Seek and You Shall Find—But Then What Do You Do? Cold Agglutinins in Cardiopulmonary Bypass and a Single-Center Experience With Cold Agglutinin Screening Before Cardiac Surgery

Jain, Michael D.; Cabrerizo-Sanchez, Rosa; Karkouti, Keyvan; Yau, Terrence M.; Pendergrast, Jacob; Cserti‐Gazdewich, Christine

doi:10.1016/j.tmrv.2012.12.001

Cited by 31 publications

(30 citation statements)

References 66 publications

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“…In a minority of healthy people, blood tests will detect CA that have no clinical significance (Bendix et al , ; Mauro et al , ). A frequency of positive screening tests at 0·3% was reported in a large cohort of patients with nonrelated disorders, but only 43% of these had demonstrable CA by titration (Jain et al , ). Among 16 subjects identified with detectable CA by screening patients scheduled for cardiac surgery, six were diagnosed with CAD (Barbara et al , ).…”

Section: Diagnosis and Clinical Featuresmentioning

confidence: 99%

“…Routine screening for CA in all individuals scheduled for such surgery is a matter of discussion. Such screening is probably not cost‐effective, because the frequency of positive findings is low and the practical consequences of incidentally detected CA not resulting in clinical disease are unclear (Barbara et al , ; Jain et al , ). Patients with manifest CAD, however, should have a TA assessment and haematology consultation before cardiac surgery and should be operated under normothermia (Barbara et al , ; Tjonnfjord et al , ).…”

Section: Non‐pharmacological Managementmentioning

confidence: 99%

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How I manage patients with cold agglutinin disease

Berentsen

2018

Br J Haematol

111

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Cold agglutinin disease (CAD) is an uncommon autoimmune haemolytic anaemia in which a well-defined, clonal low-grade lymphoproliferative disorder of the bone marrow results in erythrocyte destruction mediated by the classical complement pathway. The pathogenesis, clinical features and diagnostic criteria are reviewed. Although anaemia is mild in some patients, approximately one-third of untreated patients have a haemoglobin level of ≤80 g/l, and about 50% have been considered transfusion dependent for shorter or longer periods. Therapy has improved greatly during the last 15 years. Mild disease can be managed by avoidance of cold and adequate precautions in specific situations, without drug therapy. Corticosteroids should not be used to treat CAD. Patients requiring pharmacological therapy should be considered for prospective trials. Outside clinical studies, the rituximab-bendamustine combination or rituximab monotherapy is recommended in the first line, depending on individual patient characteristics. Second-line options are rituximab-fludarabine in fit patients or, although less strongly documented, a bortezomib-based regimen. Therapies targeting the classical complement pathway are promising, and the complement C1s inhibitor, BIVV009, has shown favourable results in preliminary studies.

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Section: Diagnosis and Clinical Featuresmentioning

confidence: 99%

Section: Non‐pharmacological Managementmentioning

confidence: 99%

How I manage patients with cold agglutinin disease

Berentsen

2018

Br J Haematol

111

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“…Agglutination can also present intraoperatively with increased pressure in the cardioplegia line (Bracken et al, 1993;Fischer et al, 1997) or with visible agglutination in the cardioplegia system. However, complications appear rare in patients with CAs undergoing CPB, even without modifications to reduce hypothermia (Jain et al, 2013) and although serological screening prior to cold cardioplegia is recommended by some, it is not currently routine practice.…”

Section: Surgery In Patients With Chad and Cold Agglutininsmentioning

confidence: 99%

The diagnosis and management of primary autoimmune haemolytic anaemia

et al. 2016

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“…Jain et al reported that the surgeons altered cardiopulmonary bypass management by avoiding hypothermia in only one-third of the identified patients. 9 Because most cardiac patients are not screened for cold agglutinins preoperatively, prompt detection upon initiation of CPB is useful to properly plan and avoid harm. The perfusionist's priming of the cold cardioplegia system with blood as soon as possible provides the longest window for CA detection before the aortic cross-clamp is applied and cold cardioplegia is administered.…”

Section: Discussionmentioning

confidence: 99%

“…11 Additionally, for cold agglutinins, in one single-center study, stroke, myocardial infarction, dialysis, low-output syndrome, sepsis, and deep vein thrombosis were measured at 14.9% in those with CA versus 9.2% for those without. 9 Although CA is a feared complication of CPB, it can be managed successfully with no increases in overall morbidity or mortality. …”

Section: Discussionmentioning

confidence: 99%

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

Yalamuri

Heath

McCartney

et al. 2017

Journal of Cardiothoracic and Vascular Anesthesia

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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...

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Seek and You Shall Find—But Then What Do You Do? Cold Agglutinins in Cardiopulmonary Bypass and a Single-Center Experience With Cold Agglutinin Screening Before Cardiac Surgery

Cited by 31 publications

References 66 publications

How I manage patients with cold agglutinin disease

How I manage patients with cold agglutinin disease

The diagnosis and management of primary autoimmune haemolytic anaemia

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

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