BACKGROUND
Chronic lymphatic leukemia (LLC) is a common disease among elderly individuals proliferation of immunologically incompetent lymphocytes, with accumulation in the bone marrow, liver, spleen and lymph nodes.

Cardiopulmonary bypass (CBP) and surgical trauma cause altered activation of the inflammatory response. This results in changes in counts and properties of lymphocytes that can cause catastrophic results.


CASE REPORT
A-78-years-old woman was referred for mitral and aortic valve replacement for increase of her dyspnea and NYHA functional class.
Medical history included aortic valve replacement 10 years before for rheumatic degeneration, hypertension, dyslipidemia, chronic atrial fibrillation and LLC-B (stage Binet C) treated with chlorambucyl until 6 months before.
Preoperative investigations revealed a 70% of infiltration of the bone marrow (biopsy) and 90% infiltration in myelogram. 
Preoperative laboratory values in Table 2.

Double valve replacement was performed with mechanical prosthesis.  The patient came off CPB easily but early in postoperative time had a major bleeding requering massive transfusion, with low output state, acute renal injuruy (AKIN 2) and low airway infection. 
Stability was achived by fourth day postoperative and she was returned to the ward on anticoagulation with UFH. By fifth day , WBC achived a total count of 56.940x109/L (lymphocytes 43.720x109/L) and no treatment was ordered because of lack of symptoms.

Late on the eleven postoperative day, her condition deteriorate to acute pulmonary oedema. Transesophageal echocardiogram showed an acute right ventricular  failure and a severe increase of median transmitral gradient (25mmHg). A pulmonary catheter revealed an C.I 1.4 L/min/m2 and a pulmonary capillary wedge pressure of 40mmHg. Laboratory values in Table 2.
An acute reactivation of LLC was diagnosed and the patient died some hours later.

DISCUSSION
Some authors have reported good postoperative outcomes in LLC patients. Main complications are coagulation disorders and infection. However, inflammatory stress of surgery and response to CPB is unpredictable,  and postoperative course is unknown. A good preoperative selection and carefully monitoring of WBC is required to avoid catastrophic results by reactivation.


06 / ACUTE AND CATASTROPHIC REACTIVATION OF CHRONIC LYMPHATIC LEUKEMIA AFTER CARDIAC SURGERY.