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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 7  |  Issue : 3  |  Page : 236-238

Hepatobiliary malignancy presenting as deranged coagulogram in postoperative mechanical valve replacement patients


Department of Cardiovascular and Thoracic Surgery, All India Institute of Medical Sciences, New Delhi, India

Date of Submission17-Apr-2021
Date of Decision26-Jul-2021
Date of Acceptance17-Oct-2021
Date of Web Publication14-Dec-2021

Correspondence Address:
Yatin Arora
Department of CTVS, CN Centre, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_20_21

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  Abstract 


Valve replacement still defines a major proportion of valvular cases in cardiothoracic surgery in a developing country like India. With most patients getting a mechanical prosthetic heart valve and dependent on lifelong anticoagulation, regular international normalized ratio (INR) monitoring is warranted to maintain the optimum range while evaluating for any adverse effects in follow-up. We describe two postoperative patients of mechanical valve replacement on anticoagulant and antiplatelet, presenting with complaints of jaundice, bleeding, and deranged INR diagnosed with hepatobiliary–pancreatic malignancies. Although deranged coagulogram is mostly resulting from dosage modification of anticoagulants and dietary modifications, it should be sought out carefully, particularly in patients with a previously stabilized profile on a similar dosage and not be dismissed on account of anticoagulant therapy, especially if the patient is icteric.

Keywords: Deranged international normalized ratio, hepatobiliary–pancreatic malignancies, mechanical valves, rheumatic heart diseases


How to cite this article:
Arora Y, Kar T, Devagourou V. Hepatobiliary malignancy presenting as deranged coagulogram in postoperative mechanical valve replacement patients. J Pract Cardiovasc Sci 2021;7:236-8

How to cite this URL:
Arora Y, Kar T, Devagourou V. Hepatobiliary malignancy presenting as deranged coagulogram in postoperative mechanical valve replacement patients. J Pract Cardiovasc Sci [serial online] 2021 [cited 2022 Aug 17];7:236-8. Available from: https://www.j-pcs.org/text.asp?2021/7/3/236/332486




  Introduction Top


Cardiovascular diseases are the leading cause of death in India.[1] Valvular heart disease shares a major burden of cardiovascular disease, in which rheumatic heart disease (RHD) is the major contributor while other important contributors are degenerative valve disease, bicuspid valves, infective etiology, myxomatous degeneration, or organic valvular disease.[2] The prevalence of RHD in India is 1.5–2 per 1000 individual.[3] Apart from preventing strategies and medical management, surgical management is an integral part of treatment of which valve replacement remains the most common procedure done.[4] Patient with RHD requiring valve replacement may present at any age; however, majority of patients affected by RHD belong to young population; mechanical valve (MV) is the most common choice for patients as well as surgeons. These patients with MV are dependent on lifelong anticoagulation with the need of constant monitoring of international normalized ratio (INR) and to be vigilant for adverse effects. Although patients often need titration for INR, spurious test results are seldom and any such result or clinical feature should raise a suspicion.


  Case Reports Top


Case 1

A 52-year-old female underwent double valve replacement (#33 St Jude mechanical [SJM] mitral valve replacement [MVR] + #21 SJM mechanical aortic valve replacement [AVR]) for RHD with severe mitral regurgitation and moderate calcific aortic stenosis, with ejection fraction of 35%, done in January 2019, with preoperative blood workup within normal limit.

She was discharged on postoperative day 8 with uneventful postoperative stay, with stable INR and called to follow-up in 1 week, 1 month, 3 months, and then 6 monthly in outdoor clinic. She was followed up in the outpatient department at 1 week, 1 month, and 3 months, with no major complaints, and INR was titrated as per reports and maintained in range; cineflouroscopy showed normal valve movement.

Ten months postsurgery, she presented in emergency with complaints of blackish discoloration of skin and blood tinged sputum for 3 days. All emergency blood investigations were sent, and the patient was admitted for management of deranged INR.

On examination, she had ecchymosis all over body, icterus was present, valve click was present, and rest system examination was within normal limits.

Blood workup revealed a very high INR and deranged liver function test (LFT) with total bilirubin (11.94 mg/dl) and direct bilirubin (9.38 mg/dl) and elevated alkaline phosphatase level (401 I.U).

On ultrasonography (USG) abdomen, dilated intrahepatic biliary radicals (IHBRDs) were dilated with nonpatent primary confluence. Contrast-enhanced computed tomography (CECT) revealed gross bilateral IHBRD with small intraluminal heterogeneous lesion in primary biliary confluence, suggestive of cholangiocarcinoma [Figure 1]. CA 19-9 was elevated (103 U/ml).
Figure 1: Computed tomography abdomen showing dilated intrahepatic biliary radicals with nonpatent primary confuence.

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As per opinion from gastrosurgery department, percutaneous drainage of biliary ducts was done under radiological guidance to relieve obstructive jaundice, and the patient is planned for resection.

