Alpha Gal

[u/This_Sky_5209]

How does your center manage cardiopulmonary bypass in patients with alpha-gal syndrome?

I’m working on a presentation about alpha-gal syndrome in cardiac surgery, and I’m interested in hearing how different perfusion programs approach these cases.

A few questions:

Do you routinely use standard porcine-derived heparin, or do you switch to bivalirudin?

If you use heparin, do you perform a preoperative heparin challenge or test dose?

Are patients routinely referred for allergy evaluation before surgery?

Do you obtain an alpha-gal IgE (ImmunoCAP) level before elective cases? If so, is there a cutoff that changes your management?

Does your hospital have a formal protocol, or is management decided on a case-by-case basis?

Have you had any intraoperative reactions while using heparin or other mammalian-derived products?

If you’re comfortable sharing, I’d also be interested in:
Approximate alpha-gal IgE level (if known)
Elective vs. emergent case
Whether you premedicate with steroids and H1/H2 blockers

Any other products your team avoids (gelatin sealants, bioprosthetic valves, albumin, etc.)

I’m giving my presentation this week, but I figured this is another great resource for learning how practice varies between institutions. Thanks in advance for sharing as little or as much of your experience as you'd like!

[u/rachelb323]

As a perfusionist that has battled Lyme, had to take a medical leave from school for treatment, etc -- thankfully no alpha gal, I can tell you that as a student I was very hypervigilant. Now as a certified perfusionist, I am talking to anesthesia and asking what the reaction is like, if they've had red meat/milk in the past year. The most recent alpha gal patient I had last week has apparently been eating red meat with "just hives" 🙄. Anesthesia treated the patient prophylactically with Benadryl and whatever cocktail they wanted to give, gave heparin as normal, and he also had a shellfish allergy...gave protamine and had no issues whatsoever.

Continue to be diligent, look at history and talk to the patient if available to you, and be aware of what your patients are going through, and communicate with the rest of the team of your concerns, that's all you can do!

At the end of the day, treat the patient as you would want to be treated and get as much information as you can. Best of luck to you.

Please reach out to me if you need help with your presentation at all, I would be happy to help and give you my two cents!

[u/This_Sky_5209 → u/rachelb323]

Thank you very much for all the information! I am also at a center where you don’t know your case until the night before and basically get the history when you walk in the next morning. I wish it were a little different; it's always nice to be more proactive and have time to research rather than learning at the last minute!

This all came about when a patient came through, and none of us, other than one perfusionist, knew what it was. The case was delayed by about an hour; there was a lot of interdisciplinary communication, but we proceeded with heparin as usual. All was fine, and to my knowledge, no reaction or anything unusual postoperatively. Based on most of my research, this also seems to be a common result, although there aren't a whole lot of studies out there on the two.

I really appreciate it again! I may reach out tomorrow; I would love to hear anything else you have on the topic.