Cold agglutinins complicating repair of aortic dissection using cardiopulmonary bypass and hypothermic circulatory arrest: case report and review

Hoffman, John W.; Gilbert, Timothy B.; Hyder, Michael

doi:10.1191/0267659102pf601cr

Cited by 23 publications

(14 citation statements)

References 21 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Complications after CA activation can include cerebral insult, ischemia due to microvascular occlusion, hemolysis, and renal and hepatic dysfunction. 8 In this patient, agglutination causing obstruction of the coronary circulation was a feared complication. Appropriate screening with CA titers and thermal threshold has been recommended for patients undergoing cardiac surgery who are suspected to be at risk.…”

Section: Discussionmentioning

confidence: 82%

Cardiopulmonary Bypass Management Complicated by a Stenotic Coronary Sinus and Cold Agglutinins

Yalamuri

Heath

McCartney

et al. 2017

Journal of Cardiothoracic and Vascular Anesthesia

View full text Add to dashboard Cite

Anesthesiology and Veteran Affairs Anesthesiology, Durham, NC COLD AGGLUTININS (CA) are circulating autoantibodies that reversibly bind red blood cells, causing agglutination and increased blood viscosity. 1 Because cardiopulmonary bypass (CPB) can involve deliberate hypothermia of the systemic and coronary circulations, the adverse sequelae of CA have been feared and reported under such conditions. The authors present a case of successful perioperative management of a patient in whom CA activation was diagnosed after the initiation of CPB for coronary artery bypass grafting (CABG) and aortic valve replacement (AVR). This patient also had a stenotic coronary sinus (CS), adding to the complexity of management of CPB and administration of cardioplegia. Patient permission was obtained for the publication of this case report. DescriptionA 67-year-old man with moderate-to-severe aortic stenosis (mean gradient 36 mm/s) and multivessel coronary artery disease presented for CABG and AVR. Preoperative workup revealed preserved biventricular function with moderate left ventricular hypertrophy, 80% stenosis of the proximal left main coronary artery, and 99% stenosis of the proximal right coronary artery. He previously underwent an uneventful anesthetic for carotid artery bypass in preparation for his cardiac surgery. After placement of a radial artery catheter for pressure monitoring, anesthesia was induced with midazolam, fentanyl, lidocaine, propofol, and rocuronium. Aminocaproic acid was used for antifibrinolysis, with a 10-g bolus dose followed by a 5-g dose infused over 5 hours. Vein graft harvest and central aortic arterial and bicaval venous cannulation were uneventful.After an activated coagulation time of 4400 seconds was achieved, CPB was initiated. Because of CS stenosis (confirmed by the small ostial opening on transesophageal echocardiography [TEE]), a retrograde catheter could not be placed even under direct vision with bicaval cannulation (performed for better visualization of the coronary sinus ostia after the initial inability to cannulate). 2 Systemic perfusion was maintained at 361C inflow temperature, and the nasopharyngeal temperature approached a nadir of 351C.Before administration of cardioplegia, crystalloid cardioplegic solution (Plegisol; Hospira, Lake Forest, IL) was mixed with blood (4:1 ratio) and cooled to 4 1 C with a BCD Vanguard heat exchanger (Sorin, Milan, Italy). Within the tubing the blood separated rapidly, and large clumps of red cells were seen settling through the plasma in the tubing (Fig 1, Video 1). Because of the high index of suspicion, no cardioplegia was given, pending laboratory confirmation. A sample of blood was sent to the laboratory immediately for a rapid test for cold agglutinins. Specific cold agglutinin testing was not available immediately; however, a small amount of blood was cooled to 41C, and 4 þagglutination was observed. This information was relayed to the operating room so that the surgical plan could be altered. Subsequent testing revealed 2 þ agglutination a...

show abstract

Section: Discussionmentioning

confidence: 82%

Cardiopulmonary Bypass Management Complicated by a Stenotic Coronary Sinus and Cold Agglutinins

Yalamuri

Heath

McCartney

et al. 2017

Journal of Cardiothoracic and Vascular Anesthesia

View full text Add to dashboard Cite

show abstract

“…The reported incidence varies among studies, ranging roughly from 0.4 to 4%. The etiology of CHAD may be idiopathic, but may also be due to tumors such as lymphoma and myeloma, or infections such as Mycoplasma, Epstein-Barr virus, cytomegalovirus, Legionnaire and Escherichia coli infection [1,2,7]. Our patient complained of worsening chest pain under cold weather, following pneumonia of unknown cause.…”

