Introduction

Chronic idiopathic thrombocytopenic purpura (ITP) patients rarely need open heart surgery and the reports in the literature are scarce. We present here a 72 years old female patient with ITP who had open heart surgery in our clinic.

Case Report

A seventy-two years old female patient was admitted to our hospital with effort dyspnea which had had started 2 years ago and increased progressively. In the physical examination there was a 3/6 systolic murmur on the apical area. The patient’s functional capacity was Class III according to the New York Heart Classification (NYHA). No other systemic findings were present. In the transthoracic echocardiography there was advanced mitral regurgitation, advanced tricuspid regurgitation, minimal aortic regurgitation, biatrial dilatation (left atrium 4,6 cm), pulmonary arterial pressure (PAP) was 50 mmHg and ejection fraction (EF) was 65%. In the medical history we learnt that patient had ITP which was diagnosed 12 years ago after a gingival bleeding and the low platelet count (14000/dL) and that she had been on corticosteroid therapy since the diagnosis. The coronary angiography revealed 70% proximal lesion on the left anterior descending (LAD) branch of left coronary artery (LCA) and plaques in the circumflex branch of LCA and the right coronary artery (RCA). Preoperatively complete blood count showed that she had 12400/dL leukocytes, 11 g/dL haemoglobine, 97000/dL platelets. All the coagulation tests were normal. We asked for a hematology consultation preoperatively and according to the consultation we started her on methyl prednisolone (20 mg/day) and were recommended to keep the platelet count over 70000/dL for a safe operation. Postoperatively 4 mg methyl-prednisolone given in an alternate day fashion was recommended. Preoperative steroid therapy increased the platelet count to 126000/day s that the patient could be taken to the operation. We performed mitral reconstruction with Alfieri technique, de Vega annuloplasty to the tricuspid valve and coronary artery bypass grafting (CABG) to LAD with left internal mammary artery. The patient did not require blood transfusion intraoperatively and was weaned from the cardiopulmonary bypass (CPB) with low dose dobutamine support. The durations of cross-clamping and CPB were 64 and 90 minutes, respectively. In the postoperative echocardiography there was 1^st degree mitral regurgitation. Postoperatively, alternate day steroid therapy was given according to the hematology consultation. Postoperative platelet counts were 65000/dL, 62000/dL, 47000/dL, 55000/dL, 65000/dL and 56000/dL on the postoperative 1^st, 2^nd, 3^rd, 4^th, 5^th and 6^th days, respectively. The total drainage from the chest tubes was 200 cc and the chest tubes were pulled on the 2^nd postoperative day. The patient was discharged on the 10^th postoperative day without additional problems.

Discussion

ITP is an autoimmune disease of the coagulation system characterized by decreased circulating platelet count and decreased platelet survival [1]. The diagnosis established with chronic thrombocytopenia accompanying a normal bone marrow morphology, insufficient amount of nondysplastic megakaryocytes, absence of splenomegaly and absence of the conditions leading to thrombocytopenia (drugs, vascular collagen diseases, lymphoproliferative disorders, infections).

Chronic ITP is a disease of adult age. Of the patients over 10 years of age, 72% are female and of these patients, more than 70% is younger than 40 years of age. In the treatment of this remitting relapsing disease corticosteroids, immunosuppressive agents, gamma globuline and danazole is recommended [2].

Some other authors report successful open heart operations on ITP patients but they required transfusion of excessive amounts of thrombocyte and erythrocyte suspensions. Mathew et.al reports a 23 patients’ series of ITP patients and 20 of them (87%) required thrombocyte replacement [3]. The physicians used corticosteroids, immunosuppressive agents and high dose gamma globuline in the preoperative period. Some other authors recommend gamma globuline instead of immunesuppressives and corticosteroids in order to avoid any postoperative infectious complications [4]. We did not have any infectious complication in our patient even though we put her on steroids preoperatively. The patient did not need any transfusion postoperatively, either.

The thrombocyte counts increase in 5 to days and stays in the elevated counts when gamma globulines are used. Another approach is to give patients human erythropoietine and draw about 800 mL blood for an autologous transfusion. Heparine coated extracorporeal surfaces may be used to avoid complement activation and thrombocyte depletion. We do not recommend perioperative splenectomy as it may increase both morbidity and mortality and this option should be reserved for patients who are refractory to medical treatment. The ITP patients who had corticosteroid therapy and had their platelet counts over 70000/mL preoperatively and who had meticulous bleeding control intraoperatively may have an uneventful recovery after an open heart operation.