Aortic Valve Replacement to a Patient with High Titer of Cold Agglutinin

Abstract

A 60-year-old man was admitted to our hospital because of aortic stenosis with a peak pressure gradient of 61 mmHg, moderate aortic regurgitation, and a dilatation of the ascending aorta of 50 mm in diameter, which had grown 5 mm in 2 years. Because of severe aortic stenosis with a bicuspid valve and fast progression of the ascending aorta in size, replacements of both the aortic valve and the ascending aorta were planned. He had experienced severe acute renal failure with hemolysis because of cold agglutinin one year before the operation. The hemoglobin had decreased to 4.3 g/dL during hemolytic attack. His titer of cold agglutinin was extremely high. The titer of cold agglutinin has kept above than 1:131072 at 4 degree Celsius. It once increased to 1:524288. Both the replacement of the aortic valve and the ascending aorta under normothermic cardiopulmonary bypass using intermittent warm blood cardioplegia were completed uneventfully. He was discharged from the hospital on postoperative day 11.

Normothermic Cardiac Surgery with Warm Blood Cardioplegia in Patient with Cold Agglutinins

“…Cold agglutinin disease (cold antibody disease) is caused by autoantibodies that react at decreased blood temperature and produce agglutination or hemolysis of red blood cells [1,2,3]. The causes of this situation include infections (especially mycoplasmal pneumonias or infectious mononucleosis), lymphoproliferative disorders, and idiopathic diseases (about half ofcases).…”

“…Cold agglutinin disease is of clinical importance for patients undergoing cardiac surgery procedures with hypothermic CPB and cold cardioplegia, or in other instances of therapeutic hypothermia [1,3,5]. Higher cold agglutinin titers and higher thermal amplitude are more clinically significant than low titers and low thermal amplitude.…”

“…In cases of cold agglutinins caused by acute infection, elective surgery should be postponed for several weeks until the antibody disappears. If the urgency of surgery precludes this approach, the most sensible alternative is to use either normothermia or mild hypothermia using blood temperatures continuously maintained above the thermal amplitude to avoid the active temperature range of agglutination [3,5]. Hence, the presence of cold agglutinins with a high titer may represent a reasonable indication for the use of warm cardioplegia myocardial protection techniques while maintaining normothermic systemic temperatures.…”