Unusual Gastrointestinal Bleeding After Sutureless Aortic Valve Replacement: A Word of Caution

摘要

We report the clinical case of a male patient who presented, after an aortic valve replacement with a rapid deployment bioprosthesis, a Heyde-like syndrome, secondary to a moderate aortic paravalvular leakage. All the digestive and hematologic investigations confirmed the diagnosis. A redo surgery to fill the paravalvular gap was accomplished and the postoperative course was uneventful, with a normalization of the biological parameters. To our knowledge, this is the first described case of such a complication with the new generation of sutureless bioprosthesis.;The Heyde syndrome, initially described in 1958, combines a calcific aortic stenosis (AS) with an occult digestive bleeding. In fact, it is an association between an intestinal angiodysplasia, frequently seen in older people, and hemostasis troubles because of the denaturation of the von Willebrand factor (vWF), in which high-weighted molecules are cut because of the hemodynamic stress in an AS flow [1, 2, 3].We report a case of an unusual gastrointestinal bleeding occurring in a patient with an aortic sutureless paravalvular leakage (PVL), cured by surgical repair of PVL. This led us to suspect a Heyde-like syndrome as observed after transcatheter aortic valve replacement (TAVR) complicated with PVL.A 77-year-old male patient with a history of metabolic syndrome, chronic kidney injury, and hypertension, but without any history of gastrointestinal bleeding, was admitted in our department for a surgical treatment of a severe AS (New York Heart Association class 2; AS murmur; aortic valve area, 0.8 cm2; maximal velocity, 4.4?m/s; and transvalvular mean gradient, 48 mm Hg).We opted for an aortic valve replacement through a J-shaped upper hemisternotomy with a rapid-deployment Edwards Intuity Elite 23-mm bioprosthesis (Edwards LifeScience, Irvine, CA). The postoperative course was uneventful. Before discharge, echocardiographic control showed mild PVL, without any hemodynamic effects.The 3-month follow-up was marked by the unexpected occurrence of iterative episodes of hematemesis and melena, leading to a severe anemia with a hemoglobin level at 5 g/dL, requiring multiple blood transfusions, up to 32 units in a month.Digestive endoscopy revealed an uncomplicated colic diverticulitis. Capsule endoscopy showed sparse areas of angiodysplasia in the small bowel without any hemorrhagic ulceration.Hematologic investigations concluded that the cause of anemia was principally iron deficiency, with discrete hemolysis and a direct bilirubin plasma level that was not increased and only scarce schizocytes found on direct examination. Coagulation vitamin K–dependent factors were normal, with a normal platelet count, but platelet occlusion time (measured by PFA-100 test) was elongated (187 s for a normal range between 68 and 121 s). A primary coagulation acquired anomaly, such as a Willebrand-like syndrome, was suspected. The Heyde-like syndrome was then evoked. Transesophageal echocardiography showed the persistence of the initial aortic PVL.After a heart team discussion, we decided to treat this PVL by a redo aortic surgery. Next, under cardiopulmonary bypass and through full sternotomy, we found a well-seated bioprosthesis with two small dehiscences (Fig?1Fig?1) associated with a large defect of endothelialization. Leaving the prosthesis in place, we easily occluded the dehiscences with mattress sutures (Fig 2Fig 2). Postoperative course was uneventful, with a discharge on the 13th postoperative day and no subsequent need for blood transfusion. The 1-year follow-up showed a complete regression of PVL. There was no recurrent gastric bleeding notified. Biological hemostasis investigations showed a normalization of the PFA-100 test.Fig 1Surgical view of the prosthesis with the endothelial defect responsible of the paravalvular leakage.;To our knowledge, this is the first reported case of a putative acquired von Willebrand syndrome caused by a paravalvular leak after sutureless aortic val