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Case Report
32 (
1
); 67-69
doi:
10.25259/VJIM_7_2021

An Unusual Case of Hyperbilirubinaemia Post Mitral Valve Replacement Surgery in a Tertiary Care Centre

Departments of Consultant Physician, Central India Cardiology Hospital and Research Institute, Nagpur, Maharashtra, India
Interventional Cardiologist, Central India Cardiology Hospital and Research Institute, Nagpur, Maharashtra, India
CVTS Surgeon, Central India Cardiology Hospital and Research Institute, Nagpur, Maharashtra, India
Consultatnt Gastroenterologist, Central India Cardiology Hospital and Research Institute, Nagpur, Maharashtra, India
Corresponding author: Dr Anil R. Jawahirani, Interventional Cardiologist, Central India Cardiology Hospital and Research Institute, Nagpur, Maharashtra, India. anilramesh123@rediffmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Mangalgiri A, Jawahirani AR, Sharma A, Washimkar S, Dongre L. An unusual case of hyperbilirubinaemia post mitral valve replacement surgery in a tertiary care centre. Vidarbha J Intern Med 2022; 32:67-9.

Abstract

Seven cases of MVR have been performed in this newly opened tertiary Care Centre till now. We present an unusual case of a 52 year old female who underwent MVR and developed hyperbilirubinaemia on 2nd postoperative day. This laso revrted the next day without any permanant sequelae. Our patient was asymptomatic through the process.

Keywords

Hyperbilirubinaemia
Post mitral valve replacement surgery

INTRODUCTION

Postoperative hyperbilirubinemia after cardiac surgery using cardiopulmonary bypass is a relatively infrequent event but may result in significantly increased adverse outcomes. The preoperative identification of patients at an increased risk for developing postoperative hyperbilirubinemia may allow heightened vigilance during the perioperative period and earlier diagnosis and intervention, possibly improving outcome. Hyperbilirubinemia was reported in early studies to occur in about 10% of patients after cardiac surgery. More recent studies estimate the incidence of postoperative hyperbilirubinemia to be more than 20% or even as high as 51% and may be associated with a mortality up to 25%.

CASE REPORT

A 52-year-old woman, a known case of rheumatic heart disease with severe mitral stenosis, was admitted for mitral valve replacement surgery. On the 2nd post-operative day, she developed jaundice, which peaked in the evening of the same day. The patient’s clinical examination was inconsistent with the total bilirubin of 11.7 mg/dl in the morning, and it increased to 13.5 mg/dl in the evening. Her abdominal examination was normal, no signs of circulatory failure was noted. The bilirubin levels dropped drastically on the 3rd post-operative day to 9.8 mg/dl in the morning and 2.7 mg/dl in the evening. Alkaline phosphatase levels were normal. The viral markers were normal. The USG abdomen did not reveal any dilatation in the intra- and extra-hepatic biliary system.

DISCUSSION

Hyperbilirubinaemia has been reported in several studies in the early post-operative period after cardiac surgery with a varying incidence between 10% and 40%.[1-3] Post-operative hyperbilirubinaemia remains a serious concern, despite marked improvement in cardiopulmonary bypass (CPB) strategies giving worse post-operative outcomes.[4,5] If liver dysfunction is an effect of CPB-associated factors that is, haemolysis, hypoperfusion, or systemic inflammatory response, it remains to be asserted.[1,6,7] Many studies were done for identifying the incidence of post-operative jaundice, following cardiac surgery. While transient moderate hyperbilirubinaemia is usually associated with a favourable outcome, late occurring ascending hyperbilirubinaemia was associated with higher mortality and morbidity.[8] The incidence of post-operative jaundice after valvular replacement/reconstruction[9] is 17.5%. According to some studies in post-operative hyperbilirubinaemia, 70% of the increase of total bilirubin was on the 1st post-operative day which was from an increase in unconjugated bilirubin.[1] The significant risk factors being, the number of valves replaced, pre-operative right atrial pressure, and pre-operative total bilirubin concentration; these in combination correctly predict the occurrence of post-operative hyperbilirubinaemia in 80% of the patients and this is associated with a high rate of in-hospital mortality. In patients with heart failure and liver dysfunction, meticulous operative measures are needed to reduce the CPB time and transfusions.[10] The pathogenesis of liver dysfunction after cardiac surgery is multifactorial. Varghese et al. stated that alterations in hepatic blood flow are a major factor in the pathogenesis of post-operative hepatic function dysfunction.[11] Collins et al. postulated that failure of the canalicular excretion of bilirubin was the main cause of conjugated hyperbilirubinaemia.[2]

Laboratory parameters
25-06 29-06 29-06 30-06 30-06 01-07 02-07 03-07
Hb 12.2 13.6 12.8
TLC 9800 38,000 29,600 20,260 11,210 12,630
Urea 16 36 32
Creat 0.8 1.1 1.0
Na 139 138 140
K 4.2 3.7 3.9
INR 1.1 2.17
T.Bil 0.3 11.7 19.5 9.8 2.7 5.1 2.5 2.1
Direct 0.2 7.3 13.5 6.2 2.6 3.2 1.8 1.9
Indirect 0.1 4.4 6.2 3.6 0.1 1.9 1.7 0.2
SGOT 18 89 83 62 53 41 46 72
SGPT 13 23 21 22 29 21 32 66
Protein 7.9 6.8 6.5 6.0 5.1 5.1 6.4 7.5
Albumin 4.1 3.6 3.4 3.4 3.0 3.2 3.1 4.3
Globulin 3.8 3.2 3.1 2.6 2.1 1.9 3.3 3.2
Alkaline phosphatase 89 82 88 103 144 114 87 101
Ammonia 35.1

Out of the total 121 cardiac surgeries in our centre and seven MVR surgeries, this was the only unusual case where we found a sudden raise in total bilirubin on the 2nd postoperative day with a sharp dip the following day. The patient was asymptomatic throughout.

CONCLUSION

Post-operative hyperbilirubinaemia remains a serious concern, despite marked improvement in CPB strategies with poor outcomes. Efforts to reduce the cardiopulmonary bypass time and transfusions specifically in patients with heart failure or liver dysfunction along with meticulous postoperative management are required. This was a rare case, which had an unusual presentation, with a good outcome.

Declaration of patient consent

Consent of Legally authorised Representative has been taken.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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