Discussion
CGs are proteins that become insoluble and typically precipitate at
temperatures below normal body temperature and dissolve back into the
serum upon rewarming CGs can be either IGs or a mixture of IGs and
complement components1. In open heart surgery,
systemic hypothermia, and cold or tepid cardioplegia procedure using CPB
are typically used to protect the myocardium and internal organs.
However, in patients with cryoglobulinemia, these methods may have
deleterious effects. Regrettably, there are no guidelines for the
management of patients with CG during CPB. Therefore, we searched an
extensive literature and found only13 cases of CPB in patients with
cryoglobulinemia.
The profiles and treatment of the 14 cases, including our case, are
presented in Table 1 and 2. The severity of preoperative CG was based on
various conditions. Among these patients, especially, our patient had
very severe symptoms and needed intensive treatment for cryoglobulinemia
(Table 1).
In many cases, surgery was performed using systemic normothermia
(>35°C) (Table 2). However, since Stanford type A
dissection may require total arch replacement, we had to lower the body
temperature of our patient. The literature review revealed thar only 3
cases have been reported which used moderate hypothermia
(25~27°C), two of them underwent PE previously for
decreasing the CG levels before surgery 2,3.
In cardioplegia, warm cardioplegia via antegrade was typically used, and
two of 3 cases used moderate hypothermia were not used blood
cardioplegia2,3. In our case, myocardial protection
was performed with intermittent retrograde cold blood cardioplegia
during hypothermia. During these procedures, there may be a risk of
thrombosis of the coronary veins. Hence, after proximal anastomosis, the
temperature was increased approximate 35°C and antegrade warm
cardioplegia was initiated for flushing thrombus.
Fortunately, in our case, the qualitative analysis result was negative
for CG after PE therapy. Hence, surgery could be performed under deep
hypothermia and cold cardioplegia, even for the patient with severe
cryoglobulinemia symptoms.