Hemolysis After Mitral Valve Repair
A54-year-old woman, status post–mitral valve repair for severe mitral regurgitation secondary to mitral valve prolapse, was admitted 7 weeks after surgery with shortness of breath and fatigue. Hematological studies revealed a Coomb’s-negative hemolytic anemia with a hematocrit of 17.1%, haptoglobin of <7.9 mg/dL (normal 51 to 192 mg/dL), LDH of 3165 U/L, total bilirubin of 6.8 mg/dL (indirect of 6.1 mg/dL), and a peripheral blood smear demonstrating mechanical hemolysis with schistocytosis and red cell fragmentation (arrows, Figure⇓, A). A transesophageal echocardiogram revealed partial dehiscence of the mitral valve annuloplasty ring (No. 28 Baxter Physio ring) from the native mitral valve annulus (arrow, B). Color Doppler images demonstrate severe regurgitation with fragmentation of the mitral regurgitation (arrow, C) into a valvular jet and a high-velocity para-ring regurgitant jet. 3D echocardiographic images reveal a paravalvular communication (white arrow, D) created by the dehiscence of the annuloplasty ring from the native mitral valve annulus. 3D color Doppler images (with color suppression of the lower-velocity valvular regurgitation) demonstrates the high-velocity para-ring regurgitant jet (white arrow, E).
Hemolytic anemia is a reported, although uncommon, complication of mitral valve repair. Mechanisms of hemolysis that have been suggested include collision of the regurgitant jet into the prosthetic ring, fragmentation of the regurgitant jet by a dehisced annuloplasty ring, and rapid acceleration of a jet through a small para-ring channel.1 2 The probable mechanism in the present case is fragmentation of the regurgitant jet, with rapid acceleration through the para-ring dehiscence. The patient returned to the operating room for mitral valve replacement, after which the hemolytic anemia resolved.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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