Anesthetic management of antiphospholipid syndrome patients who underwent cardiac surgery: three cases report
A 65-year-old woman (153 cm, 62.9 kg) presented to the authors for MV leaflet mass excision. She already had percutaneous mitral valvuloplasty 10 years ago, MV replacement with tissue valve 8 years ago, and MV thrombectomy and MV replacement with mechanical valve 7 years ago. Since the final surgery, she had been on an anticoagulation regimen with warfarin. Recently she had gone to emergency room after experiencing sudden onset language disturbance, and had been diagnosed with left middle cerebral artery territory infarction. She also underwent routine follow-up transesophageal echocardiography (TEE) and a mobile mass was found which was attached to the prosthetic MV leaflet. To prevent an embolic event and decrease the size of the thrombus, the patient was started on heparin several days before the surgery was scheduled. Despite heparinization, however, the thrombus showed no change in size on TEE. The surgeon therefore considered that the patient might have a disease causing a hypercoagulable state and ordered laboratory examinations to investigate this possibility. The results of the tests were as follows: Protein C (-), protein S (-), antithrombin III 80 (80-120%), ACA IgM 15.5 mg/dl (<20), ACA IgG negative, LA (+), dRVVT 69.1 s (reference: 24-37.5 s), SCT 137.2 (reference: 23.4-39.2 s), mixing test with patient plasma 137.2 s, mixing test with mixed plasma (1 : 1) 99.3 s. Twelve weeks later, the LA test was performed again, and the patient was finally diagnosed with APS. Preoperative PT/INR was 1.37 and aPTT was 59.8 s.\nThe planned surgery was MV leaflet mass excision. The patient's left radial artery was cannulated under local anesthesia for invasive blood pressure monitoring. Routine induction and maintenance of anesthesia with IV anesthetics were performed. The central venous catheter was accessed and a TEE probe was inserted. The patient's basal ACT was 113 s and 180 mg of heparin was administered for vessel cannulations. The ACT level increased to 742 s and CPB was begun after insertion of cannulas into the aorta, superior vena cava and inferior vena cava. Twenty minutes after the start of CPB, the ACT level was found to be 826 s, and an additional 60 mg of heparin was administered. The target ACT level during CPB was over 800 s. After 50 min, the ACT level had decreased to 682 s, and another 100 mg of heparin was given. At the end of CPB, the ACT level was 668 s, and the surgeon decided not to administer protamine, concerned about possible postoperative thrombotic complications. One hour after the cessation of CPB, the ACT level decreased to 577 s. The total time of CPB was 99 min, and the total administered dose of heparin was 340 mg. The EBL during surgery was 600 ml and the urine output was 2,710 ml. 200 ml of crystalloid and 2,000 ml of colloid were infused during surgery. No transfusion was administered during the surgery.\nFollowing the procedure, the patient was transferred to the ICU. The immediate postoperative PT/INR was 2.93 and aPTT was over 400 s. Due to a bleeding tendency, 30 mg of protamine was administered to the patient. With that exception, there were no other specific complications. Warfarin was used for prophylactic anticoagulation and the patient was discharged 9 days after the operation.\nThe three case mentioned above are summarized in .