Ann Thorac Surg 2008;85:1784-1787. doi:10.1016/j.athoracsur.2007.11.057
© 2008 The Society of Thoracic Surgeons
Case Reports
Hemolytic Anemia After Operation for Aortic Dissection Using Teflon Felt Strips
Yuki Nakamura, MD,
Hitoshi Ogino, MD*,
Hitoshi Matsuda, MD,
Kenji Minatoya, MD,
Hiroaki Sasaki, MD,
Soichiro Kitamura, MD
Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan
Accepted for publication November 19, 2007.
* Address correspondence to Dr Ogino, Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, 565-8565, Japan (Email: hogino{at}hsp.ncvc.go.jp).
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Abstract
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We report three cases of hemolytic anemia caused by anastomotic stenosis after surgical treatment for aortic dissection in which internal and external Teflon (DuPont, Wilmington, DE) felt strips were used for reinforcement of the aortic stump. To detect this complication, laboratory findings typical of red cell fragmentation syndrome as well as appropriate imaging modalities are necessary. As a precaution, it is necessary to be meticulous when stitching the internal felt strip.
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Introduction
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Operative survival for aortic dissection has recently improved with advances in surgical techniques and perioperative management; however, there are still several potential early and long-term postsurgical complications. Since 1986, we have used internal and external Teflon (DuPont, Wilmington, DE) felt strips for the reinforcement of the aortic stump. Here, we report three cases of hemolytic anemia caused by anastomotic stenosis after surgical treatment for aortic dissection using felt strips for the reinforcement of the aortic stump.
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Case Reports
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Patient 1
A 48-year-old man underwent emergency ascending and total arch replacement with an elephant trunk technique for acute type A dissection at the National Cardiovascular Center. We reinforced the proximal stump using internal and external felt strips and gelatin-resorcin-formalin glue. The patient's postoperative course was uneventful. One month later, he presented with high-grade fever, anemia, and systolic murmur of Levine 3/6. The hemoglobin level was 7.3 g/dL, the lactate dehydrogenase (LDH) level was 650 IU/L, the reticulocyte percentage was 6.2%, and schistocytes appeared in the peripheral blood.
Two-dimensional computed tomographic (CT) scans failed to demonstrate any abnormalities at the anastomoses. The transesophageal echocardiography (TEE) showed an abnormal projection in the aortic lumen at the proximal anastomosis. Color Doppler echocardiography demonstrated an acceleration in flow, with a peak velocity of 3.4 m/s.
During reoperation, we found the internal felt strip at the proximal anastomosis was turned upward, which reduced the inner diameter to 13 mm. We completely removed the internal felt strip and reanastomosed the previous graft to the ascending aorta. The LDH level decreased to 133 IU/L, and the patient was discharged at postoperative day 21.
According to the pathologic examination, inflammatory cells, including eosinophils, macrophages, and lymphocytes, infiltrated the aorta near the felt strip. During the follow-up for 6 years, laboratory findings have shown no sign of hemolytic anemia, and the latest LDH value was 175 IU/L.
Patient 2
A 60-year-old man underwent emergency ascending and total arch replacement for acute type A dissection at another hospital. Two months later, the hemoglobin level was 9.4 g/dL, the LDH level was 578 IU/L, and schistocytes appeared in the peripheral blood. Two years later, hemoglobin level was 8.7 g/dL, the LDH level was 1535 IU/L, and the reticulocyte percentage was 2.6%. A TEE showed an abnormal projection into the aortic lumen at the proximal anastomosis, which caused an acceleration in the flow, with a peak velocity of 4.2 m/s (Fig 1).
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Fig 1. Transesophageal echocardiography image demonstrates an abnormal projection into the aortic lumen at the proximal anastomosis (arrow).
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During reoperation, we found that the internal felt strip at the proximal anastomosis was stiff and turned upward, which reduced the inner diameter to 11 mm (Fig 2). We replaced the ascending aorta with a new graft and removed the internal felt strip. The patient's hemolytic anemia was cured, with a reduced LDH level that reached 251 IU/L at discharge. The patient has been followed-up for 1 year, and the LDH level is 167 IU/L now. The latest CT scans showed no sign of anastomotic stenosis.
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Fig 2. Intraoperative finding shows stenotic aortic lumen (arrow) caused by the circumferentially inverted internal felt strip.
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Patient 3
A 79-year-old woman underwent emergency graft replacement of the descending aorta for acute type B dissection at our hospital. We reinforced the proximal stump using internal and external felt strips and gelatin-resorcin-formalin glue. Two years later, she had dyspnea on exertion. Levels were hemoglobin, 6.6 g/dL, LDH, 1913 IU/L; reticulocyte percentage, 8.4%; and platelet count, 87000/µL. Computed tomography scans (Fig 3) and TEE revealed an abnormal projection in the aortic lumen at the proximal anastomosis, which caused the flow to accelerate. The estimated pressure gradient was 100 mm Hg. Indicator levels in further laboratory examination were fibrinogen, 109 mg/dL; fibrinogen degradation product, 51 µg/mL; thrombin-antithrombin complex, 46 µg/L; and D-dimmer, 23.7 µg/mL.
