Enjaymo, warmth protect CAD patient during surgery: Case report
Woman didn't experience hemolysis during surgery for atrial fibrillation
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A 70-year-old woman with cold agglutinin disease (CAD) avoided disease-related complications from surgery related to a heart condition, in part because she took Enjaymo (sutimlimab-jome) before the operation for a heart condition, a case study from the U.S. reported.
In addition to giving the woman Enjaymo, an approved CAD treatment, the clinical team kept her body warm during the operation and warmed fluids before infusing them. The woman didn’t experience CAD-related red blood cell destruction (hemolysis), which can be triggered by drops in temperature due to anesthesia.
This case “adds to a newly developing body of literature that suggests that the use of [Enjaymo] may be effective in preventing procedurally triggered hemolysis in patients with cold agglutinin disease,” the researchers wrote.
They also noted a relationship between episodes of CAD-related hemolysis and her heart disease, atrial fibrillation (AF), which is marked by irregular heartbeats.
The study, “Keeping it Hot: Radiofrequency Ablation of Atrial Fibrillation in a Patient with Cold Agglutinin Disease,” was published in HeartRhythm Case Reports.
Enjaymo and AF
CAD is an autoimmune condition in which cold temperatures trigger attacks on red blood cells. Surgical procedures are a concern because anesthesia can lower body temperature, increasing the risk of hemolysis and low red blood cells, or anemia.
Previous reports have suggested that Enjaymo, a medication that blocks a part of the immune system involved in CAD-related autoimmune attacks, can help prevent these types of complications.
However, there is little evidence that using Enjaymo or taking other precautions can help during procedures for AF, a condition in which the heartbeat becomes irregular and often fast, potentially leading to problems with circulation.
The 70-year-old woman in the case report came to the researchers’ clinic about 10 years after her CAD diagnosis and five years after her AF diagnosis. Her doctors had prescribed rituximab, an antibody-based therapy sold as Rituxan, with biosimilars available, that kills immune cells involved in CAD.
She consulted the doctors because she had noticed intermittent episodes of AF. “In addition to infrequent infections and dehydration, her atrial fibrillation appeared to be primarily driven by episodes of anemia with exacerbations of her cold agglutinin disease,” the team wrote.
To treat the AF, the team prescribed the heart medication diltiazem and recommended monitoring her heart rate. But at a 12-month follow-up visit, she “reported increasing frequency of episodes of both anemia and symptomatic atrial fibrillation despite daily diltiazem use,” the researchers wrote.
Because the medication wasn’t effective, the clinicians decided to perform an ablation, a surgical procedure that creates small scars on the heart to reduce AF. During an ablation, surgeons guide a thin, flexible tube (catheter) through the veins and to the heart. Then they use extreme cold or extreme heat to form the small scars.
The cold version of this procedure, cryoablation, could theoretically be risky for people with CAD. While there are few reports on this in practice, cryoablation and other catheter-guided procedures have caused hemolysis in CAD.
“These cases highlight the risk of catheter directed procedures in this patient population, particularly when special precautions are not taken,” the researchers wrote.
Because of these risks, the team opted to use radiofrequency energy, a technique that employs heat rather than cold to create the small scars on the heart. They believed this might lower the risk of hemolysis.
In preparation for the procedure, the woman started taking Enjaymo, and used a body-warming device on the day of the procedure. The surgical team raised the operating room temperature and warmed fluids they planned to administer via into-the-vein infusions. They monitored her temperature and watched closely for signs of hemolysis while she was under anesthesia.
No complications emerged during the procedure or the initial recovery period.
Four and a half months after the procedure, the woman returned to the clinic for a follow-up. “At that visit, she reported feeling well with no further instances of palpitations or atrial fibrillation,” the researchers wrote.
They concluded that Enjaymo and other precautions effectively kept the woman safe during her procedure. “In the future, proceduralists may consider the methods described to optimize safety for catheter directed interventions in patients likewise requiring strict temperature management,” the team wrote.
The researchers also said the relationship between CAD attacks and episodes of AF deserves more study. “Further research is needed to determine how the progression and severity of atrial fibrillation may differ in patients with cold agglutinin disease,” they wrote.
