Anesthetic management of antiphospholipid syndrome patients who underwent cardiac surgery: three cases report
A 34-year-old man (160.5 cm, 48.9 kg) was presented to the authors for mitral valve (MV) replacement. The patient had been diagnosed with SLE and APS after being admitted to the hospital for treatment of palpitations and dyspnea ten years earlier, and he had taken an anticoagulant medication. During the outpatient clinic follow-up, 24-hr Holter monitoring revealed the increasing frequency of non-sustained atrial fibrillation. An operation was thus scheduled to reduce the risk of atrial thrombosis. The preoperative blood coagulation tests showed prolonged results. The aPTT was 57.8 s and dRVVT was 47.2 s (reference: 25.9-35.7 s). The result with patient plasma from the mixing test was 27.3 s, and the mixed plasma result was 37.6 s, while SCT was 52.1 s (reference: 22.3-42.7 s). In addition, the patient was positive for LA, negative for ACA IgG, and had borderline results for ACA IgM. Intravenous heparin and oral deflazacort tablets were used for preoperative management.\nInvasive blood pressure monitoring was conducted via the patient's radial artery. Anesthesia induction and maintenance were performed as usual, and routine cardiac anesthesia monitoring was done. The ACT level increased from 129 s to 850 s after the injection of 150 mg of heparin. After the insertion of cannulas into the aorta, superior vena cava, and inferior vena cava, CPB was started. One hour after the administration of heparin, the ACT level was found to have decreased to 524 s. Therefore, an additional 50 mg of heparin was injected. After the mitral annuloplasty, valvuloplasty was performed, and weaning from CPB was attempted. Due to the risk of thrombosis, a half dose (75 mg) of protamine was administered. Five minutes after the injection of protamine, the ACT level was found to be 220 s. The total administered dose of heparin during the surgery was 200 mg, and the total CPB time was 52 min. The EBL during surgery was 500 ml and urine output was 455 ml. 800 ml of crystalloid and 500 ml of colloid were infused during surgery. The patient did not receive any transfusion during the surgery.\nFollowing the surgery the patient was transferred to the ICU without significant bleeding. The immediate postoperative PT/INR was 1.39 and aPTT was over 180 s. Postoperative prophylactic anticoagulation was maintained with warfarin. Ten days after the operation, the patient was discharged without specific complications.