Postoperative thrombotic thrombocytopenic purpura after open heart operations.
BACKGROUND
Postoperative thrombotic thrombocytopenic purpura (pTTP) after cardiovascular operations has an alarmingly high mortality rate if untreated. Five patients after coronary artery bypass graft (CABG) procedure were diagnosed with pTTP when they were observed to have a persistent thrombocytopenia associated with symptoms of fever, renal insufficiency, thromboembolic events, or altered mental status in conjunction with a microangiopathic hemolytic anemia (MAHA). A guideline for early diagnosis, followed by timely treatment in these cases, is reviewed.


METHODS
A retrospective record review of postoperative patients with thrombocytopenia identified 5 patients that met the criteria for pTTP from 2004 to 2008. We examined these 5 cardiovascular surgical patients in terms of clinical presentation, laboratory data, and outcomes.


RESULTS
All patients had the combination of an unexplained thrombocytopenia (platelets < 50,000 mm(3)) in conjunction with a MAHA as determined by the presence of schistocytes. Symptoms of neurologic dysfunction and renal insufficiency developed in all patients. Thromboembolic events were noted in 1 patient. All patients underwent plasmapheresis. In 3 patients, response time to clinical recovery and normalization of hematologic laboratory values after plasmapheresis was 3, 4, and 8 days. Two patients did not recover and died. One patient had a clinical and laboratory recovery after 19 days of plasmapheresis; however, after 11 days, thrombocytopenia with MAHA developed and he died on day 53 from complications related to the operation.


CONCLUSIONS
Postoperative TTP should be recognized as a possible pathophysiologic mechanism for unexplained postoperative thrombocytopenia and treatment should be initiated once the diagnosis is established.
Saltzman
Darin J
DJ
Department of Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles 90095, USA. dsaltzman@mednet.ucla.edu
Chang
Jae C
JC
Jimenez
Juan C
JC
Carson
John G
JG
Abolhoda
Amir
A
Newman
Richard S
RS
Milliken
Jeffrey C
JC
D000368:Aged; D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D003937:Diagnosis, Differential; D005260:Female; D005500:Follow-Up Studies; D006331:Heart Diseases / Q000601:surgery*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D010956:Plasmapheresis; D011379:Prognosis; D011697:Purpura, Thrombotic Thrombocytopenic / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D014841:von Willebrand Factor / Q000378:metabolism
D014841:von Willebrand Factor