Annotations Hemolysis in Starr-Edwards mitral valve prostheses
cloth-covered
The first totally cloth-covered Starr-Edwards prostheses for the aortic valve (Series 2,300) and for the mitral valve (Series 6,300) were introduced into clinical use in 1967. Since that time these prostheses, and their subsequently introduced improved models of the same series, have come into wide usage. The incidence of thromboemboliam has been significantly reduced in comparison with previous models.‘, * It was soon noted, however, that in the case of aortic valve prostheses, the incidence and degree of hemolysis was considerably increased with the cloth-covered series.3.” An increase in this complication was not initially reported with the mitral prostheses. Indeed, Starr stated in 1970, that “chronic traumatic hemolytic anemia is unknown after mitral valve replacement with the various model ball-valve prostheses except in the presence of perivalvular leak.“’ More recently, Crexells and co-workers” found an overall incidence of hemolysis of 92 per cent among 36 patients with mitral Starr-Edwards totally cloth-covered valves, with 30 per cent showing severe hemolysis. In the study of Slater and Fell,’ there was a lower incidence, some degree of hemolysis being present in 60 per cent and marked hemolysis (as evidenced by red-cell fragmentation) in 15 per cent of 47 cases of Starr-Edwards mitral prostheses; the totally cloth-covered model “was used in most cas+ in this series. We studied 14 patie ts who had undergone mitral valve Table
replacement one-half to three years previously with StarrEdwards protheses, Model 6,310 or 6,320. Plasma hemoglobin,’ serum haptoglobinY serum lactic dehydrogenase,‘O as well as complete blood count, serum biliiubin, serum iron, iron binding capacity, and urine hemosiderin determinations were performed by the clinical laboratory.” Peripheral blood smears were screened for the presence of schistocytes by counting 200 erythrocytes. In order to rule out the possibility of hemolysis due to factors other than the prosthetic valve, the following tests were also carried out: electrophoresis of hemoglobin on cellular acetate membrane,” fetal hemoglobin by the alkali denaturation technique,” and screening for non-ABH red-cell antibodies on reference cells in saline and albumin, and with antihuman serum (antiglobulin test)‘“; the results were normal in all 14 patients. The results are listed in Table I, as well as our assessment of the degree of hemolysis based on these findings. The presence of hemosiderinuria, of low serum haptoglobin levels, and increased serum lactic dehydrogenase levels indicate that defmite hemolysis is present in all cases. The hemolysis is considered marked in one case and moderate in three cases. It is to be noted that most of the patients had received oral iron and folic acid therapy at some time, which probably explains the absence an severe anemia in any of them; nevertheless, five of the patients were iron deficient. In none of the cases
I Iron Reticulocytes &J
1
Schistocytes Urine (per 200 hemosidRBC) erin
Plasma hemoglobin (mg. 73)
Serum iron @g/l00 ml.)
binding capacity (&q/100 ml.)
210 370 396
60 85 25
332
Haptoglobin L.D.H. (mg. 90) (units)
11.7 16.8 12.2
36
49 38
2.8 1.6 1.6
0 0 1
+
2 3 4 5 6
11.2 11.2 10.3
36 36 35
2.6 4.0 3.0
1 1 0
+ + +
2.7
8.8
0.9
310 360 227
70 127 48
415 587
5.4
10.0 9.1
7
11.6
41
1.0
1
+
2.3
9.4
430
48
410
8 9
10.6
42 35
2.6 2.6
8 2
++ +
7.3 15.0
16.4
315
8.5
470
277 35
524 385
10 11 12
15.5 12.0 13.6
1.0
1
0.2 12.3 0.8
10.9 9.7 19.8
270 360 480
66 118
43
2 2
+ + +
231
2.2 3.0
13 14
13.8 13.0
46 40
2.6
1
2.8 1.3
239
112
2
f +
12.0
1.4
11.2
304
11.9
American
Heart
42 40
Journal
+ -I-
12.8 3.0 1.7
9.4 13.2
13.2
445
373
383
30 90
392 270
~~
.-~-
- ..~ - ..~
Hemol-vsis Moderate Mild Mild with iron deficiency Mild Mild Mild with iron deficiency Mild with iron deficiency Marked Moderate with iron deficiency Mild Moderate Mild with iron deficiency Mild Mild
405
Annotations was there any clinical evidence of malfunction of the prosthesls. Our findings confirm the definite association of chronic hemolysis with the totally cloth-covered Starr-Edwards mitral prostheses. Although the hemolysis is not usually severe, these patients frequently develop iron deficiency which can lead to serious anemia. It is to be emphasized, therefore, that patients with cloth-covered mitral prostheses, as well as those with aortic prostheses, must be carefully. followed hematologically. Iron and folic acid therapy is necessary in many of the cases in order to prevent anemia which may further compromise their hemodynamic status. K. L. Wanderman, M.D. A. Dvilansky, M.D. C. Yoran, M.D. M. Gueron, M.D. Cardiac Laboratory and Hematology Service Soroka Medical Center Beer Sheva, Israel
REFERENCES
1. Starr, A.: Mitral valve replacement with ball-valve prostheses, Br. Heart J. 33 (Suppl.): 47, 1971. 2. Winter, T. Q., Reis, R. L., Glancy, D. L., et al.: Current status of Starr-Edwards cloth-covered prosthetic cardiac valves, Circulation 44 (Suppl. 2): 69, 1971. 3. Myhre, E., Dale, J., and Rasmussen K.: Erythrocyte destruction in different types of Starr-Edwards aortic ball valves, Circulation 42:515, 1970.
