Modern Treatment of Valvulopathies in Patients with Congenital Hemophilia
Abstract
:1. Introduction
2. Etiological Spectrum of Valvular Lesions
3. Prosthetic Cardiac Devices
Author, Year | Patient Characteristics | Indication for Valvular Surgery | Procedure | Comorbidities | Outcome | Antithrombotic Treatment after Surgery |
---|---|---|---|---|---|---|
Xu et al., 2019 [5] | 54 years HA severe I—NR | MV prolapse (posterior leaflet, mainly P2) + moderate-to-severe MR due to rupture of tendinae | MV repair: triangular resection of the posterior leaflet, creation of an artificial chordae (Gortex CV-4), insertion of an annuloplasty ring (Sorin, no. 28) + CABG | 60% stenosis in the proximal LAD; LVEF 70%; bilateral knee replacement | uneventful recovery; discharged home on POD 8; one-year follow-up: no bleeding or thrombosis complications; no MR on TTE; I—NR | life-long aspirin (due to CABG) |
Odonkor et al., 2017 [8] | 59 years HA mild I—no | symptomatic MR | minimally invasive MV repair | chronic hepatitis C | uneventful recovery; discharged home on POD 9; I—NR | aspirin |
Bhave et al., 2015 [7] | 59 years HA moderate I—no | NR | MV repair | NR | wound ooze and small retrosternal hematoma on POD 12 managed conservatively; aspirin withheld temporarily; I—bleeding phenotype typical of inhibitor development absent during the follow-up period | aspirin |
Tran et al., 2015 [17] | 60 years HA moderate I—yes (high-titer inhibitor: 12.4 BU) | MR + flail of the posterior leaflet | mitral valve repair: Gore-Tex neochord to the P3 segment; 28 mm Simulus ring around the mitral annulus; suture ligation of the left atrial appendage; pulmonary vein isolation using cryoablation; endoscopic robotic approach (da Vinci telemanipulation system) | HF with preserved LVEF | pleural effusion requiring ultrasound-guided thoracentesis (POD 3, POD 16, POD 27); I: high-titer inhibitor (6.2 BU) at 6-month follow-up | none |
Zatorska et al., 2012 [15] | 30 years HA mild I—no | IE of the MV with Staphyloccocus aureus MSSA; perforation of the posterior MV leaflet; prolapse of the anterior MV leaflet; considerable MR (acute) | triangular resection of anterior leaflet; quadrangular resection of the posterior leaflet; mitral valve annuloplasty with ring implantation (Edwards Phisio, 28 mm) | arthroscopic surgery for post-traumatic chondral and ligamentous damage of the left knee; bacterial pneumonia; left HF | no bleeding complications; the valve functioned very well at 1-year follow-up; I—NR | acenocoumarol, target INR 2–3, for 4 weeks (starting from POD 7), then aspirin for 2 months |
Tang et al., 2009 [30] | 72 years HA mild I—no | NR | LV aneurysm resection + MV repair | hypertension; congestive HF; LVEF = 30–35% | I—no (3-month follow-up) | aspirin |
Stine et al., 2006 [29] | 64 years HA mild I—NR | significant MR | MV repair (annuloplasty ring) + CABG | one stenotic coronary artery | no bleeding; no thrombosis; I—NR | aspirin and coumadin 7.5 mg each day for 30 days |
Author, Year | Patient Characteristics | Indication for Valvular Surgery | Procedure | Comorbidities | Outcome | Antithrombotic Treatment after Surgery |
---|---|---|---|---|---|---|
Surgically implanted biological prostheses | ||||||
Cusano et al., 2022 [6] | 54 years HA severe I—NR | group B Streptococcus IE + aortic root abscess + AR | AVR + bovine patch reconstruction + aortic root repair | hepatitis C (treated); Child–Pugh B cirrhosis; HIV on antiretroviral therapy (undetectable viral load); GI bleeding treated with FEIBA and tranexamic acid, complicated by portal vein thrombosis | no excessive intraoperative bleeding; chest reopening for bleeding from the sternal bone and muscle (OD); no further bleeding until POD 14; I—NR | none |
Serban et al., 2022 [35] | 64 years HA severe I—no | large AR | AVR | HF | discharged POD 10 immediate and long-term outcomes were good, without complications; I—NR | 3 months LMWH, then 3 months aspirin |
