Cardiovascular Surgery, Vol. 3, No. ,!, pp 191 -192. 1995 Copyright @ 1995 Elsevier Science Ltd Printed in Great Britain. Ail rights reserved 09h7--2 1oyi’)i % 10.00 i 0.00 Warm heart surgery in cold hae nin dbe F.Donatelli, M.A. Mariani, M.Triggiani, M. Pocar, F.Santoro and A. Grossi Institute for Cardiovascrtar and RespiratooryDisease, Univer5@ of Milan, Scientific institute KS. Raffaele, Milan, Italy Continuous warm retrograde blood cardioplegia and systemic normothermia are a promising method for heart surgery in patients with cold autoimmune disorders in order to avoid the adverse effects of both systemic and coronary hypothermia during cardiac arrest and cardiopulmonary bypass. A SS-year-old white man with cold haemagglutinin disease who underwent coronary surgery using continuous retrograde normothermic blood cardioplegia and systemic normothermia is reported. Keywords: cold autoimmune disorders, warm heart surgery. cold haemagglutinin disease, coronall$ bypass surgery The benefits of warm heart surgery in perioperative results for patients undergoing cardiac surgery are ’ widely reported - 6. In fact a trend towards a reduction of the incidence of myocardial infarction and the use of mechanical support has been demonstrated3. In addi- tion, warm aerobic arrest seemsto minimize ischaemia and anaerobic metabolism during cardiac arrest6. Cold haemagglutinin disease is one of the most common cold autoimmune disorders, causing im- munoglobulin agglutination when the patient’s temper- ature falls below a critical value: microvascular thrombosis and hyperviscosity may be untoward consequences7. A case of coronary surgery using continuous retro- grade warm blood cardioplegia and systemic nor- mothermia in a patient with cold haemagglutinin disease is described. Case report In January 1993 a 59-year-old white man was admitted to the authors’ institute with chronic stable angina and a critical stenosis of the left anterior descending artery. During hospitalization the type and screen*test revealed the presence of cold haemagglutinins against I erythro- cytes antigen with a titre equal to 1:2048; the patient was discharged with medical therapy and scheduled for percutaneous transluminal coronary angioplasty. In March I993 an indirect Coombs’ test after cold Correspondence to: Dr F. Donatelli, Department of Thoracic and Cardiovascular Surgery, Scientific Institute H.S.Raffaele, Via Olget- tina, 60 20132, Milan, Italy CARDIOWWULAR SURGERY APRIL 1995 VOL 3 NO 2 autoadsorbance excluded the presenceof alloantibodies and the patient underwent successful percutaneous transluminal coronary angioplasty of the left anterior descending artery and first diagonal branch. In May 1993 the patient was readmitted with low threshold angina and underwent coronary angiography which showed a critical stenosis of the first tract of the left anterior descending artery at the site of prior angioplas- ty. Four days before surgery the cold haemagglutinins titre was equal to 1512; the test was performed at 28°C 32°C and 37°C for 30min and gave negative results without evidence of in vitro complement fixation. Type and screen and indirect Coombs’ tests on cold autoadsorbed serum were also negative, On the basis of these results it was concluded that systemic hypothermia below 28°C was contraindicated. Cardiopulmonary bypass was performed with con- ventional cannulation of the right atrium and ascending aorta at 3PC in normovolaemic haemodihrtion and systemic heparinization. The coronary sinus was cannu- lated used a retrograde can&a (Research Medical International, Salt Lake City, Utah, USA). Aprotinin was administered according to the protocol recom- mended by Bidstrup et ~1.~. The aorta was cross- clamped and cardiac arrest induced by anterograde warm blood cardioplegia (300-350mYmin for 2 min containing K + 16 mmol and Mg’” 12 mmolf and maintained by continuous retrograde infusion of warm blood solution (K + 7-10 mmol/l) according to the method described by Menasche et a1.‘e., Myocardial revascularization was performed with the left internal thoracic artery to the left anterior descending artery and a saphenous vein graft to the first diagonal branch. No interruptions of cardioplegia were necessarvthroughout 191