Physician education resuscitation
in cardiopulmonary
Cardiopulmonary resuscitation (CPR) is an integral part of emergency medical practice, dependent for its widespread application and success upon the skill of both physicians and paramedical personnel (nurses, ambulance drivers, emergency mobile units, etc.). Physicians in emergency rooms and coronary- and intensive-care unit settings are exposed to and welltrained in these methods. Other physicians for whom the use of CPR is an infrequent and sporadic event are usually less knowledgeable in this area. For this reason it seems appropriate that programs of instn&on in CPR techniques be provided continuously. Instruction in CPR ia usually made available by local and national organizations and is dependent for its success upon adequate physician attendance at their meetings. However, a larger number of physicians could more easily be reached on a repetitive and frequent basis by means of educational programs within the hospitals in which they practice. In an effort to determine to what extent this is being done, brief questionnaires were sent to the directors or administrators of hospitals in the state of Connecticut. Pertinent questions were: (1) Does your hospital have a program of instruction in cardiopulmonary resuscitation for attending physicians? (2) If
406
4. Santinga, J. T., and Kirsch, M. M.: Hemolytic anemia in the 2,396 and 2,310 series of Starr-Edwards prosthetic valves, Ann. Thorac. Surg. 14:539, 1972. 5. Arrigoni, M. G., Danielson, G. K., Mankin, H. T., and Pluth, J. R.: Aortic valve replacement with cloth-covered composit Starr-Edwards prosthesis. A review of 32 months of clinical experience, J. Thorac. Cardiovasc. Surg. 65:376, 1973. 6. Crexells, C., Aerichide, N., Bonny, Y., et al.: Factors influencing hemolysis in valve prosthesis, AY. HEART J. 84:161, 1972. 7. Slater, S. D., and Fell, G. S.: Intravascular hemolysis and urinary iron losses after replacement of heart valves by a prosthesis, Clin. Sci. 42545, 1972. 8. Crosby, W. H., and Furth, F. W.: A modification of the be&dine method for measurement of hemoglobin in plasma and urine, Blood 11:380, 1956. 9. Connell, G. E., and Smithies, 0.: Plasma haptoglobins, estimation and purification, Biochem. J. 72:115, 1959. 10. Wootton, I. D. P.: Micro-analysis in medical biochemistry, ed. 4, London, 1964, J. A. Churchill Ltd., p. 117. 11. Dacie, J. V.: Practical hematology, London, 1968, J. A. Churchill Ltd. 12. Singer, K., Chemoff, A. I., and Singer, L.: Studies on abnormal hemoglobins. I. Their demonstration in sickle cell anemia and other hematologic disorders by means of alkali denaturation, Blood 6:413, 1951. 13. Technical methods and procedures of the American Association of Blood Banks, ed. 5, Chicago, 1970, American Association of Blood Banks.
