Haemostatic management for aortic valve replacement in a patient with advanced liver disease

摘要

Redo-sternotomy and aortic valve replacement in patients with advanced liver disease is rare and associated with a prohibitive morbidity and mortality.Refractory coagulopathy is common and a consequence of intense activation of the coagulation system that can be triggered by contact of blood with the cardiopulmonary bypass circuitry,bypass-induced fibrinolysis,platelet activation and dysfunction,haemodilution,surgical trauma,hepatic decompensation and hypothermia.Management can be further complicated by right heart dysfunction,porto-pulmonary hypertension,poor myocardial protection,and hepato-renal syndrome.Complex interactions between coagulation/fibrinolysis and systemic inflammatory response syndrome reactions like“post-perfusion-syndrome”also compound haemostatic failure.Given the limited information available for the specific management and prevention of cardiopulmonary bypass-induced haemostatic failure,this report serves to guide the anaesthesia and medical management of future cases of a similar kind.We discuss our multimodal management of haemostatic failure using pharmacological strategies,thromboelastography,continuous cerebral and liver oximetry,and continuous cardiac output monitoring.