Researchers presented the case study of a patient who was incidentally discovered to have cold agglutinin disease (CAD) during a coronary artery bypass graft surgery. Their report was published in the Journal of Cardiothoracic Society. 

A 76-year-old man presented with a 10-month history of chest pain which was exacerbated by cold weather. The chest pain first started when he was being treated for pneumonia 10 months earlier. His past medical history included being treated with aspirin and warfarin when he underwent stenting for iliac artery stenosis 2 years earlier. 

The only abnormalities detected in a general blood test were elevated prothrombin time and international normalized ratio, thought to be due to warfarin. The working diagnosis was unstable angina; an angiography revealed left-main and triple-vessel disease. His surgeons planned for a coronary artery bypass graft surgery with cardiopulmonary bypass. 


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During the procedure, shortly after the aorta was cross-clamped and cold blood cardioplegia (4oC) infusion was initiated, the surgeons found massive blood clots in the cardioplegia line. The surgeons suspected CAD and took immediate action to stop the cold cardioplegia infusion and changed the thrombosed cardioplegia line. 

Read more about CAD etiology 

They initiated warm blood cardioplegia infusion (35 oC) with high potassium in a retrograde manner to induce cardiac arrest and increase body temperature and the temperature of the operating room. After cardiac arrest, the surgeons opened the left anterior descending artery, posterolateral branch, and obtuse marginal artery and found a number of blood clots, which were removed. 

Throughout the rest of the procedure, all infusions of blood cardioplegia were warm. Postoperatively, blood was drawn for a cold-reactive antibody titer test. When the blood sample was stored in the refrigerator (4o C), the research team noted abnormal blood clotting; the cold-reactive antibody titer rose over 1024-fold. The patient was hence diagnosed with CAD and was discharged without complications. 

“Incidental CAD during cardiac surgery may cause severe complications,” the authors of the study wrote. “In such rare and critical cases, immediate active rewarming and myocardial protection are desirable, along with elimination of blood clots and microemboli through various methods.” 

References

Chung E, Park S, Lee J. Incidentally discovered cold hemagglutinin disease with massive blood clots in the cardioplegia line and coronary artery, during coronary artery bypass graftJ Cardiothorac Surg. 2020;15(1):79. doi:10.1186/s13019-020-01130-1