Chamos et al., 2017 [14] | 57 years HA severe I—no | severe AR secondary to IE with Staphylococcus epidermidis antibiotics iv for 6 weeks | AVR with 23 mm Perimount Magna Ease bioprosthetic valve through an anterior right thoracotomy | hemophilic arthropathy; HIV; HCV; hemodialysis thrice weekly for AKI | no bleeding complications associated with the procedure; renal function recovered completely; discharged home on POD 10; I—NR | none; allergy to aspirin and penicillin |
Bhave et al., 2015 [7] | NR HA mild I—no | NR | AVR | NR | no complications; I—bleeding phenotype typical of inhibitor development absent during the follow-up period | NR |
NR HA severe I—no | NR | AVR + CABG | NR | no complications; discharged to a rehabilitation facility due to significant de-conditioning; I—bleeding phenotype typical of inhibitor development absent during the follow-up period | NR | |
Damodar et al., 2014 [12] | 23 years HA severe I—yes (low-titer inhibitor 2.8 BU) | severe rheumatic AR | AVR | HF | uneventful recovery; discharged on POD 15; normal AV function, without any complications at 1-year follow-up; I—reevaluation of the titer was not considered necessary | heparin iv infusion, 48 h; LMWH for 10 days; discharged without anticoagulant |
Fitzsimons et al., 2013 [36] | 53 years HA mild I—no | redo aortic valve replacement | AVR | aortic valve replacement (1997); antiphospholipid antibody syndrome; hepatitis C; hematuria; complex migraine headaches; grand mal and petit mal seizures; IgA deficiency; anaphylactic reaction after a blood transfusion; chronic pain (requiring methadone); hemolytic anemia; idiopathic thrombocytopenia from interferon treatment; splenectomy | cardiac tamponade 6 h postoperatively; chest left open for 4 days to ensure hemostasis; discharged to rehabilitation on POD 27; 1-year follow-up: good exercise tolerance, no cardiac symptoms, minimal trouble with swallowing; I—NR | none |
Quader et al., 2013 [37] | 63 years HA mild I—NR | moderate AR | LVAD (HeartMate II) + AVR 23 mm Magna valve + CABG heart transplant (after 156 days) | ischemic cardiomyopathy; severe MR; moderate TR; advanced HF (severe biventricular failure); elevated pulmonary artery pressures; cardiogenic shock; multivessel coronary artery disease; motor vehicle accident 20 years previously: repair of the left temporal artery associated with excessive bleeding | HF symptoms improved; purse-string skin stitches to contain oozing from insertion site of chest tubes after their removal; multiple episodes of GI bleeding; possible pump thrombosis; transient ischemic attacks; discharged on POD 22 after heart transplant; good health at 4-month follow-up; I—NR | warfarin from POD 2; changed to heparin due to recurrent bleeding and thrombotic events |
Lison et al., 2011 [19] | 67 years HA moderate I—NR | AS and mild AR | AVR + CABG | two-vessel disease with 60% left main stem occlusion | uneventful recovery; discharged on POD 7; I—NR | none |
Tang et al., 2009 [30] | 60 years HA mild I—no | NR | AVR | hypertension, LVEF = 35–40% | postoperative duodenal ulcer 13 days after discharge, requiring readmission; I—no (3-month follow-up) | LMWH 6 weeks postoperatively (stopped because of GI bleeding) |
68 years HA moderate I—no | NR | AVR + CABG | atrial fibrillation; hypertension; hypercholesterolemia; LVEF = 40% | I—no (3-month follow-up) | LMWH 3 months | |
61 years HA mild I—no | NR | AVR + CABG | hypertension; hypercholesterolemia; LVEF = 55% | atrial flutter, sinus rhythm 1 month after surgery; I—no (3-month follow-up) | LMWH 1 month | |
Gasparovic et al., 2007 [18] | 47 years HA severe I—no | critical aortic stenosis | AVR | clinical stigmata of severe hemophilia | uneventful recovery | none |
