
3. Marked limitation of ordinary physical activity	10	14%	6	8%
4. Symptoms at rest or minimal activity	2	3%	2	3%
Dyspnoea status pre-surgery	65	90%	82	82%	0.13
1. No limitation of physical activity	7	10%	18	18%
2. Slight limitation of ordinary physical activity	23	32%	39	39%
3. Marked limitation of ordinary physical activity	41	57%	40	40%
4. Symptoms at rest or minimal activity	1	1%	3	3%
History of diabetes mellitus	13	18%	20	20%	0.75
Preoperative heart rhythm
0. Sinus rhythm	55	76%	84	87%
1. Atrial fibrillation/flutter	16	22%	12	12%	0.07
2. Complete heart block/pacing	1	1%	__	__	0.24
3. Other abnormal rhythm	__	__	1	1.0%
Ejection fraction category
1. Good (LVEF > 50%)	58	81%	84	84%
2. Fair (LVEF 30-50%)	12	17%	15	15%	0.77
3. Poor (LVEF < 30%)	2	3%	1	1%	0.38

	Perceval			Perimount			t-Test
	Range	Mean	Median	Range	Mean	Median	Two-Sample Assuming Unequal Variances
Age of patients at time of procedure	54-84	74	75	47-86	70	70.5	<0.001
Logistic EuroSCORE comparison	0.53-18.89	3.07	2.41	0-7.57	1.87	1.44	0.001
Height (cm)	140-185	164.1	163	138-185	167.3	169	0.029
Weight (kg)	40.3-158	82.2	80.1	50-181.6	84.90	81.1	0.387

Perceval valve sizes	N	%	Perimount Magna valve sizes	N	%
			19	1	1
Small	8	11	21	20	11
Medium	20	28	23	42	42
Large	22	31	25	29	29
X large	22	31	27	10	18
			29	__	__
Total	72			101

Perceval valve Size %	Perimount Magna valve Size %	P value
Small 66.11%	19-21 mm 48.36%	0.0001
Medium 56.28%	23 mm 43.25%	0.0003
Large 59.41%	25 mm 44.85%	0.0003
X large 56.89%	27-29 mm 39.3%	0.0005

	Perceval valve N=72	Perimount Magna N=101	P
Maximum drop in platelet count: "which day"	Mean 2.3 Median 2 Range 0-5	Mean 1.7 Median 2 Range 0-6	0.0005
Maximum drop in platelet count: "what %"	Mean 58.0% Median 58.3% Range 35-84%	Mean 44.3% Median 45.0% Range 14-64%	<0.0001
Blood transfusion: units	Mean 1.5 Median 0.5 Range 0-10	Mean 0.7 Median 0 Range 0-8	0.0091
Platelet transfusion: pool of platelets	Mean 0.3 Median 0 Range 0-4	Mean 0.1 Median 0 Range 0-2	0.0075
FFP Transfusion: units	Mean 0.2 Median 0 Range 0-4	Mean 0.1 Median 0 Range 0-3	0.21

Patients having postoperative thrombocytopenia	Perimount Magna valve	Perceval valve	P value
Moderate thrombocytopenia: <100 x 109	N=26 (26%)	N=34 (41%)	0.008
Severe thrombocytopenia: <50 x 109	__	N=5 (6%)
Patients whose platelet level returned to preoperative level following surgery/did not return to preoperative	Perimount Magna valve N=44/57 (44/56%)	Perceval valve N=20/56 (26/74%)	0.018

Platelet count on days	Perimount Magna valve	Perceval valve	P value
Preoperative platelet count	244	239.8	=0.73
Operation day platelet count	158.6	144.6	=0.07
Postoperative day 1 platelet count	158.7	132.8	=0.0007
Postoperative day 2 platelet count	145.9	112.8	<0.0001
Postoperative day 3 platelet count	158.4	111.4	<0.0001
Postoperative day 4 platelet count	183.5	130.0	<0.0001
Postoperative day 5 platelet count	216.4	157.5	<0.0001
Postoperative day 6 platelet count	260.3	174.4	<0.0001
Postoperative day 7 platelet count	254.6	205.7	=0.23

	Perceval			Perimount			t-Test: Two-Sample Assuming Unequal Variances
	Range	Mean	Median	Range	Mean	Median	P
Cumulative cross-clamp time (min)	23-76	39.2	38	24-133	54.1	48.5	<0.001
Cumulative bypass time	25-119	59.3	56.5	19-175	71.6	63.5	<0.001
Post operative blood loss @ 12 hours	15-2000	304	212.5	100-2000	359.7	300	0.197
ITU stay in days	1-13	3.2	2	1-17	1.9	1	0.005

	Perceval		Perimount		Chi-squared Test
Total	n=72	%	n=100	%	P
Reoperation for bleeding, tamponade	2	2.78%	2	2.00%	0.738
Patient status at discharge (mortality)	1	1.39%	__	0.00%	0.237

Authors' roles & responsibilities
SSM	Drafting the work or revising it critically for important intellectual content; final approval of the version to be published
SL	Drafting the work or revising it critically for important intellectual content; final approval of the version to be published
ARS	Drafting the work or revising it critically for important intellectual content; final approval of the version to be published
SS	Drafting the work or revising it critically for important intellectual content; final approval of the version to be published
SC	Drafting the work or revising it critically for important intellectual content; final approval of the version to be published
TP	Drafting the work or revising it critically for important intellectual content; final approval of the version to be published

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[1] Correspondence Address: Syed Saleem Mujtaba, Department of Cardiothoracic Surgery, Freeman Hospital, Freeman Road Newcastle upon Tyne, NE3 1YS, United Kingdom. E-mail: saleemmujtaba@yahoo.com