the answer to question 1 is yes, is participation mandatory? (3) Is there a hospital bylaw or regulation concerning this? Table I analyzes the answers to these questions by hospital size. Only those hospitals with a positive reply to question 1 recorded an answer to questions 2 and 3. Responses were received from all 41 of the hospitals to whom the questionnaire was sent (Table I). Fifteen hospitals indicated that there was a CPR training program for attending staff in existence at their institution. Twenty-six had no such program or did not answer the question, although several responses indicated that they were in the process of arranging one. In only four hospitals was attendance mandatory, in two of which it was apparently a hospital rule or bylaw. A few hospitals stated that there was a program for housestaff, nurses, and emergency teams, but none for the attending medical staff. A breakdown of hospitals by size revealed a similar frequency of CPR programs in both large and small institutions (Table I). No attempt was made in this survey to analyze program content, which varied from sporadic to regularly held meetings utilizing standard demonstration manikins, discussions, lectures, slides, and movies. It behooves all physicians to be thoroughly competent in
September,
1975, Vol. 90, NO. 3
cloth-covered
The first totally cloth-covered Starr-Edwards prostheses for the aortic valve (Series 2,300) and for the mitral valve (Series 6,300) were introduced into clinical use in 1967. Since that time these prostheses, and their subsequently introduced improved models of the same series, have come into wide usage. The incidence of thromboemboliam has been significantly reduced in comparison with previous models.‘, * It was soon noted, however, that in the case of aortic valve prostheses, the incidence and degree of hemolysis was considerably increased with the cloth-covered series.3.” An increase in this complication was not initially reported with the mitral prostheses. Indeed, Starr stated in 1970, that “chronic traumatic hemolytic anemia is unknown after mitral valve replacement with the various model ball-valve prostheses except in the presence of perivalvular leak.“’ More recently, Crexells and co-workers” found an overall incidence of hemolysis of 92 per cent among 36 patients with mitral Starr-Edwards totally cloth-covered valves, with 30 per cent showing severe hemolysis. In the study of Slater and Fell,’ there was a lower incidence, some degree of hemolysis being present in 60 per cent and marked hemolysis (as evidenced by red-cell fragmentation) in 15 per cent of 47 cases of Starr-Edwards mitral prostheses; the totally cloth-covered model “was used in most cas+ in this series. We studied 14 patie ts who had undergone mitral valve Table
replacement one-half to three years previously with StarrEdwards protheses, Model 6,310 or 6,320. Plasma hemoglobin,’ serum haptoglobinY serum lactic dehydrogenase,‘O as well as complete blood count, serum biliiubin, serum iron, iron binding capacity, and urine hemosiderin determinations were performed by the clinical laboratory.” Peripheral blood smears were screened for the presence of schistocytes by counting 200 erythrocytes. In order to rule out the possibility of hemolysis due to factors other than the prosthetic valve, the following tests were also carried out: electrophoresis of hemoglobin on cellular acetate membrane,” fetal hemoglobin by the alkali denaturation technique,” and screening for non-ABH red-cell antibodies on reference cells in saline and albumin, and with antihuman serum (antiglobulin test)‘“; the results were normal in all 14 patients. The results are listed in Table I, as well as our assessment of the degree of hemolysis based on these findings. The presence of hemosiderinuria, of low serum haptoglobin levels, and increased serum lactic dehydrogenase levels indicate that defmite hemolysis is present in all cases. The hemolysis is considered marked in one case and moderate in three cases. It is to be noted that most of the patients had received oral iron and folic acid therapy at some time, which probably explains the absence an severe anemia in any of them; nevertheless, five of the patients were iron deficient. In none of the cases
I Iron Reticulocytes &J
1
Schistocytes Urine (per 200 hemosidRBC) erin
Plasma hemoglobin (mg. 73)
Serum iron @g/l00 ml.)
binding capacity (&q/100 ml.)
210 370 396
60 85 25
332
Haptoglobin L.D.H. (mg. 90) (units)
11.7 16.8 12.2
36
49 38
2.8 1.6 1.6
0 0 1
+
2 3 4 5 6
11.2 11.2 10.3
36 36 35
2.6 4.0 3.0
1 1 0
+ + +
2.7
8.8
0.9
310 360 227
70 127 48
415 587
5.4
10.0 9.1
7
11.6
41
1.0
1
+
2.3
9.4
430
48
410
8 9
10.6
42 35
2.6 2.6
8 2
++ +
7.3 15.0
16.4
315
8.5
470
277 35
524 385
10 11 12
15.5 12.0 13.6
1.0
1
0.2 12.3 0.8
10.9 9.7 19.8
270 360 480
66 118
43
2 2
+ + +
231
2.2 3.0
13 14
13.8 13.0
46 40
2.6
1
2.8 1.3
239
112
2
f +
12.0
1.4
11.2
304
11.9
American
Heart
42 40
Journal
+ -I-
12.8 3.0 1.7
9.4 13.2
13.2
445
373
383
30 90
392 270
~~
.-~-
- ..~ - ..~
Hemol-vsis Moderate Mild Mild with iron deficiency Mild Mild Mild with iron deficiency Mild with iron deficiency Marked Moderate with iron deficiency Mild Moderate Mild with iron deficiency Mild Mild
405
Annotations was there any clinical evidence of malfunction of the prosthesls. Our findings confirm the definite association of chronic hemolysis with the totally cloth-covered Starr-Edwards mitral prostheses. Although the hemolysis is not usually severe, these patients frequently develop iron deficiency which can lead to serious anemia. It is to be emphasized, therefore, that patients with cloth-covered mitral prostheses, as well as those with aortic prostheses, must be carefully. followed hematologically. Iron and folic acid therapy is necessary in many of the cases in order to prevent anemia which may further compromise their hemodynamic status. K. L. Wanderman, M.D. A. Dvilansky, M.D. C. Yoran, M.D. M. Gueron, M.D. Cardiac Laboratory and Hematology Service Soroka Medical Center Beer Sheva, Israel
REFERENCES
1. Starr, A.: Mitral valve replacement with ball-valve prostheses, Br. Heart J. 33 (Suppl.): 47, 1971. 2. Winter, T. Q., Reis, R. L., Glancy, D. L., et al.: Current status of Starr-Edwards cloth-covered prosthetic cardiac valves, Circulation 44 (Suppl. 2): 69, 1971. 3. Myhre, E., Dale, J., and Rasmussen K.: Erythrocyte destruction in different types of Starr-Edwards aortic ball valves, Circulation 42:515, 1970.
