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Postoperative bleeding from Impella insertion site: case report A 25-year-old man developed postoperative bleeding from Impella insertion site following antiplatelet therapy with tirofiban, aspirin and ticagrelor. The man had a medical history of anxiety and thrombocytosis and was on oral aspirin 81 mg/day for thrombocytosis. He presented to an emergency department with acute chest discomfort. Initial examination showed the following: a body temperature of 97.4°F, a pulse of 98 beats/min, a RR of 20 breaths/min, a BP of 192/139mm Hg, and 100% oxygen saturation on room air. A physical examination revealed a significant diaphoresis and distress. Laboratory test results were as follows: a WBC count of 19.8×103/µL, a hemoglobin concentration of of 15.5 g/dL, a platelet count of 1472×103 /µL, a PTT of 32.8 sec, and an INR of 1.1. His troponin level increased from 0.41 µg/L to 72 µg/L. An ECG revealed significant ST elevation in the anterior precordial leads, consistent with anterior ST-elevated myocardial infarction. Emergency cardiac catheterisation showed a thrombotic occlusion of the left anterior descending (LAD) artery and the right posteriolateral system, with an ejection fraction of 25%. He underwent thrombectomy and balloon angioplasty with LAD stenting. An Impella 2.5 was inserted due to severe left ventricular dysfunction with akinesia. After the procedure, he was continued on the antiplatelet agent tirofiban [Aggrastat], in addition to a loading dose of dual antiplatelet therapy with aspirin and ticagrelor [routes and dosages not stated]. He started bleeding from the Impella insertion site, and the bleeding could not be controlled despite femostop or manual pressure application. Despite placement of a 50-pound bag, blood constantly oozed from the site, but there was no active bleeding at any other site. He was suspected of having underlying acquired Von Willebrand’s syndrome (AVWS) secondary to his triple-negative essential thrombocythaemia and addition to acute platelet dysfunction secondary to treatment with aspirin and ticagrelor resulted in postoperative bleeding. Further testing during hospitalisation revealed low von Willebrand factor ristocetin cofactor activity, consistent with AVWS. The man was further treated with emergency plateletpheresis. Further workup showed that he was triple-negative for JAK2, MPL, and CALR gene mutations. Two weeks after discharge, his platelet count was 1393×103/µL and decreased significantly to 652×103/µL three months after discharge. He was then continued with the treatment with aspirin and ticagrelor. Kanderi T, et al. Triple-negative essential thrombocythemia complicated by thrombosis and acquired von willebrand disease in a young man. American Journal of Case 803501764 Reports 21: 1-5, Jan 2020. Available from: URL: http://doi.org/10.12659/AJCR.924560

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Reactions 19 Sep 2020 No. 1822