Perioperative Management of Emergency Off-pump Coronary Artery Bypass Grafting in a Patient with Pan-reactive Red Blood Cell Alloantibodies: A Case Report

Red Blood Cell (RBC) alloimmunisation poses critical challenges in cardiac surgery, particularly during emergency Coronary Artery Bypass Grafting (CABG), due to the risks of haemolytic reactions and incompatible transfusions. This case report details the perioperative management of a 67-year-old female with severe triple-vessel coronary artery disease, left main stenosis, and panreactive RBC alloantibodies, who underwent emergency off-pump CABG without allogeneic transfusion. The patient presented with progressive retrosternal chest pain radiating to the left arm, lasting 4 hours, against a background of Type 2 Diabetes Mellitus (T2DM) and systemic hypertension. The electrocardiogram showed ST-segment depression and T-wave inversion in Leads I, aVL, V4, V5, and V6. Coronary angiography revealed ostial left main 80-90% stenosis, proximal left anterior descending artery 80%, mid-segment 90%, proximal ramus intermedius 60-70%, proximal left circumflex artery 80%, and right coronary artery ostial 80-90% with midsegment 90% lesions. Echocardiography indicated hypokinesia in the basal and mid inferoseptal and inferolateral walls, mild left ventricular systolic dysfunction (ejection fraction 48%), grade 2 diastolic dysfunction, and mild mitral and tricuspid regurgitation, along with mild pulmonary hypertension. The preoperative haemoglobin level was 9.5 g/dL, and the blood group was B positive. A blood sample from the patient was sent for crossmatching for potential intraoperative transfusion. The indirect Coombs test with an 11-cell panel confirmed pan-reactive alloantibodies, rendering all screened units incompatible. The uniqueness of this case lies in the emergent setting with ongoing chest pain and moderate left ventricular dysfunction, where routine crossmatching failed across 20 donor units. This situation necessitated exclusive reliance on intraoperative cell salvage in conjunction with a multidisciplinary team approach—a strategy rarely documented in such high-risk, pan-reactive antibody scenarios in cardiac surgery.