Problems of cold agglutinins in cardiac surgery: how to manage cardiopulmonary bypass and myocardial protection

ABSTRACT

Cold agglutinins are of unique relevance in cardiac surgery because of the use of hypothermic cardiopulmonary bypass [CPB]. Cold autoimmune diseases are defined by the presence of abnormal circulating proteins [usually IgM or IgA antibodies] that agglutinate in response to a decrease in body temperature. These disorders include cryoglobulinemia and cold hemagglutinin disease. Immunoglobulin M autoantibodies to red blood cells, which activate at varying levels of hypothermia, can cause catastrophic hemagglutination, microvascular thrombosis, or hemolysis. Management of anesthesia in these patients includes strict maintenance of normothermia. Patients scheduled for the surgery requiring cardiopulmonary bypass present significant challenges. Use of systemic hypothermia may be contraindicated, and cold cardioplegia solutions may precipitate intracoronary hemagglutination with consequent thrombosis, ischemia, or infarction. Management of CPB and myocardial protection requires individualized planning. We describe a case of MV repair and CABG in a patient with high titer cold agglutinins and high thermal amplitude for antibody activation. Normothermic CPB and continuous warm blood cardioplegia were successfully used