Use of an Intravascular Warming Catheter during Off-Pump Coronary Artery Bypass Surgery in a Patient with Severe Cold Hemagglutinin Disease

Abstract

C old hemagglutinin disease (CHAD) is a type of autoimmune hemolytic anemia that results in the harmful presence of cold autoantibodies against red blood cells (RBCs). The cold agglutinins (CAs) found in patients with CHAD have a broad thermal amplitude that enables them to activate in exposed parts of the body, such as the peripheral circulatory system. The disease can be especially troublesome-to the point of causing serious morbidity-in patients who undergo perioperative hypothermia. In this case study, we report the novel use of an intravascular warming device to maintain normothermia and prevent RBC agglutination during off-pump coronary artery bypass (OPCAB) surgery. Case ReportIn June 2011, a 77-year-old man with long-standing hypertension was evaluated for dyspnea on exertion, of 6 months' duration. Results from prior studies, including a sleep study, computed tomographic scan, and ultrasonography, were all noncontributory. The results of a nuclear stress test were normal, but coronary angiography revealed non-stentable coronary artery disease in the left anterior descending coronary artery (LAD). The patient was then referred to our institution for possible coronary artery bypass grafting.The patient's medical history included, at the age of 63 years, hemolysis and chronic anemia that had led to a diagnosis of CHAD. In the past, he had experienced-after exposure to cold-black discoloration of his fingertips, toes, nose, and ears, which symptoms had been followed by dark urine and jaundice. As a result, he took special precautions to dress warmly and avoided going outside during winter months. In addition, hemolysis in association with a previous prostatectomy had necessitated 2 RBC transfusions.The patient's laboratory values on admission to our institution were as follows: hemoglobin, 9.8 g/dL; reticulocyte count, 4.3% (normal range, 0.5%-1.5%); total bilirubin, 1.4 mg/dL (normal range, 0.3-1.1 mg/dL); direct bilirubin, 0.4 mg/dL (normal range, 0.1-0.4 mg/dL); lactate dehydrogenase, 382 U/L (normal range, 107-206 U/L); and haptoglobin, <8 mg/dL (normal range, 14-258 mg/dL).In his initial blood-bank examination, antibody screening by gel methodology was negative. However, a direct antiglobulin test (DAT) was scored as 4+ agglutination for Case ReportsAshok Tholpady, MD

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice – Evidence‐Based Approach from the Writing Committee of the American Society for Apheresis: The Ninth Special Issue

“…TPE might also be beneficial in patients with CAD before surgeries requiring hypothermia (Barbara, 2013). One CR described the management of CAD in off-pump coronary artery bypass surgery with an intravascular warming catheter instead of TPE (Tholpady, 2016). Response after TPE is often temporary, depending on the characteristics and rate of autoantibody production and thus, should be combined with immunosuppression.…”

Neonatal Fc receptor in human immunity: Function and role in therapeutic intervention

“…88 Because IgM is 95% intravascular, a single PLEX is very effective for IgM-mediated autoimmune diseases. 89 PLEX is required for a minimum of 2 to 3 days, because IgG is 60% extravascular. 90 PLEX may be associated with a rebound overshoot of IgG production and accelerated recovery of pathologic autoantibodies and, as such, is often combined with an immunosuppressive agent to block the rebound synthesis.…”