Cardiovascular Journal of Africa: Vol 26 No 3 (May/June 2015)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 3, May/June 2015 AFRICA e11
A fatal complication after repair of post-infarction
ventricular septal rupture: heparin-induced
thrombocytopenia with thrombosis
Yunus Nazli, Necmettin Colak, Bora Demircelik, Mehmet Fatih Alpay, Omer Cakir, Kerim Cagli
Abstract
Heparin-induced thrombocytopenia (HIT) is a rare but
potentially devastating and life-threatening complication
from using heparin. HIT not only causes thrombocytope-
nia, but it also carries an increased risk for fatal thrombotic
complications. In this report, we describe the case of a patient
in whom fatal HIT developed after successful surgical repair
of a posterior post-infarction ventricular septal rupture with
cardiopulmonary bypass.
Keywords: heparin, thrombocytopenia, thrombosis, post-infarc-
tion ventricular septal rupture
Submitted 25/2/14, accepted 10/1/15
Cardiovasc J Afr 2015; 26: e11–e15
DOI: 10.5830/CVJA-2015-001
Heparin-induced thrombocytopenia (HIT) is a rare but
potentially devastating and life-threatening complication of
heparin therapy. HIT not only causes thrombocytopenia, but
it also carries an increased risk for both arterial and venous
thrombotic complications, despite the administration of heparin
as an anticoagulating agent.1
HIT is associated with antibodies to a complex of heparin–
platelet factor 4 (H-PF4). HIT-associated antibodies are generally
detected after open-heart surgery.2,3 Post-infarction ventricular
septal rupture (PI-VSR) following acute myocardial infarction
has a high mortality rate and surgical repair also presents a high
risk of mortality.
In this report, we describe the case of a patient in whom fatal
HIT developed after successful surgical repair of a posterior
PI-VSR on cardiopulmonary bypass (CPB). This is rare, and a
limited number of cases have been reported following surgical
repair of a PI-VSR.
Case report
A 74-year-old man presented with chest pain to a local hospital,
from where he was transferred to our institution, with a PI-VSR.
He had been anticoagulated with unfractioned heparin (UFH)
(1 000 IU/h daily) for three days since the myocardial infarction
(MI) had occurred.
On admission, his heart rate was 92 beats/min, blood pressure
was 90/50 mmHg and weight was 85 kg. Physical examination
showed a systolic murmur at the left sternal border. Cardiac
catheterisation was performed, during which a single intravenous
dose of 2 500 units of heparin was administered. Coronary
angiography showed critical stenoses in the mid segment of
the left anterior descending artery and ostium of the second
diagonal branch, and occlusion in the distal segment of the right
coronary artery (Fig. 1A, B). The time between the onset of
acute MI and surgery was three days.
Transthoracic echocardiography revealed poor left ventricular
wall motion and a large postero-inferior ventricular septal
rupture (Fig. 1C). To prevent cardiogenic shock, intra-aortic
balloon pump assistance was initiated and anticoagulation was
continued with a heparin infusion of 500 IU/h over three hours.
Thereafter, the patient was taken to the operating room for
emergency surgery because of haemodynamic deterioration.
After induction of general anaesthesia, transoesophageal
echocardiography (TEE) was performed to evaluate the
repair of the VSR. A median sternotomy was performed.
Cardiopulmonary bypass was instituted with ascending aortic
and bicaval venous cannulation. Heparin (300 U/kg) was given
to obtain an activated clotting time of more than 400 s.
Firstly, a longitudinal transinfarction incision was made
in the left ventricular myocardium parallel to and 1 cm away
from the posterior descending artery. The post-infarction VSR
was closed with a double velour fabric polyester patch (Bard®
Debakey®, IMPRA, Inc) using a 3-0 polypropylene suture
(Ethicon, Inc, Somerville, NJ) with a teflon pledget through the
left ventricle (Fig. 1D).
The posteromedial papillary muscle was carefully inspected
and the basal portion of the posteromedial papillary muscle
Department of Cardiovascular Surgery, Faculty of
Medicine, University of Turgut Ozal, Ankara, Turkey
Yunus Nazli, MD,
Necmettin Colak, MD
Mehmet Fatih Alpay, MD
Omer Cakir, MD
Department of Cardiology, Faculty of Medicine, University
of Turgut Ozal, Ankara, Turkey
Bora Demircelik, MD
Department of Cardiovascular Surgery, Turkiye Yuksek
Ihtisas Hospital, Ankara, Turkey
Kerim Cagli, MD
Case Report