Influence of The Prosthesis Type and Diameter in The Thrombocytopenia Associated with Aortic Valve Replacement Surgery

Document Type : Original Article


1 Department of Cardiovascular Surgery, CMN “20 de Noviembre”, ISSSTE, Mexico.

2 Department of Cellular and Tissue Biology, Faculty of Medicine, UNAM, Mexico.


Introduction: Aortic valve replacement with either mechanical or bioprosthetic valves is the gold standard treatment for severe aortic stenosis. Unfortunately, enhanced bleeding and hemodynamic decompensation thrombocytopenia is a frequent postoperative complication. The latter could be secondary to the shearing effect of mechanical prosthesis upon the blood flow that favors platelet aggregation or the presence of thrombogenic materials such as glutaraldehyde used to preserve bioprosthetic valves. Our aim was to discern which type of valve is associated with a more severe post-surgery thrombocytopenia so we compared postoperative platelet counts in patients treated with mechanical vs bioprosthetic valves.
Material and Method: Two hundred and fifty patients with severe aortic stenosis underwent valve replacement surgery were included in the analysis. 126 patients received a mechanical (group A) and 124 patients received a biological (group B) prosthesis. A conventional surgical procedure with Extracorporeal Life Supports (ECLS) was performed in all. Patients’ age, gender, cardiovascular risk factors, type and time length of antiaggregant treatment, size of the implanted valve, and perioperative events were recorded. Pre-surgery platelet count and daily post-surgery registers of platelets count for a 10-day period was documented.
Results: Platelet count before surgery was within normal values in both groups. There was a significant decrease the first postsurgical day in both groups (127±48 vs 224±56 in group A, and 132±45 vs 229±54 in group B, p <0.001). Normal platelet count, was reached the fourth post-surgery day in group A patients compared to the eighth day of group B. The differences in platelet count between both groups, independently of the postsurgical day, were highly significant. Thrombocytopenia remained significantly lower and did not reach normal values (141) in the 10 days follow-up in patients that received the 19 mm prosthesis, whereas those receiving the 21 mm valves reached normal values (150) the eighth day.
Conclusion : Thrombocytopenia in patients undergoing aortic valve replacement is secondary to the synergic effect of ECLS, aldehydes present on the preservation solution of prosthesis, and the shear flow induced by the prosthesis diameter. The implant of small diameter prosthesis prolongs thrombocytopenia.


