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Case report: Management of immediate post-cardiopulmonary bypass massive intra-cardiac thrombosis

[Prise en charge d’une thrombose intracardiaque majeure immédiatement après la circulation extra-corporelle]

Victor M. Neira, MD^*, Corey Sawchuk, MD^*, Kenneth S. Bonneville, MD^*, Victor Chu, MD and Theodore E. Warkentin, MD

^* From the Departments of Anesthesia,
Surgery, Pathology and Molecular Medicine, and
Medicine, McMaster University, Hamilton, Ontario, Canada.

Address correspondence to: Dr. Corey Sawchuk, Department of Anesthesia (HSC-2U1), McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada. Phone: 905-521-2100, ext. 75171; Fax: 905-523-1224; E-mail: sawchukcorey{at}rogers.com

Purpose: To describe the management of severe acute intracardiac thrombosis in a patient who underwent redo multiple valve replacement and valvular repair. The diagnostic features, associated risk factors, and anesthetic management are reviewed.

Clinical features: A 67-yr-old woman undergoing redo mitral and aortic mechanical valve replacement and tricuspid annuloplasty under aprotinin prophylaxis exhibited severe refractory hypotension that began immediately after protamine reversal of intraoperative heparin anticoagulation following separation from cardiopulmonary bypass. Intraoperative transesophageal echocardiography revealed severe thrombosis in the right atrium, right ventricle and pulmonary artery. The patient was managed by immediate reheparinization and return to cardiopulmonary bypass (CPB), surgical thrombectomy, and intraoperative administration of recombinant tissue-plasminogen activator. After removal of the thrombi, and separation from CPB, no further protamine was given. One hundred units of blood products and two surgical re-explorations were required to manage subsequent massive postoperative bleeding. Acute heparin-induced thrombocytopenia (HIT) was ruled out using sensitive assays for HIT antibodies. After 16 days in the intensive care unit and 30 more days in hospital, the patient was subsequently transferred to a chronic care facility and succumbed several weeks later.

Conclusion: Acute intraoperative thrombosis is a rare and potentially fatal complication of cardiac surgery. Intraoperative transesophageal echocardiography was essential for rapid diagnosis in this case. Multiple interacting prothrombotic factors (e.g., aprotinin use, acquired antithrombin deficiency, long pump time, post-protamine status, transfusion of blood components) were likely contributing factors related to this rare complication.