Anestesia e Pesquisa Clínica
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Cardiopulmonary Bypass - Case Report

Emayah Tenzing, Noel Pio Samy, Satyen Parida, P. Ram Sankar

Purpose: Cold agglutinins are autoantibodies that agglutinate Red Blood Cells (RBC) at low temperatures, creating hemagglutination and hemolysis. The normal coldagglutinin titer is below 1:32. Any titer more than 1:64 is considered positive with associated clinical significance. They are basically of no clinical gravity, though when people with cold agglutinins encounterheart surgery with hypothermia and cold cardioplegia, they can come up againstproblems. Thus, unique perioperative direction is needed for such patients.

Clinical Features: We set out a 52 years old woman with cold agglutinindisease (CAD) diagnosed and managed in a cardiac surgery during hypothermia on Cardiopulmonary Bypass (CPB). She had never suffered from any problems nor didshe have anyhematologicalmalady that emerged during routine preoperative evaluation. Since clots and clumps were revealed by accident on the CPB circuit, cannula and tubings, a certain scheme was used to manage the temperature of CPB and cardioplegia. She had normothermic heart surgery with warm cardioplegia.

Conclusion: An antegrade and retrograde warm cardioplegia with normothermic CPB is the best modus operandi to avoid disaster in these situations, and keep anappropriatesurgical field to complete the surgery and bail out.

Cold agglutinin disease is a rare autoimmune hemolyticanemia characterized by IgM antibodies against the patient’s own RBC. These are typically activated between 28-31°C, but occasionally at body temperature . They can have myriad presentations like anemia, jaundice, hematuria, cold limbs, acrocyanosis, splenomegaly and livedo reticularis. Primary cold agglutinin disease is idiopathic. The reported incidence of cold agglutinins among screened cardiac surgical patients is low but not too rare (approximately 0.8%–4%), and different perioperative management is required for such patients.

Secondary cold agglutinin disease can be triggered by cold temperatures, viral/bacterial infections and cancers. Cold agglutinins are auto antibodies that agglutinate red blood cells at low temperatures, creating hemagglutination and hemolysis. They are basically of no clinical gravity, though when people with cold agglutinins encounter heart surgery with hypothermia and cold cardioplegia, they can come up against problems. Thus, unique perioperative direction is needed for such patients.

We report a rare case of cold agglutinin disease diagnosed intra-operatively in cardiac surgery during hypothermia on Cardiopulmonary Bypass (CPB), after having obtained written consent from the patient. Furthermore, we reflect on whether there should be a pre-pump routine of screening for cold agglutinin disease.