CASE REPORT
Successful treatment of thrombotic thrombocytope-nic purpura associated with mitral valve replacement Yong Liu,I Jian Zhu,I,II Er-Ping Xi,I Wei Jiang,I Feng Xia,III Shui-Bo Zhu I,II
I Wuhan General Hospital of Guangzhou Command,Department of Thoracic Cardiovascular Surgery,Wuhan,People’s Republic of China.II Southern Medical University,Guangzhou,People’s Republic of China.III Liaocheng People’s Hospital,Department of Cardiovascular Surgery,Liaocheng,People’s Republic of China.
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INTRODUCTION
Thrombotic thrombocytopenic purpura(TTP)is a rare hematologic syndrome.It is a multisystem disorder characterized by microangiopathic hemolytic anemia and thrombocytopenia and may be accompanied by fever and renal or neurologic abnormalities(1,2).Most adult patients acquire(3)the dia as a result of autoantibodies against ,idiopathic TTP),or it is obrved in association with coll
agen vascular dia,bone marrow transplantation,systemic sclerosis,infections,polymyosi-tis,pregnancy,or drug treatment,including cyclosporine, tacrolimus,ticlopidine,and antineoplastic ,non-idiopathic TTP)(1,4).However,TTP associated with mitral valve replacement surgery has not been reported. In this paper,we describe a ca of a41-year-old female who developed acute TTP after mitral valve replacement surgery.The patient was treated with plasma exchange(PE)and recovered following an uneventful cour.
CASE DESCRIPTION
A41-year-old woman with a four-year history of shortness of breath and chest tightness was admitted to our hospital for evaluation.Echocardiography revealed mitral valve stenosis (mitral valve area1.06cm2)as a result of rheumatic heart dia.The patient underwent mitral valve replacement via a right atriotomy with a mechanical mitral valve(tissue annulus diameter of27mm;St.Jude Medical,St.Paul,Minnesota USA).Cardiopulmonary bypass lasted for115minutes,and the aortic clamp time was43minutes.Postoperative echocardiography revealed satisfactory valve function and confirmed the successful removal of the intracavitary lesion. Cefoxitin(3g/day)was initiated on postoperative day1 for prophylaxis.A complete blood count(CBC)was obtained daily and revealed a low platelet count(Table2)on day2. Platelets(400ml)were transfud,but the patient developed fever(
Table1),and the platelet count dropped continuously (Table2).In addition,the patient developed neurological symptoms and subcutaneous ecchymosis.A blood biochem-ical analysis revealed a rum lactate dehydrogena of 821U/L and7.7m mol/L total bilirubin(direct bilirubin, 2.1m mol/L;indirect bilirubin,5.6m mol/L).Her urine exam was positive for protein(3+),leukocytes(normal),hemoglo-bin(2+),and bilirubin(1+).A direct Coombs test was negative,and PT and aPTT were within the normal range. Liver and renal function tests were normal.Physical examinations of the cardiovascular and respiratory systems and abdomen were normal.Abdominal ultrasonography, computed tomography,and magnetic resonance imaging of the brain revealed no abnormalities.The patient was diagnod with acquired TTP and received a bolus of dexamethasone(10mg),an infusion of a high volume of fresh frozen plasma,and a red blood cell transfusion. However,the patient did not respond adequately.Until eight hours after one-volume(2000ml fresh frozen plasma) PE was treated,the patient’s body temperature began to normalize,and her neurologic and respiratory parameters improved.The patient was discharged after an additional eight days of hospitalization without plasma exchange. DISCUSSION
flowrveTTP is a rare hematologic emergency with an abrupt ont,and it is potentially fatal.It is clinically characterized by five typical symptoms:hemolytic anemia,thrombocyto-penia,renal impairment,fever,
and neurological disorders. Although TTP is associated with a vere deficiency of ADAMTS13activity(5),measurements of ADAMTS13 activity are not required to conclusively confirm the diagnosis(6).Therefore,the diagnosis of TTP is bad on the prenting clinical features(1).As in this ca,there is typically insufficient time to evaluate ADAMTS13activity, and a prompt diagnosis of TTP is critical for initiating treatment and reducing patient mortality.
当我想起你张学友Mitral valve replacement is one of the best treatments for mitral stenosis.It has been performed successfully with excellent results and limited complications.The major complications of mitral valve replacement surgery include postoperative bleeding,ischemic stroke,myocardial infarc-tion and death.This is the first ca report of TTP as a complication of mitral valve replacement surgery.Although ADAMTS13activity was not measured in our ca,the clinical cour was not affected by PC transfusion,and the rapid respon to plasma exchange supports the TTP diagnosis.We will follow up this ca and evaluate plasma ADAMTS13activity and autoantibodies to exclude the
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CLINICS2012;67(12):1527-1528DOI:10.6061/clinics/2012(12)31
creep歌词possibility of hereditary ADAMTS13deficiency,which is extremely rare,or acquired autoantibodies against ADAMTS13,which often persist despite clinical resolution or remission (7).
Daily plasma exchange remains the mainstay of treat-ment for acquired TTP regardless of its etiology (1).However,plasma infusion once every two weeks appears to be sufficient for hereditary TTP (8).Our patient recovered with one plasma volume and showed a good clinical outcome,with a normal temperature and improve-ment of neurological and respiratory parameters eight hours later.The cour over the next eight days of hospitalization was uneventful and did not require a cond plasma exchange.
初中英语语法
Although the occurrence of TTP associated with mitral valve replacement surgery is extremely rare,it is important to recognize TTP as a cau of thrombocytopenia and hemolytic anemia in any patient with mitral valve replacement surgery.The prompt initiation of treatment with plasma exchange remains the cornerstone of TTP treatment.Despite the prognosis of TTP associated with mitral valve replacement surgery,the schedule for PE remains poor,and further studies are necessary to improve the management of this dia.
化学补习ACKNOWLEDGMENTS
The authors thank X.Long Zheng at The Children’s Hospital of Philadelphia and University of Pennsylvania for his careful revision of the manuscript.
AUTHOR CONTRIBUTIONS
Zhu J and Xi EP wrote the manuscript first draft.Zhu SB,Liu Y,Jiang W and Xia F contributed to the patient treatment and took part in the care of the patient.Liu Y participated in data collection and analysis.Zhu J conceived the study and performed the literature arch.Xi EP revid the manuscript.Zhu SB was the first surgeon who provided clinical experti,reviewed the manuscript and approved the manuscript final version.
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勇敢英文
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Table 1-Patient body temperature over the cour of
treatment.
英语 mp3Table 2-Patient platelet counts over the cour of treatment.
Mitral valve replacement-associated TTP Liu Y et al.
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