@article{383730ff9e4249b1b04ff9fdf525d180,
title = "Cold agglutinins in patients undergoing cardiac surgery requiring cardiopulmonary bypass",
abstract = "Objectives: Cold agglutinins (CA) are circulating autoantibodies present in most humans. They are active below normal body temperatures. Cold hemagglutinin disease involves the presence of CA sufficiently active at temperatures in the periphery to produce hemolysis or agglutination. Systemic hypothermia and cold cardioplegia may result in agglutination or hemolysis. We reviewed the experience of a large referral center in managing patients with CA and cold hemagglutinin disease undergoing cardiac surgery requiring cardiopulmonary bypass. Methods: The electronic medical records from 2002 to 2010 were searched to identify patients with CA or cold hemagglutinin disease who underwent cardiac surgery requiring cardiopulmonary bypass. Information related to preoperative CA testing and treatment, surgery, cardiopulmonary bypass, postoperative complications, and mortality was recorded. Results: Sixteen patients underwent 19 procedures requiring cardiopulmonary bypass. Six patients had cold hemagglutinin disease. The identification of CA was made intraoperatively in 3 patients. One patient underwent preoperative plasma exchange. Cold blood cardioplegia was used in 2 of 16 procedures using cardioplegia, with the remaining using warmer blood cardioplegia. The lowest recorded intraoperative core temperature was less than 34 C in 1 case. CA-related postoperative hemolysis requiring transfusion was present in 1 patient, which was resolved with active warming. No patient had evidence of permanent myocardial dysfunction, had a neurologic event, required dialysis, or died within 30 days. Conclusions: All patients with CA/cold hemagglutinin disease at the Mayo Clinic College of Medicine safely underwent cardiac surgery without major adverse morbidity or mortality. Patients with CA but without evidence of cold hemagglutinin disease can safely undergo normothermic cardiopulmonary bypass at 37 C and warm cardioplegia without further testing. Patients with cold hemagglutinin disease should undergo laboratory testing including CA titers and thermal amplitude and hematology consultation before cardiac surgery.",
keywords = "CA, CHAD, CPB, IABP, cardiopulmonary bypass, cold agglutinins, cold hemagglutinin disease, intra-aortic balloon pump",
author = "Barbara, {David W.} and Mauermann, {William J.} and Neal, {James R.} and Abel, {Martin D.} and Schaff, {Hartzell V.} and Winters, {Jeffrey L.}",
note = "Funding Information: This study was approved by the Mayo Foundation Institutional Review Board. A computer-generated search of the electronic medical records from 2002 to 2010 (the time period from the implementation of the electronic anesthesia record to the end of the searchable patient records at initiation of this study) was performed to identify patients aged 16 years or greater with a diagnosis of CA, CHAD, or related diagnoses, such as cold autoimmune hemolytic anemia, cold hemolysis, and paroxysmal cold hemoglobinuria, who had given permission for their medical record to be used for research. These patients were then cross-referenced for those who underwent surgery requiring CPB. Individual patient records were then reviewed by one of the authors (D.W.B.) to verify the presence of CA or CHAD and surgery requiring CPB. A standardized data-collection form was used. Demographic information (age at time of surgery and gender) was recorded. The electronic medical records of each patient were reviewed for preoperative information related to the surgery (diagnosis and operation type) and CHAD or CA (method of diagnosis; timing of diagnosis in relation to surgery; presence of CHAD signs and symptoms, eg, anemia, hemolysis, acrocyanosis; cause of CHAD, eg, infections, lymphoproliferative disorder, or unknown; presence of paroxysmal cold hemoglobinuria; CA antibody titer; CA thermal amplitude; direct antiglobulin test; hemoglobin; creatinine; whether valvular pathology was thought to contribute to hemolysis as indicated in physician notes; dialysis dependency; ejection fraction from transthoracic echocardiogram; lactate dehydrogenase; haptoglobin; and whether a hematologist was consulted before surgery). Details of treatments of CHAD within 90 days of surgery were recorded (plasma exchange; medical therapies, including rituximab, cyclophosphamide, chlorambucil, and glucocorticoids; intravenous immunoglobulin; history of splenectomy; erythropoietin; and transfusions). Generalized anesthetic information consisting of American Society of Anesthesiologists physical status classification and emergency or scheduled nature of surgery was noted. The intraoperative anesthetic record, surgical note, and perfusionist's record were reviewed for documentation of warming methods used; duration of CPB; duration of aortic crossclamp; presence of circulatory arrest; cardioplegia techniques, including delivery method, temperature, composition, intervals, number of doses, and specific notations by the surgeon or perfusionist related to the cardioplegia; notations related to agglutination by the surgeon or perfusionist; nadir nasal and bladder temperatures; use of antifibrinolytics; and fluid and transfusion requirements. The postoperative record was reviewed for details of vasoactive medication or intra-aortic balloon pump (IABP) therapies as a marker of heart failure, transfusion requirements, aforementioned laboratory studies (including hemoglobin nadir and creatinine peak in the first 2 postoperative days), chest tube output in the first 48 postoperative hours, complications of transfusions as noted in the daily progress notes, and death within 30 days. Statistical analysis consisted of determination of mean ± standard deviation, median, and range for continuous variables and quantification (%) for categoric variables. ",
year = "2013",
month = sep,
doi = "10.1016/j.jtcvs.2013.03.009",
language = "English (US)",
volume = "146",
pages = "668--680",
journal = "Journal of Thoracic and Cardiovascular Surgery",
issn = "0022-5223",
publisher = "Mosby Inc.",
number = "3",
}