Mackinlay et al., 2000 [27] | 54 years HA moderate I—no | second valvular replacement | AVR + MVR | AVR + MVR (bioprostheses) at the age of 49 | surgical bleeding due to severe uncontrolled hypertension, requiring reintervention; I—no | none |
Transcatheter aortic bioprostheses | ||||||
Merron et al., 2015 [20] | 84 years HA mild I—no | severe AS with recurrent exacerbations of acute HF | TAVR (transfemoral) | transient ischemic event; stented stenosis of left ICA; quadruple CABG; large spontaneous gluteal bleed while on aspirin without FVIII prophylaxis; congestive HF; left ventricular dysfunction; type 2 diabetes mellitus; essential hypertension; hiatus hernia repair; cholecystectomy; bilateral total hip replacement and subsequent revision | no excessive bleeding; discharged on POD 21; I—NR | aspirin |
Surgically implanted mechanical prostheses | ||||||
Mannucci et al., 2010 [31] | 45 years HA mild I—NR | NR | AVR | NR | no postoperative bleeding complications; no increase in hemorrhagic tendency; I—NR | life-long coumarin (target INR 2.5–3.5) |
De Bels et al., 2004 [28] | 53 years HA mild I—NR | grade III MR | MVR (Carbomedics mechanical prosthesis) + CABG | arterial hypertension; stable angina pectoris; two-vessel disease (occlusion RCx, triple stenosis LAD) | discharged on POD 9; I—NR; no bleeding complication at 6- week follow-up | coumarin |
Ghosh et al., 2003, 2004 [4,38] | 27 years undiagnosed HA mild | severe rheumatic MV stenosis previously treated by balloon valvuloplasty | MVR | large hematoma at the puncture site at the time of balloon mitral valvuloplasty; hematomas at the site of intramuscular benzathine penicillin injections | excessive bleeding and persistent hypotension during surgery; after surgery: hemoperitoneum; pericardial hematoma without tamponade; right-sided hemothorax; shock; ventilatory support; I—no; hematoma in right upper and mid thorax; I—yes (2.4 BU); no bleeding at 1-month follow-up after the start of VKA (INR 1.3–1.6) + I—yes (<2 BU); patient is well at 2.5-year follow-up, on VKA (INR 1.3–1.8) | discharged without anticoagulant; warfarin 1 mg/day (target INR 1.5–2) started 3 months after the operation; last report: warfarin 2.5 mg/day |
Mackinlay et al., 2000 [27] | 58 years HA mild I—no | NR | AVR (Medtronic Hall valve) | NR | no major bleeding complications related to warfarin therapy; I—no | warfarin (target INR 2–2.5) |
Author, Year | Patient Characteristics | Indication for Valvular Surgery | Procedure | Comorbidities | Outcome | Antithrombotic Treatment after Surgery |
---|---|---|---|---|---|---|
Biological aortic prostheses | ||||||
Yildirim et al., 2016 [22] | 43 years HA severe I—no | grade 3/4 AR, dilated aortic root and ascending aorta | Bentall operation; biologic composite graft (Sorin Mitraflow Valsalva conduit, no. 23) | Marfan syndrome; hemarthroses of the ankles, wrists, and knees; left knee fixation; operated hepatic hydatid cyst; LVEF 60% | uneventful recovery; discharged on POD 7; I—NR | none |
Bhave et al., 2015 [7] | NR HA mild I—no | NR | aortic root replacement (Valsava graft 30 mm + Carpentier Edwards Perimount Magna AV) | NR | no complications; I—bleeding phenotype typical of inhibitor development absent during the follow-up period | NR |
Diplaris et al., 2012 [25] | 54 years HA severe I—no | acute type A aortic dissection + bicuspid AV | Bentall operation: composite graft with a biologic valve (Biovalsalva 23) | hepatitis C infection; knee arthroplasty | re-exploration for bleeding on POD 1; sternal wound bleeding on POD 6 managed conservatively; discharged on POD 11; good condition at 3-month follow-up; I—NR | no postoperative prophylactic anticoagulation |
Mechanical aortic prostheses | ||||||
Bhave et al., 2015 [7] | 44 years HA mild I—no | NR | aortic root replacement (St Jude valved conduit 25 mm) | NR | frank hematuria 5 weeks postoperatively at INR 2.9; patient received TXA; INR target lowered at 2–2.5; I—bleeding phenotype typical of inhibitor development absent during the follow-up period | warfarin (target INR 2–3) |
