Hemolytic Anemia Associated with Mitral Valve Repair
Authors: Elaine Huang, MD; Michael Crawford, MD; Laura Padilla-Carrasquillo, MD; Rohan Samson, MD
Introduction:
Cardiac prosthesis-related hemolytic anemia has been well documented, particularly with older generation valves or regurgitant prosthetic valves. Prosthetic aortic valves are particularly susceptible due to turbulent flow and high-pressure gradients that can lead to microangiopathic hemolytic anemia (MAHA). Hemolytic anemia following mitral valve repair or annular ring placement is rare and less documented, comprising <1% of reported cases. We report a case of hemolytic anemia following failure of a mitral valve (MV) repair resulting in severe mitral regurgitation (MR).
Case Presentation:
A 59-year-old man with a recent MV repair for management of symptomatic, severe MR with reduced left ventricular ejection fraction (LVEF) presented with painless hematuria and symptomatic anemia. Repair was performed with a 30-mm annuloplasty ring and creation of three NeoChords to the A2 and A3 sections of the anterior leaflet. Labs showed evidence of hemolytic anemia. Workup for other etiologies of hemolysis, including autoimmune, congenital, drug-induced, were negative. Transthoracic echocardiogram (TTE) showed a moderately reduced LVEF and severe MR. Transesophageal echocardiogram (TEE) confirmed severe MR with an incompetent MV ring, an anteriorly directed jet, and partial flail of the posterior leaflet due to chordal rupture. Systolic flow reversal was present on pulmonary vein doppler. Patient was subsequently scheduled for repeat MV surgery with repair or replacement.
Discussion:
Hemolytic anemia due to prosthetic valves is most commonly associated with valve replacements but can also occur with valve repairs. Median interval from surgical repair to diagnosis of MAHA is three months. Echocardiographic findings may show varying grades of MR with differing regurgitant jet types. The primary mechanism of hemolysis appears to be independent of MR severity and more so from the direct collision of the regurgitant jet with the annuloplasty ring. Management includes MV replacement or re-repair.
Conclusion:
Hemolytic anemia is a rare complication that may occur following the failure of a MV repair. Early recognition is important to allow for prompt treatment and prevention of further complications. Subsequent valve replacement or repeat valve repair yields favorable outcomes for patients.
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