Ram Kakaiya, MD
Medical Director
LifeSource Blood Center

INTRODUCTION:  Bleeding after cardiopulmonary bypass surgery is a common occurrence with 0.6% to 15% of patients requiring re-operation to control bleeding.¹ Pre-operative thrombocytopenia would be expected to increase bleeding risk.  A pre-operative diagnosis of idiopathic thrombocytopenic purpura (ITP) is present in 0.2% of patients.² Therefore, assessing the magnitude of surgical bleeding risk in ITP patients is a particularly important consideration in managing such cases.  Below is a brief review of the published literature citing outcomes in ITP patients undergoing cardiac surgery.

Literature search:  The literature regarding ITP patients undergoing cardiac surgery consists mostly of single case reports, many of which are published in Japanese with English abstracts. A recent paper describes 23 such cases.³ Twenty-one additional cases were identified by performing a Medline search.^4-25 A brief summary of the collective experience in these 44 cases follows.   

Patient characteristics and types of cardiac surgery:  Of the total 44 patients, 18 were females and 26 were males. The average age of the patients was 60.7 years (SD = 11.6 years; range: 28-70 years). The types of cardiac surgeries performed were as follows: coronary artery bypass grafting (N=20), mitral valve replacement (N=10), aortic valve replacement (N=5), mitral + aortic valve replacement (N=3), closure of atrial septal defect (N=3), and one case each of aortic aneurysm repair, aortic arch replacement and mitral commissurotomy. The average CPB time was 120 minutes (N=13; range: 30-197 minutes; SD=51 minutes). The average cross-clamp time was 66 minutes (N=10; range: 14-139 minutes; SD=42 minutes). In ten patients, a splenectomy was performed in conjunction with cardiac surgery. Three additional patients were treated with aprotinin during the surgery. Chest tube drainage in the immediate post-operative period averaged 748 ml (N=13, SD=374 ml; range: 286-1380 ml).

Pre-surgical thrombocytopenia treatment:  A total of twenty-five patients were treated with intravenous immunoglobulin (IVIG) infusions before surgery. The number of patients receiving the IVIG course for 2-7 days was as follows: 2-day (N=5), 4-day (N=2), 5-day (N=13), 6-day (N=1), and 7-day (N=1). Two patients received only post-operative IVIG. Two patients received both pre-operative and post-operative IVIG therapy. In one case, the details of IVIG therapy were lacking.

Degree and severity of thrombocytopenia:

Platelet counts at admission and post-treatment, immediately prior to surgery: The admission platelet count averaged 47,900/uL (range: 8,000-180,000/μL; SD=29,400/μL). After IVIG or corticosteroid treatment and at the time of the surgery, the platelet count averaged 105,600/μL (range: 20,000-240,000/μL, SD=56,500/μL).

Platelet counts intraoperatively: In 15 cases, data were available for intra-operative counts. The average intra-operative platelet count was 51,500/μL (range: 18,000 – 100,000/μL, SD=22,600/μL).

Platelet counts after surgery: In 18 cases, data were available for post-operative platelet counts performed within 24 hours after the surgery (i.e., recovery room/first post-operative day). The average count was 116,200/μL  (range: 21,000 – 242,000/μL; SD = 59,800/μL).

Platelet transfusions:  Overall, 32 of 44 patients (73%) were transfused with platelets. Sixteen patients were given platelet transfusions, but no details were available regarding the number of units or the timing of transfusions. An additional 16 patients received transfusions during or after surgery for which the details were available.

Four patients received pre-operative transfusions with the respective number of units transfused for each patient as follows: 2, 3, 15, and 20. A total of 15 patients were transfused during surgery and/or immediately after CPB. These transfusions included random donor platelets (number of units transfused per transfusion episode: 6, 6, 7, 8, 10, 20, 20, 20, and 20, respectively) or apheresis platelets (number of units transfused per transfusion episode: 1, 1, 1, 2, 2, and 2, respectively). Three patients were transfused during their stay in the recovery room immediately after the surgery and these transfusions included 6 units of random donor platelets in one case and 1 unit of apheresis platelets in each of the two other cases. Transfusions during the first post-operative day were given to three patients and consisted of 10 units and 8 units of random donor platelets in one patient each and an apheresis platelet unit in the third case.  