Section: Discussionmentioning

confidence: 83%

Incidentally discovered cold hemagglutinin disease with massive blood clots in the cardioplegia line and coronary artery, during coronary artery bypass graft

Chung

Park

Lee

2020

J Cardiothorac Surg

View full text Add to dashboard Cite

Background: Cold hemagglutinin disease (CHAD) is a rare autoimmune disease, in which patients manifest symptoms when the body temperature decreases. It causes critical problems with blood clotting and hemolysis during hypothermia in cardiac surgery. Although various methods are recommended, the CHAD discovered incidentally during cardiac surgery is still a clinical challenge. Case presentation: A 76-year-old male visited our hospital for chest pain. Angiography revealed unstable angina, left-main and three-vessel disease. We performed coronary artery bypass graft (CABG) with cardiopulmonary bypass after heparin injection. Shortly after aorta cross-clamping (ACC) and infusion of cold blood cardioplegia, we found massive blood clots in the cardioplegia line. Upon suspicion of CHAD, we raised the temperature and infused warm blood cardioplegia in a retrograde manner. After performing cardiac arrest, we opened the coronary artery and found blood clots in the coronary artery. We eliminated the clots and washed with warm crystalloid cardioplegia simultaneously in an antegrade and retrograde manner. During the ACC, warm cardioplegia was infused every 15 min, via retrograde and antegrade techniques simultaneously. After distal anastomosis of the saphenous venous graft (SVG) to the coronary artery, we performed a direct SVG warm cardioplegia infusion. Finally, before the proximal SVG anastomosis to the aorta, we used warm cardioplegia to eliminate the remaining microemboli. The cold reactive protein test showed a positive result. The patient was discharged without any complications. Conclusion: In this rare case, we incidentally discovered CHAD associated with massive blood clots in the cardioplegia line and the coronary artery, during CABG. However, we performed CABG without any complications using a reasonable and appropriate cardioplegia infusion technique, including direct SVG warm cardioplegia infusion.

show abstract

“…The critical temperature at which this condition is elicited should be determined during preoperative evaluation. Operative strategies, such as preoperative steroid administration and plasmapheresis [2], surgery under systemic normothermia or mild hypothermia, and cardiac arrest with warm cardioplegia above the critical temperature [3] should be considered. Valvulopathy and coronary artery disease can be surgically treated under normothermic or mildly hypothermic conditions, the thermal amplitude of which is higher than that required for antibody activation [4].…”

Section: Discussionmentioning

confidence: 99%

Normothermic total arch replacement without hypothermic circulatory arrest to treat aortic distal arch aneurysm in a patient with cold agglutinin disease

Ishida

Takemura

Shimabukuro

et al. 2011

Interactive CardioVascular and Thoracic Surgery

View full text Add to dashboard Cite

Cold agglutinin disease although rare, can lead to serious complications for patients undergoing cardio-thoracic surgery, especially when cardiopulmonary bypass is applied under hypothermic circulatory arrest. We describe normothermic total arch replacement without hypothermic circulatory arrest in a patient with cold agglutinin disease. The patient tolerated all procedures well and did not develop cerebral ischemia due to surgical maneuvers or thrombotic or haemolytic complications due to cold agglutinin disease. Although endovascular aortic repair is the first choice under such complex conditions, this method could also serve as an alternative strategy when endovascular aortic repair is precluded.

show abstract

Cold agglutinins complicating repair of aortic dissection using cardiopulmonary bypass and hypothermic circulatory arrest: case report and review

Cited by 23 publications

References 21 publications

Cardiopulmonary Bypass Management Complicated by a Stenotic Coronary Sinus and Cold Agglutinins

Cardiopulmonary Bypass Management Complicated by a Stenotic Coronary Sinus and Cold Agglutinins

Incidentally discovered cold hemagglutinin disease with massive blood clots in the cardioplegia line and coronary artery, during coronary artery bypass graft

Normothermic total arch replacement without hypothermic circulatory arrest to treat aortic distal arch aneurysm in a patient with cold agglutinin disease

Contact Info

Product

Resources

About