Use of a total wash-out method in an open heart operation

Suspected cold agglutination during mild hypothermic pediatric open heart surgery: a report of two cases

Cold agglutination was suspected in 2 pediatric open heart surgery cases during mild hypothermic cardiopulmonary bypass. The first patient was a 2-year-old boy with secundum atrial septal defect. Fifteen minutes after the initiation of mild hypothermic cardiopulmonary bypass, the inlet pressure of oxygenator suddenly elevated from 250 to over 500 mmHg, whereas outlet pressure was maintained. The blood flow rate decreased from 140 to 85 ml/kg/min. At that time, the arterial blood temperature was less than 32°C. Cold agglutinin was highly suspected, so patient was immediately warmed, and the inlet pressure of oxygenator decreased to 250 mmHg when the arterial blood temperature reached to 36°C. Second patient was a 3-year-old boy with secondary developed subvalvular pulmonary stenosis after the repair of double chambered right ventricle at 10 months of his age. Eighteen minutes after the initiation of mild hypothermic cardiopulmonary bypass, the inflow pressure suddenly elevated to 500 mmHg and transmission flow decreased to 55 ml/kg/min. Twenty-three minutes after warming, the pressure fell to a normal level and transmission flow was recovered. The operation continued with normo-thermic cardiopulmonary bypass and crystalloid cardioplegia. Both cases had no postoperative complications related to cold agglutinin such as myocardial infarction, cerebral infarction, or renal insufficiency.

Normothermic cardiac surgery with warm blood cardioplegia in patient with cold agglutinins

Cold agglutinins are predominately immunoglobulin M autoantibodies that react at cold temperatures with surface antigens on the red blood cell. This can lead to hemagglutination at low temperatures, followed by complement fixation and subsequent hemolysis on rewarming. Development of hemagglutination or hemolysis in patients with cold agglutinins is a risk of cardiac surgery under hypothermia. In addition, there is the potential for intracoronary hemagglutination with inadequate distribution of cardioplegic solutions, thrombosis, embolism, ischemia, or infarction. We report a patient with incidentally detected cold agglutinin who underwent normothermic cardiac surgery with warm blood cardioplegia.

Aortic Arch Repair and Cold-Reactive Agglutinins: What to Do?

We describe a modified perfusion technique for aortic arch repair under mild hypothermia and continuous cerebral and systemic perfusion.

Cardiac surgery and cold-reactive proteins

Cold agglutinins are commonly found in sera of healthy persons. They rarely become clinically apparent due to their activity at low temperatures. In these patients, cardiovascular operations requiring hypothermia can result in complications such as hemolysis, renal failure, and myocardial damage and can cause unexpected morbidity and mortality. The literature on cold-reactive proteins is reviewed, and methods of diagnosis and management related to cardiac surgery are suggested. Ideally all patients should be routinely tested preoperatively for the antibodies, and appropriate changes in cardiopulmonary bypass and myocardial management plans should be made in positive patients. Preoperative plasmapheresis may be a useful adjunct, especially in patients requiring operation under profound hypothermia and circulatory arrest. Currently, warm heart surgery appears to be the most expedient method. Unexpected detection of agglutination during operation or hemolysis after operation requires a specific treatment plan.

Cold agglutinins: preoperative diagnosis leads to an uneventful perfusion

This report presents the successful use of normothermic cardiopulmonary bypass (CPB) and warm continuous retrograde cardioplegia to facilitate coronary artery bypass grafting (CABG) in a patient with cold agglutinins. As a result of their agglutinating action and resultant haemolysis, cold-reactive autoantibodies have the potential for causing morbidity and mortality when a patient is placed on hypothermic CPB and the heart is arrested with profoundly cold cardioplegia. The crux of the situation is to keep the temperature above the critical temperature of the cold agglutinin; this technique guarantees accomplishing that goal.