DP22: ALPHA-GAL SYNDROME IN ELECTIVE LEFT ATRIAL APPENDAGE OCCLUSION: A PERIOPERATIVE MANAGEMENT CHALLENGE.
Courtney Payne, MD; Aaron Hacker, DO; Edward Parker, DO
HCA Westside Hospital
Introduction: Alpha-gal Syndrome (AGS) is an IgE-mediated delayed hypersensitivity reaction to galactose-α-1,3-galactose (alpha-gal), an oligosaccharide present in non-primate mammalian meat and many biologic or pharmaceutical products derived from animal sources. Sensitization most commonly follows bites from the Amblyomma americanum (Lone Star tick), endemic in the southeastern and central United States. Unlike typical food allergies, reactions in AGS are often delayed by several hours and may range from urticaria to life-threatening anaphylaxis. Although dietary triggers are well recognized, the implications of AGS in perioperative and procedural medicine remain incompletely defined, particularly given the widespread use of mammalian-derived agents such as gelatin, albumin, and heparin.
Case Presentation: A 73-year-old male with non-valvular atrial fibrillation was referred for elective percutaneous left atrial appendage occlusion (LAAO) using the Watchman™ device. He had a history of recurrent gastrointestinal distress and anaphylaxis following ingestion of mammalian meat. Laboratory evaluation revealed elevated serum IgE antibodies to alpha-gal, confirming AGS.
LAAO was indicated due to an elevated CHA2DS2-VASc score and contraindication to long-term oral anticoagulation secondary to recurrent gastrointestinal bleeding. Preoperative evaluation identified potential risks from standard perioperative medications containing mammalian derivatives. A multidisciplinary team—including anesthesiology, cardiology, allergy-immunology, and pharmacy—conducted a comprehensive review of all planned medications, anticoagulants, and procedural materials.
Total intravenous anesthesia was administered using ketamine, midazolam, and dexmedetomidine. Neuromuscular blockade was achieved with rocuronium and reversed with sugammadex. Propofol was avoided due to theoretical concerns regarding excipient-related cross-reactivity and formulation variability. Standard unfractionated heparin, derived from porcine intestinal mucosa and routinely used for LAAO procedures, was contraindicated. Bivalirudin, a synthetic direct thrombin inhibitor, was selected as an alternative anticoagulant. Activated clotting time monitoring guided intraoperative dosing to maintain therapeutic anticoagulation.
The procedure was completed successfully without hemodynamic instability, hypersensitivity reaction, or bleeding complication. The patient’s postoperative course was uneventful, and he was discharged home in stable condition with planned outpatient follow-up.
Discussion: This case highlights the expanded clinical relevance of AGS beyond food-related reactions. Many perioperative agents—including heparin, gelatin-based products, albumin, and biologic excipients—contain mammalian components that may precipitate hypersensitivity in sensitized individuals. Because these ingredients are often not immediately apparent, careful medication review and interdisciplinary collaboration are essential.
The successful use of bivalirudin in place of heparin demonstrates a viable strategy for anticoagulation in AGS patients undergoing structural cardiac interventions. Its synthetic origin and predictable pharmacokinetic profile make it particularly suitable in patients with mammalian product sensitivity.
Conclusion: AGS presents unique challenges in procedural and cardiovascular medicine. This case demonstrates that with meticulous preoperative planning, interdisciplinary coordination, and strategic selection of non-mammalian alternatives, safe implantation of the Watchman™ device can be achieved without allergic complication. As AGS prevalence increases, heightened awareness and improved identification of animal-derived medical products will be critical to ensuring patient safety.