Coronary artery bypass grafting in a patient with active idiopathic cryoglobulinemia: revisiting the issue

Abstract

BackgroundCryoglobulinemia is a cold-reactive autoimmune disease. It is of distinctive importance in cardiac surgery because of the use of hypothermic cardiopulmonary bypass (CPB). Cryoglobulins, which activate at variable levels of hypothermia, can cause precipitation during surgery leading to possibly severe leukocytoclastic or necrotizing vasculitis, clinically manifested as ischemic events, such as cutaneous ulcerations, glomerulonephritis, arthritis, or peripheral neuropathies among the most reported associated comorbidities. Management of CPB and systemic protection in this rare but unique scenario requires individualized planning. We report the case of a patient with active cryoglobulinemia who was preoperatively managed with plasmapheresis. He underwent hypothermic coronary bypass with no precipitation and flare during and after surgery.Case presentationWe describe the case of a 59-year-old Caucasian male with clinically significant idiopathic cryoglobulinemia and history of recurrent skin lesions and toe amputations secondary to cold exposure. He presented with 2-h duration of chest pain and new onset atrial fibrillation. After cardiac catheterization, a diagnosis of three-vessel coronary artery disease was established and coronary artery bypass grafting (CABG) was scheduled. Because of a high risk of flare-up during surgery, the patient was preemptively treated with two sessions of plasmapheresis before bypass. He then underwent hypothermic CABG. The pre- and perioperative course was unremarkable without any clinical evidence of precipitation. The patient was discharged on day 6 postoperatively without any complications.ConclusionPreoperative plasmapheresis before hypothermic coronary bypass can prevent fatal cryoglobulinemia-related complications in patients with active disease.

Literature review of apheresis procedures performed perioperatively in cardiac surgery for ASFA category indications

“…33 There no reported complications in the postoperative period and none were diagnosed with exacerbation of hemolysis. [29][30][31][32][33]…”

“…In one patient, TPE cycles were continued intraoperatively and postoperatively . There no reported complications in the postoperative period and none were diagnosed with exacerbation of hemolysis …”

“…The severity of the hemolysis varies according to antibody titer, thus preoperative TPE could represent an effective treatment approach in selected patients by reduction of the cold agglutinins titers . Comparably TPE has also been used preoperatively in patients with cryoglobulins . In all cases TPE was performed preoperatively and the most common replacement fluid was 5% human albumin, in some cases combined with FFP .…”

“…In all cases TPE was performed preoperatively and the most common replacement fluid was 5% human albumin, in some cases combined with FFP . In one patient, TPE cycles were continued intraoperatively and postoperatively . There no reported complications in the postoperative period and none were diagnosed with exacerbation of hemolysis …”

“…27,31,32 Comparably TPE has also been used preoperatively in patients with cryoglobulins. 33,34 In all cases TPE was performed preoperatively and the most common replacement fluid was 5% human albumin, [29][30][31][32] in some cases combined with FFP. [29][30][31] In one patient, TPE cycles were continued intraoperatively and postoperatively.…”