Interactive CardioVascular and Thoracic Surgery 20 (2015) 687–688 doi:10.1093/icvts/ivu424 Advance Access publication 5 February 2015
CHALLENGE OF THE MONTH – ADULT CARDIAC
Cite this article as: Miyahara S, Kano H, Okada K, Okita Y. Aortic arch aneurysm in a patient with cold agglutinin disease. Interact CardioVasc Thorac Surg 2015;20:687–8.
Aortic arch aneurysm in a patient with cold agglutinin disease Shunsuke Miyahara, Hiroya Kano, Kenji Okada and Yutaka Okita* Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan * Corresponding author. Department of Surgery, Division of Cardiovascular Surgery, Kobe University School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan. Tel: +81-783-825942; fax: +81-783-825959; e-mail: [email protected] (Y. Okita). Received 11 July 2014; received in revised form 13 November 2014; accepted 17 November 2014
Keywords: Total arch replacement • Mild hypothermia • Cold agglutinin disease
CLINICAL PROBLEM Cold agglutinin disease is a form of antiglobulin-positive haemolysis caused by circulating autoantibodies that are present in most humans and become active at temperatures below a threshold value [1]. Cardiac surgery requiring systemic hypothermia and cold cardioplegia carries a significant risk of agglutination of red blood cells or haemolysis in patients with cold agglutinin disease. We herein report this case to discuss treatment options with the readers.
CASE DESCRIPTION
thoracic aortic aneurysm in the distal arch (Fig. 1). Preoperative testing demonstrated elevated cold agglutinins with a titre of 1:128; the red blood cells coagulated in the patient’s serum at 27°C. Conflict of interest: none declared.
REFERENCE [1] Barbara DW, Mauermann WJ, Neal JR, Abel MD, Schaff HV, Winters JL. Cold agglutinins in patients undergoing cardiac surgery requiring cardiopulmonary bypass. J Thorac Cardiovasc Surg 2013;146:668–80.
A 70-year old man presented with hoarseness a year ago, and saw an otolaryngologist 2 months ago. Computed tomography showed a
Treatment solution by Miyahara et al. Treatment of choice for aortic arch aneurysm in a patient with cold agglutinin disease
Figure 1: Preoperative computed tomography.
Our surgical plan for the reported challenging case was total arch replacement under mild hypothermia [1]. Through a median sternotomy, mild hypothermic cardiopulmonary bypass (CPB) with a minimum tympanic temperature of 31.2°C and rectal temperature of 33.6°C was established with arterial return in the ascending aorta and bicaval drainage, and then warm blood cardioplegia with a temperature of 30.0°C was administered retrogradely to achieve cardiac arrest. The left ventricle was vented through the right upper pulmonary vein. A 7-Fr aortic occlusion balloon catheter (Equalizer™ Occluder Balloon Catheter, Boston Scientific, Japan) was placed into the proximal descending aorta through the left femoral artery. After the aortic arch was opened, a balloon-tipped cannula (Fuji Systems, Tokyo, Japan) was inserted into the arch vessels, with the total selective cerebral perfusion (SCP) flow maintained at 12–14 ml kg−1 min−1 and adjusted to maintain a perfusion pressure below 60 mmHg with a temperature from 32.2 to 36.4°C. Simultaneously, the aortic occlusion balloon was inflated (to 20 ml) in the descending aorta, and perfusion of the lower body was initiated via the right femoral artery, maintaining a perfusion flow rate of 1.5 l/min (Fig. 1). After completion of the distal aortic anastomosis, antegrade perfusion of the lower body and rewarming was started using a graft branch. The duration of lower body perfusion from the right femoral artery was 29 min. Subsequently, a proximal
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
CHALLENGE OF THE MONTH
Authors: Shunsuke Miyahara, Hiroya Kano, Kenji Okada and Yutaka Okita Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan doi: 10.1093/icvts/ivu436 © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
CHALLENGE OF THE MONTH – ADULT CARDIAC
Cite this article as: Miyahara S, Kano H, Okada K, Okita Y. Aortic arch aneurysm in a patient with cold agglutinin disease. Interact CardioVasc Thorac Surg 2015;20:687–8.
Aortic arch aneurysm in a patient with cold agglutinin disease Shunsuke Miyahara, Hiroya Kano, Kenji Okada and Yutaka Okita* Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan * Corresponding author. Department of Surgery, Division of Cardiovascular Surgery, Kobe University School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan. Tel: +81-783-825942; fax: +81-783-825959; e-mail: [email protected] (Y. Okita). Received 11 July 2014; received in revised form 13 November 2014; accepted 17 November 2014
Keywords: Total arch replacement • Mild hypothermia • Cold agglutinin disease
CLINICAL PROBLEM Cold agglutinin disease is a form of antiglobulin-positive haemolysis caused by circulating autoantibodies that are present in most humans and become active at temperatures below a threshold value [1]. Cardiac surgery requiring systemic hypothermia and cold cardioplegia carries a significant risk of agglutination of red blood cells or haemolysis in patients with cold agglutinin disease. We herein report this case to discuss treatment options with the readers.
CASE DESCRIPTION
thoracic aortic aneurysm in the distal arch (Fig. 1). Preoperative testing demonstrated elevated cold agglutinins with a titre of 1:128; the red blood cells coagulated in the patient’s serum at 27°C. Conflict of interest: none declared.
REFERENCE [1] Barbara DW, Mauermann WJ, Neal JR, Abel MD, Schaff HV, Winters JL. Cold agglutinins in patients undergoing cardiac surgery requiring cardiopulmonary bypass. J Thorac Cardiovasc Surg 2013;146:668–80.
A 70-year old man presented with hoarseness a year ago, and saw an otolaryngologist 2 months ago. Computed tomography showed a
Treatment solution by Miyahara et al. Treatment of choice for aortic arch aneurysm in a patient with cold agglutinin disease
Figure 1: Preoperative computed tomography.
Our surgical plan for the reported challenging case was total arch replacement under mild hypothermia [1]. Through a median sternotomy, mild hypothermic cardiopulmonary bypass (CPB) with a minimum tympanic temperature of 31.2°C and rectal temperature of 33.6°C was established with arterial return in the ascending aorta and bicaval drainage, and then warm blood cardioplegia with a temperature of 30.0°C was administered retrogradely to achieve cardiac arrest. The left ventricle was vented through the right upper pulmonary vein. A 7-Fr aortic occlusion balloon catheter (Equalizer™ Occluder Balloon Catheter, Boston Scientific, Japan) was placed into the proximal descending aorta through the left femoral artery. After the aortic arch was opened, a balloon-tipped cannula (Fuji Systems, Tokyo, Japan) was inserted into the arch vessels, with the total selective cerebral perfusion (SCP) flow maintained at 12–14 ml kg−1 min−1 and adjusted to maintain a perfusion pressure below 60 mmHg with a temperature from 32.2 to 36.4°C. Simultaneously, the aortic occlusion balloon was inflated (to 20 ml) in the descending aorta, and perfusion of the lower body was initiated via the right femoral artery, maintaining a perfusion flow rate of 1.5 l/min (Fig. 1). After completion of the distal aortic anastomosis, antegrade perfusion of the lower body and rewarming was started using a graft branch. The duration of lower body perfusion from the right femoral artery was 29 min. Subsequently, a proximal
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
CHALLENGE OF THE MONTH
Authors: Shunsuke Miyahara, Hiroya Kano, Kenji Okada and Yutaka Okita Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan doi: 10.1093/icvts/ivu436 © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
