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

Abstract

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...

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

“…During ACC, continuous or intermittent warm cardioplegia infusion is recommended to maintain the temperature and protect the myocardium [2,4,6,13,14]. The cardioplegia flush-out eliminates hidden microemboli before the removal of the ACC [7,15].…”

Differentiating between cold agglutinins and rouleaux: a case series of seven patients

“…Priming the cardioplegia delivery line up to the sterile field and filling the cold cardioplegia unit with blood right after CPB is initiated is one suggested method to allow for earlier detection of cold agglutinins. 3,4,15 Avoidance of agglutination, especially in the coronary arteries, is vital, so discovery/confirmation before the cross-clamp is applied is ideal. In addition, the preparation and execution of a new surgical plan will take time and the myocardial ischemic time needs to be kept as low as possible.…”

“…The first case (as previous reported by Yalamuri et al) was our most severe case, a 67-year-old male who presented for coronary artery bypass grafting (CABG) and aortic valve replacement (AVR). 3 Promptly after the initiation of CPB, the cardioplegia system was flushed and filled with the patient’s blood and crystalloid cardioplegic solution (Plegisol ® , Hospira, Lake Forest, IL) in a 4:1 blood to cardioplegia mixture. As the blood cooled to the preset 4 ° C in a BCD Vanguard™ (Sorin, Milan, Italy) heat exchanger, it was noted that the blood rapidly separated into large clumps (Figure 1a).…”

“…The myocardial preservation strategy was altered to the use of intermittent cold crystalloid cardioplegia (Plegisol ® ) with warm crystalloid cardioplegia for the first portion of the arrest dose and a warm crystalloid reperfusion before the cross-clamp was removed. 3 Two pRBCs were transfused for low hemoglobin by anesthesia through a blood warmer while still on CPB, but after the diagnosis of cold agglutinins. No complications were observed and, on POD 26, the patient returned for routine postoperative evaluation and no cold agglutination was observed at 4°C.…”