Kaminishi et al., 2003 [23] | 53 years HA mild I—no | severe AR + dilation of ascending aorta | modified Bentall operation: 28 mm vascular graft (Hemashield Gold) and a 25 mm mechanical valve (Carbomedics) | shoulder trauma in a motor vehicle accident; congestive HF | no excessive bleeding; neurologically intact and cardiovascularly stable upon discharge on POD 23; I—NR | warfarin from POD 4 |
Author, Year | Patient Characteristics | Indication for Valvular Surgery | Procedure | Comorbidities | Outcome | Antithrombotic Treatment |
---|---|---|---|---|---|---|
Mitral valve repair | ||||||
Miller et al., 2020 [16] | 38 years HB mild | severe symptomatic MR with posteriorly directed jet related to an anterior mitral leaflet flail (Carpentier type II MV dysfunction) | robotic MV repair; five neochordae to segments A1 and A2 of the anterior mitral leaflet; 33 mm ATS annuloplasty band (Medtronic Inc) to the posterior annulus | severe LA and LV dilatation; mild AR; bicuspid AV; LVEF 55% | uneventful recovery; discharged home POD 7 | none at discharge |
Surgically implanted biological prostheses | ||||||
Shalabi et al., 2020 [39] | 74 years HB mild | NR | AVR + CABG | risk factors for ischemic heart disease; LVEF 55%; hepatitis C | GI bleeding requiring rehospitalization; I—no | antiplatelet at discharge |
Krakow et al., 2008 [21] | 61 years HB mild I—no | critical aortic stenosis; bicuspid aortic valve | AVR | NR | no bleeding complications; discharged on POD 7; I—no | heparin 5000 IU sc/12 h in POD 1–7; aspirin from POD 5 |
Surgically implanted mechanical prostheses | ||||||
Thankachen et al., 2007 [13] | 25 years HB mild | rheumatic mitral and aortic valvular disease | MVR with 2 M Starr Edwards valve (Model 6120, Edwards Lifesciences) + AVR with 22 Medtronic valve | intracerebral bleed with complete neurological recovery | cardiac tamponade (POD 4) treated by subxiphoid pericardiocentesis; acute renal failure treated conservatively (no dialysis required); discharged on POD 17; the patient was doing well at 9- month follow-up. | heparin 10 IU/Kg/h followed in POD 3–11 by dalteparin 2500 IU sc/12 h; none at discharge; acenocoumarol (INR 1.5–2.0) once the renal failure resolved completely |
Surgery involving the aortic valve and the ascending aorta | ||||||
Bohn et al., 2022 [24] | 60 years HB mild | degenerative aneurysms of aortic root and ascending aorta | Bentall operation type of graft—NR | uncomplicated dental extraction | uneventful recovery; I—no at 6-week follow-up | enoxaparin 40 mg/day sc from POD 1 throughout intensified FIX prophylaxis |
4. Surgical Procedures
5. Overview of the Surgical Protocol
6. Risk of Developing Inhibitors
7. Antithrombotic Treatment
8. Final Considerations
Author Contributions
Funding
Conflicts of Interest
References
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Badescu, M.C.; Badulescu, O.V.; Gheorghe, L.; Butnariu, L.I.; Ouatu, A.; Popescu, D.; Buliga-Finiș, O.N.; Gorduza, E.V.; Ciocoiu, M.; Rezus, C. Modern Treatment of Valvulopathies in Patients with Congenital Hemophilia. Life 2024, 14, 354. https://doi.org/10.3390/life14030354
Badescu MC, Badulescu OV, Gheorghe L, Butnariu LI, Ouatu A, Popescu D, Buliga-Finiș ON, Gorduza EV, Ciocoiu M, Rezus C. Modern Treatment of Valvulopathies in Patients with Congenital Hemophilia. Life. 2024; 14(3):354. https://doi.org/10.3390/life14030354
Chicago/Turabian StyleBadescu, Minerva Codruta, Oana Viola Badulescu, Liliana Gheorghe, Lăcrămioara Ionela Butnariu, Anca Ouatu, Diana Popescu, Oana Nicoleta Buliga-Finiș, Eusebiu Vlad Gorduza, Manuela Ciocoiu, and Ciprian Rezus. 2024. "Modern Treatment of Valvulopathies in Patients with Congenital Hemophilia" Life 14, no. 3: 354. https://doi.org/10.3390/life14030354