Case 2

A 60-year-old female underwent coronary artery bypass grafting and AVR (#19 mm SJM regent) for coronary artery disease with triple-vessel disease, having severe calcific aortic stenosis in February 2019. Preoperative blood work was normal. The patient was discharged on postoperative day 6 after titrating anticoagulants to optimum range.

The patient was then followed up at 1 week and 1 month postoperatively as per the institutional protocol, when her INR had stabilized to a fixed dose regimen and cinefluoroscopy revealed normally functioning valve.

At 6 months postoperatively, on routine evaluation, the patient's INR was found to be on lower side (despite titration to higher side earlier) while cine revealed prosthetic heart valve thrombosis. The patient was admitted and thrombolysis was done achieving normal leaflet movement and anticoagulant titrated optimally and was followed up.

At 12 months postoperatively, the patient presented to emergency for blackish spots over skin and yellowish discoloration of eyes with abdominal pain radiating to back.

On examination, ecchymosis spots were present and she was icteric. On per abdominal examination, epigastric lump of size approximately 3 cm × 3 cm was palpable, which was hard in consistency and nontender.

Blood investigation revealed high INR, with elevated total bilirubin (7.8 mg/dl) and elevated ALP of 563 I.U. Abdominal USG revealed IHBRD. CECT whole abdomen revealed a hypo-dense mass of size 4 cm × 4 cm with fat stranding s/o carcinoma head of pancreas.

The patient underwent pancreaticoduodenctomy and was discharged uneventfully after surgery.


  Discussion Top


Thromboembolism related to prosthetic heart valves is the most dreaded complication, which necessitates the need for anticoagulation. Optimum range of INR 2–3 and INR 2.5–3.5 needed to maintain postoperatively for preventing antithrombotic events in AVR and MVR, respectively, along with low-dose antiplatelet.[5] Increased INR can be attributed to either to increase dosing, recent usage of new drugs which interacts with warfarin such as antifungal agents, macrolide antibiotics, or increase in alcohol consumption and decrease in intake of Vitamin K-containing diet. It could suggest several underlying conditions causing acute decompensation of synthetic functions of liver such as infection, congestion due to tricuspid regurgitation, inflammation, malignancy, obstruction in biliary pathway, and end-stage liver disorders.

Any patient admitted with deranged INR should be thoroughly examined and especially if patient has features of jaundice should get routine investigation done, and any deviation in investigation, especially LFT, should be properly investigated.

In our setup, a vast majority of patients with valvular heart disease have rheumatic etiology come from the northern and eastern part of India, which also happen to be the belt for hepatobiliary pancreatic malignancy.[6]

A patient undergoing valve replacement may have a normal LFT and have an underlying malignancy at the same time, since derangement of LFT is not seen very early in the disease process but only when there is decompensation.

As presented in above two cases, once the patient reaches decompensation phase after developing hepatobiliary–pancreatic malignancy and continues taking anticoagulation, it can cause catastrophic bleeding which may be fatal.

Hepatobiliary pancreatic malignancies specifically pose a very difficult situation with prosthetic heart valve management, since certain conditions such as pancreatic carcinoma can themselves create a prothrombotic state while hepatobiliary malignancies may alter coagulation profile very unpredictably with erratic tendencies to bleed.[7] Any condition causing obstructive jaundice can jeopardize the normal synthetic function of liver and alter coagulation profile, with increasing the risk of thromboembolic events as well as bleeding tendency.

No clearly defined guidelines have been available in general practice for such group of patients, and no case reports of similar kind could be found.


  Conclusion Top


Patients with deranged INR should be thoroughly examined and icterus should be looked for and ruled out. If found, icteric should be thoroughly investigated to rule out sinister causes. We should Offer complete evaluation of the patient with inpatient INR management to determine the underlying etiology.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Srinath Reddy K, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet 2005;366:1744-9.  Back to cited text no. 1
    
2.
Manjunath CN, Srinivas P, Ravindranath KS, Dhanalakshmi C. Incidence and patterns of valvular heart disease in a tertiary care high-volume cardiac center: A single center experience. Indian Heart J 2014;66:320-6.  Back to cited text no. 2
    
3.
Kumar RK, Tandon R. Rheumatic fever and rheumatic heart disease: The last 50 years. Indian J Med Res 2013;137:643-58.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Choudhary SK, Talwar S, Airan B. Choice of prosthetic heart valve in a developing country. Heart Asia 2016;8:65-72.  Back to cited text no. 4
    
5.
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:e57-185.  Back to cited text no. 5
    
6.
Dhir V, Mohandas KM. Epidemiology of digestive tract cancers in India IV. Gall bladder and pancreas. Indian J Gastroenterol 1999;18:24-8.  Back to cited text no. 6
[PUBMED]    
7.
Campello E, Ilich A, Simioni P, Key NS. The relationship between pancreatic cancer and hypercoagulability: A comprehensive review on epidemiological and biological issues. Br J Cancer 2019;121:359-71.  Back to cited text no. 7
    


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