Physician education resuscitation
in cardiopulmonary
Cardiopulmonary resuscitation (CPR) is an integral part of emergency medical practice, dependent for its widespread application and success upon the skill of both physicians and paramedical personnel (nurses, ambulance drivers, emergency mobile units, etc.). Physicians in emergency rooms and coronary- and intensive-care unit settings are exposed to and welltrained in these methods. Other physicians for whom the use of CPR is an infrequent and sporadic event are usually less knowledgeable in this area. For this reason it seems appropriate that programs of instn&on in CPR techniques be provided continuously. Instruction in CPR ia usually made available by local and national organizations and is dependent for its success upon adequate physician attendance at their meetings. However, a larger number of physicians could more easily be reached on a repetitive and frequent basis by means of educational programs within the hospitals in which they practice. In an effort to determine to what extent this is being done, brief questionnaires were sent to the directors or administrators of hospitals in the state of Connecticut. Pertinent questions were: (1) Does your hospital have a program of instruction in cardiopulmonary resuscitation for attending physicians? (2) If
406
4. Santinga, J. T., and Kirsch, M. M.: Hemolytic anemia in the 2,396 and 2,310 series of Starr-Edwards prosthetic valves, Ann. Thorac. Surg. 14:539, 1972. 5. Arrigoni, M. G., Danielson, G. K., Mankin, H. T., and Pluth, J. R.: Aortic valve replacement with cloth-covered composit Starr-Edwards prosthesis. A review of 32 months of clinical experience, J. Thorac. Cardiovasc. Surg. 65:376, 1973. 6. Crexells, C., Aerichide, N., Bonny, Y., et al.: Factors influencing hemolysis in valve prosthesis, AY. HEART J. 84:161, 1972. 7. Slater, S. D., and Fell, G. S.: Intravascular hemolysis and urinary iron losses after replacement of heart valves by a prosthesis, Clin. Sci. 42545, 1972. 8. Crosby, W. H., and Furth, F. W.: A modification of the be&dine method for measurement of hemoglobin in plasma and urine, Blood 11:380, 1956. 9. Connell, G. E., and Smithies, 0.: Plasma haptoglobins, estimation and purification, Biochem. J. 72:115, 1959. 10. Wootton, I. D. P.: Micro-analysis in medical biochemistry, ed. 4, London, 1964, J. A. Churchill Ltd., p. 117. 11. Dacie, J. V.: Practical hematology, London, 1968, J. A. Churchill Ltd. 12. Singer, K., Chemoff, A. I., and Singer, L.: Studies on abnormal hemoglobins. I. Their demonstration in sickle cell anemia and other hematologic disorders by means of alkali denaturation, Blood 6:413, 1951. 13. Technical methods and procedures of the American Association of Blood Banks, ed. 5, Chicago, 1970, American Association of Blood Banks.
the answer to question 1 is yes, is participation mandatory? (3) Is there a hospital bylaw or regulation concerning this? Table I analyzes the answers to these questions by hospital size. Only those hospitals with a positive reply to question 1 recorded an answer to questions 2 and 3. Responses were received from all 41 of the hospitals to whom the questionnaire was sent (Table I). Fifteen hospitals indicated that there was a CPR training program for attending staff in existence at their institution. Twenty-six had no such program or did not answer the question, although several responses indicated that they were in the process of arranging one. In only four hospitals was attendance mandatory, in two of which it was apparently a hospital rule or bylaw. A few hospitals stated that there was a program for housestaff, nurses, and emergency teams, but none for the attending medical staff. A breakdown of hospitals by size revealed a similar frequency of CPR programs in both large and small institutions (Table I). No attempt was made in this survey to analyze program content, which varied from sporadic to regularly held meetings utilizing standard demonstration manikins, discussions, lectures, slides, and movies. It behooves all physicians to be thoroughly competent in
September,
1975, Vol. 90, NO. 3