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Fig 3. Computed tomographic scan demonstrates stenotic aortic lumen caused by an abnormal projection into the aortic lumen at the proximal anastomosis.
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To reduce the stenosis at the proximal anastomosis, and considering her age and coagulopathy, we performed a palliative axillobilateral femoral bypass. The postoperative echocardiography revealed that the pressure gradient through the stenosis decreased to 30 mm Hg. The LDH level at discharge declined to 459 IU/L, but the bleeding tendency caused by coagulopathy continued. The patient was lost to follow-up after 9 months. The latest LDH level was 455 IU/L.
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Comment
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Teflon felt has been widely used in cardiovascular operations to reinforce the anastomoses; however, several reports have described complications related to the usage of felt strips. First, it is a foreign body that is subject to infection. Second, it may cause distal embolism. Sogawa and colleagues [1] reported a 60-year-old woman who had multiple cerebral infarctions after an operation for acute type A dissection caused by a mobile thrombus on the internal felt strip. Bedetti and colleagues [2] have also reported a patient presenting with coronary embolism of a felt used in the placement of a Bjork-Shiley aortic valve. Third, like in our patients, the use of felt strips may cause hemolytic anemia. Moreira Neto and colleagues [3] reported 2 patients presenting with hemolytic anemia after mitral valve plasty with the use of Teflon felt strip for posterior annuloplasty. Shingu and colleagues [4] have also reported a similar case to ours, although they did not mention the postoperative follow-up.
In 2 of the 3 patients presented in this report, the proximal part of the internal felt strip was turned upward circumferentially and had stiffened to form stenosis at the anastomotic site. It is unknown whether red cell fragmentation syndrome was caused by the stenosis or by the turbulence caused by the collision of blood with the internal felt strip that was turned upward. In the third patient, the pressure gradient through the stenosis decreased from 100 to 30 mm Hg by means of a palliative axillobilateral femoral bypass, but there still remained a mechanical destruction of red blood cells.
In terms of diagnosis of this complication, the clues are systolic ejection murmur at the anastomotic site, laboratory findings compatible with red cell fragmentation syndrome, including anemia, elevated LDH level and reticulocyte percentage, and schistocytes. Imaging studies are also needed for the diagnosis. In our series, TEE, which clearly demonstrated an abnormal projection in the aortic lumen at the anastomotic site, was more useful than CT scans. The degree of stenosis can be evaluated by a color Doppler technique. In addition, Garcia and colleagues [5] have advocated the efficacy of magnetic resonance angiography for the evaluation of complications in surgically treated aortic dissection.
Laboratory findings in our 3 patients had already shown red cell fragmentation syndrome within a few months after the first operation. We speculated that the syndrome had developed as the internal felt strip became stiffer over time. To prevent this complication, the internal felt strip should be narrow, and stitches should be put in the more proximal portion of the felt strip so that the proximal part will not turn upward.
In summary, hemolytic anemia caused by anastomotic stenosis after surgical treatment for aortic dissection using Teflon felt strips for reinforcement is a rare complication. To detect this complication, laboratory findings typical of red cell fragmentation syndrome as well as appropriate imaging modalities, such as TEE or CT scans, are needed, and necessary precautions should be exercised while stitching the internal felt strip.
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References
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- Sogawa M, Moro H, Namura O, Ishiyama T, Hayashi J. Thrombus on the intraluminal felt strip. A possible cause of postoperative stroke. Jpn J Thorac Cardiovasc Surg 2001;49:333-335.[Medline]
- Bedetti CD, Siewers RD, Dunsford HA. Teflon felt embolism of coronary arteries after cardiac surgery: a case report Am Heart J 1978;96:802-805.[Medline]
- Moreira Neto FF, Evora PR, Ribeiro PJ, Sgarbieri RN, de Freitas JN. Hemolytic anemia following surgical repair of mitral valve insufficiency in children Arq Bras Cardiol 1990;55:55-58.[Medline]
- Shingu Y, Aoki H, Ebuoka N, et al. A surgical case for hemolytic anemia after ascending and total arch replacement Ann Thorac Cardiovasc Surg 2005;11:416-418.[Medline]
- Garcia A, Ferreiros J, Santamaria M, Bustos A, Abades JL, Santamaria N. MR angiographic evaluation of complications in surgically treated type A aortic dissection Radiographics 2006;26:981-992.[Abstract/Free Full Text]
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Abstract
Introduction