  1. Mujtaba SS, Ledingham S, Shah AR, Schueler S, Clark S, Pillay T. Thrombocytopenia after aortic valve replacement: comparison between sutureless perceval S valve and perimount magna ease bioprosthesis. Brazilian Journal of Cardiovascular Surgery. 2018 Mar;33:169-75.
  2. Santarpino G, Pfeiffer S, Concistrè G, Fischlein T. Perceval S aortic valve implantation in mini-invasive surgery: the simple sutureless solution. Interactive cardiovascular and thoracic surgery. 2012 Sep 1;15(3):357-60.
  3. Kertai MD, Zhou S, Karhausen JA, Cooter M, Jooste E, Li YJ, et al. Platelet counts, acute kidney injury, and mortality after coronary artery bypass grafting surgery. Anesthesiology. 2016 Feb;124(2):339-52.
  4. Griffin BR, Bronsert M, Reece TB, Pal JD, Cleveland JC, Fullerton DA, et al. Thrombocytopenia after cardiopulmonary bypass is associated with increased morbidity and mortality. The Annals of thoracic surgery. 2020 Jul 1;110(1):50-7.
  5. Jiritano F, Lorusso R, Santarpino G. Causes of thrombocytopenia in cardiac surgery: looking for the Holy Grail?. The Annals of Thoracic Surgery. 2020 Aug 1;110(2):751-2.
  6. Wahba A, Videm V. Heart surgery with extracorporeal circulation leads to platelet activation at the time of hospital discharge. European journal of cardio-thoracic surgery. 2003 Jun 1;23(6):1046-50.
  7. Bari G, Érces D, Varga G, Szűcs S, Varga Z, Bogáts G, et al. Methane inhalation reduces the systemic inflammatory response in a large animal model of extracorporeal circulation. European Journal of Cardio-Thoracic Surgery. 2019 Jul 1;56(1):135-42.
  8. McDonald CI, Fraser JF, Coombes JS, Fung YL. Oxidative stress during extracorporeal circulation. European Journal of Cardio-Thoracic Surgery. 2014 Dec 1;46(6):937-43.
  9. Lopez-Moya M, Melgar-Lesmes P, Kolandaivelu K, de la Torre Hernández JM, Edelman ER, Balcells M. Optimizing glutaraldehyde-fixed tissue heart valves with chondroitin sulfate hydrogel for endothelialization and shielding against deterioration. Biomacromolecules. 2018 Mar 14;19(4):1234-44.
  10. Jiritano F, Santarpino G, Serraino GF, Ten Cate H, Matteucci M, Fina D, et al. Peri-procedural thrombocytopenia after aortic bioprosthesis implant: a systematic review and meta-analysis comparison among conventional, stentless, rapid-deployment, and transcatheter valves. International Journal of Cardiology. 2019 Dec 1;296:43-50.
  11. Davies RA, Bandara TD, Perera NK, Orr Y. Do rapid deployment aortic valves improve outcomes compared with surgical aortic valve replacement?. Interactive CardioVascular and Thoracic Surgery. 2016 Nov 1;23(5):814-20.
  12. LeGuyader A, Watanabe R, Berbé J, Boumediene A, Cogné M, Laskar M. Platelet activation after aortic prosthetic valve surgery. Interactive CardioVascular and Thoracic Surgery. 2006 Feb 1;5(1):60-4.
  13. Pouplard C, May MA, Regina S, Marchand M, Fusciardi J, Gruel Y. Changes in platelet count after cardiac surgery can effectively predict the development of pathogenic heparin‐dependent antibodies. British journal of haematology. 2005 Mar;128(6):837-41.
  14. Nagrebetsky A, Al-Samkari H, Davis NM, Kuter DJ, Wiener-Kronish JP. Perioperative thrombocytopenia: evidence, evaluation, and emerging therapies. British Journal of Anaesthesia. 2019 Jan 1;122(1):19-31.
  15. Goldsmith IR, Blann AD, Patel RL, Lip GY. von Willebrand factor, fibrinogen, and soluble P-selectin levels after mitral valve replacement versus mitral valve repair. The American Journal of Cardiology. 2000 May 15;85(10):1218-22.
  16. Squiccimarro E, Labriola C, Malvindi PG, Margari V, Guida P, Visicchio G, et al. Prevalence and clinical impact of systemic inflammatory reaction after cardiac surgery. Journal of cardiothoracic and vascular anesthesia. 2019 Jun 1;33(6):1682-90.
  17. Squiccimarro E, Jiritano F, Serraino GF, Ten Cate H, Paparella D, Lorusso R. Quantitative and qualitative platelet derangements in cardiac surgery and extracorporeal life support. Journal of Clinical Medicine. 2021 Feb 6;10(4):615.
  18. Yoshimoto Y, Hasebe T, Takahashi K, Amari M, Nagashima S, Kamijo A, et al. Ultrastructural characterization of surface‐induced platelet activation on artificial materials by transmission electron microscopy. Microscopy Research and Technique. 2013 Apr;76(4):342-9.
  19. Sun W, Wang S, Chen Z, Zhang J, Li T, Arias K, et al. Impact of high mechanical shear stress and oxygenator membrane surface on blood damage relevant to thrombosis and bleeding in a pediatric ECMO circuit. Artificial organs. 2020 Jul;44(7):717-26.
  20. Fuchs G, Berg N, Broman LM, Prahl Wittberg L. Flow-induced platelet activation in components of the extracorporeal membrane oxygenation circuit. Scientific reports. 2018 Sep 18;8(1):1-9.
  21. Velho TR, Pereira RM, Fernandes F, Guerra NC, Ferreira R, Nobre Â. Bioprosthetic aortic valve degeneration: a review from a basic science perspective. Brazilian Journal of Cardiovascular Surgery. 2021 Dec 15;37:239-50.
  22. Kizilay M, Elbir F, Aglar AA, Vural U, Balci AY, Yekeler İ. An overlooked fact: thrombocytopenia following bioprosthetic aortic valve replacement. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2019 Mar 1;16(1):19-26.
  23. Campinho P, Vilfan A, Vermot J. Blood flow forces in shaping the vascular system: a focus on endothelial cell behavior. Frontiers in Physiology. 2020 Jun 5;11:552.
  24. Roka-Moiia Y, Miller-Gutierrez S, Palomares DE, Italiano JE, Sheriff J, Bluestein D, et al. Platelet dysfunction during mechanical circulatory support: elevated shear stress promotes downregulation of αIIbβ3 and GPIb via microparticle shedding decreasing platelet aggregability. Arteriosclerosis, thrombosis, and vascular biology. 2021 Apr;41(4):1319-36.
  25. Rana A, Westein E, Niego BE, Hagemeyer CE. Shear-dependent platelet aggregation: mechanisms and therapeutic opportunities. Frontiers in cardiovascular medicine. 2019 Sep 20;6:141.
  26. Deng W, Xu Y, Chen W, Paul DS, Syed AK, Dragovich MA, et al. Platelet clearance via shear-induced unfolding of a membrane mechanoreceptor. Nature communications. 2016 Sep 27;7(1):1-3.
  27. Kaul S, Makkar RR, Nakamura M, Litvack FI, Shah PK, Forrester JS, et al. Inhibition of acute stent thrombosis under high-shear flow conditions by a nitric oxide donor, DMHD/NO: an ex vivo porcine arteriovenous shunt study. Circulation. 1996 Nov 1;94(9):2228-34.