Excessive bleeding complications:  Excessive bleeding complications were seen in 13 patients. Of these, only 2 required re-exploration. One was for bleeding in the mammary artery bed that occurred within a day after surgery. Another patient required re-exploration for pericardial effusion one week after the surgery. The remaining patients had mild to moderate bleeding that was controlled without intervention or by platelet transfusions. However, two of these patients had prolonged post-operative bleeding from chest tubes, requiring nine and seven separate transfusions over 14-15 days post-operatively. No post-operative deaths from the bleeding were observed.

Conclusion:  Based on 44 case reports, it appears that patients with ITP presenting with moderate thrombocytopenia could be successfully treated before cardiac surgery with a typical course of IVIG for 2-5 days to raise the pre-operative platelet count from 50,000/uL to 100,000/uL. These patients could then successfully undergo coronary artery bypass or valve replacement surgery. During cardiac surgeries, an average count of 50,000/uL in these patients did not result in severe intra-operative bleeding complications. The vast majority of the patients required platelet transfusions either during or immediately after the CPB. Excessive bleeding was experienced in approximately 30% of the patients; however, only about 5% of the patients required re-exploration for bleeding. No deaths from bleeding occurred.

References:

1. Herwaldt LA et al. Infect Control Hosp Epidemiol 19(1):6-8, 1998.

2. Christiansen S, et al. Ann Thorac Surg 69:61-4, 2000.

3. Mathew TC et al. Ann Thorac Surg 64:1059-62, 1997

4. Aleskog AE et al. Semin Thromb Hemost 21(Suppl 2): 59-65, 1995.

5. Gaudino M et al. J Cardiovasc Surg (Torino) 40(2):227-8, 1999.

6. Goshima M et al. Kyobu Geka 52(7):573-7, 1999.

7. Gotoh H et al. Kyobu Geka 55(12):1049-52, 2002.

8. Hayashi S et al.  J Jpn Assoc Thorac Surg 44(11):2091-4, 1996.

9. Kaneda T et al. J Card Surg 14(5):386-9, 1999.

10. Koner O et al. J Thoarac Cardiovasc Anesth 15(4): 483-484, 2001.

11. Koyanagi T et al. Ann Thorac Surg 69:1261-3, 2000.

12. Matsuzaki K et al. Ann Thorac Surg 7(5):315-8, 2001.

13. Mori Y et al. Heart Vessels 6:121-4, 1991.

14. Nagumo M et al. J Cardioavsc Surg (Torino) 40(4):549-52, 1999.

15. Nakamura K et al. Ann Thorac Surg 70(6):2161-3, 2000.

16. Nakazawa M et al. J Jpn Surg Soc 91:108-9, 1973.

17. Oba J et al. Jpn J Thorac Cardiovasc Surg 48(2):129-31, 2000.

18. Ohno H et al.  J Cardiovasc Surg (Torino) 43(2):185-8, 2002.

19. Onoe M et al. Kyobu Geka 52(2):112-4, 1999.

20. Usui A et al. Surgery Today 26(10):828-30, 1996.

21. Whitten CW et al. Anesth Analg 79(4):796-800, 1994.

22. Yamada T et al. Nippon Kyobu Geka Gakkai Zasshi 44(9):1809-13, 1996.

23. Yanagiya A et al. Nippon Kyobu Geka Gakkai Zasshi 44(8):1168-71, 1996.

24. Yoshida H et al. Jpn J Cardiovasc Surg 22:372-5, 1993.

25. Christiansen S et al. Thorac Cardiov Surg 49:316-317, 2001.

For questions regarding this TMU, please contact Ram Kakaiya, MD at: (847) 803-7825