He was eventually discharged to a cardiac rehabilitation center.

He underwent an exhaustive evaluation and planning for LVAD placement with periprocedural anticoagulation using bivalirudin. His hemodynamics subsequently deteriorated, and a refractory requirement for progressively increasing doses of inotropes leads to evaluation for advanced heart failure therapies. His hospital course was complicated by cardiogenic shock approximately 48 hours following PCI requiring intravenous diuresis and inotrope support. He was anticoagulated with bivalirudin given his AG allergy. He underwent PCI with successful drug-eluting stent placement in the mid LAD. The patient was taken immediately to the catheterization lab, where he underwent left heart catheterization, which revealed 50% stenosis of the proximal LAD, 100% occluded mid LAD with thrombus in place, and 30% in-stent restenosis in the distal LAD. Electrocardiogram revealed 3 mm ST segment elevation in leads V2-V4 and reciprocal 1 mm ST segment depression in leads I and aVL, consistent with a diagnosis of anterior wall ST segment elevation MI. On initial presentation, he was hemodynamically stable. Case PresentationĪ 56-year-old male with a past medical history of coronary artery disease (status post percutaneous coronary intervention (PCI) to the distal left anterior descending artery (LAD) in 2011), ischemic cardiomyopathy (ejection fraction of 20-25%), type 2 diabetes mellitus, hypertension, hyperlipidemia, and AG allergy presented with chest pain and dyspnea on exertion of one-day duration. Intolerance to heparin products poses challenges for anticoagulation in patients with MI and postoperatively, in those with mechanical circulatory support devices such as LVAD. Although data on the degree of heparin cross-reactivity with AG antigen is still lacking, it is highly likely that such patients will react to heparin. Heparin products, either unfractionated or low-molecular weight, are derived from porcine intestinal tissue. The severity of the reaction varies, but it usually manifests as a late yet powerful anaphylactic reaction 3-6 hours after ingestion, rather than a simple allergic one, and is therefore important to recognize. The prevalence of AG allergy is steadily increasing with an estimated 10% of certain populations, especially in southeastern US, reported to have elevated antibody titers against AG antigen.

It usually occurs following a tick bite, with the lone star tick being the most predominant cause in the US. IntroductionĪG allergy, also known as AG syndrome or red meat allergy, is an IgE-mediated allergic reaction to galactose-alpha-1,3-galactose carbohydrate found in mammalian meat such as pork and beef.

nonheparinoid products in such a population. Therefore, individualized assessment and preoperative planning is needed regarding the use of heparin vs. This is especially important in patients with myocardial infarction (MI) and mechanical circulatory support, such as a left ventricular assist device (LVAD), since anticoagulation is immediately required. Heparin, being derived from porcine intestinal tissue, may have a degree of cross-reactivity with AG antigen and thus place patients at risk for allergic and even anaphylactic reactions. Alpha-gal (AG) allergy is an IgE-mediated allergic reaction to galactose-alpha-1,3-galactose found in mammalian meat.