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.