Review the literature with heparin in alpha gal. Can heparinized saline flushed be utilized in these patients? What is the incidence of risk? What alternatives are recommended for line care in alpha gal patients (especially in cath lab)?

Review the literature with heparin in alpha gal. Can heparinized saline flushed be utilized in these patients. What is the incidence of risk. What alternatives are recommended for line care in alpha gal patients (especially in cath lab).

Comment by InpharmD Researcher

Literature suggests heparin use in alpha-gal syndrome is usually tolerated, with most retrospective cohorts reporting very low rates of clinically significant reactions and only rare hypersensitivity events, typically in higher-risk patients or high-alpha-gal IgE settings. However, true incidence remains uncertain and appears to vary with dose, route, and degree of sensitization, with higher-risk settings like cardiac surgery or cath lab procedures showing more unpredictability. Evidence regarding heparinized saline flushes is limited to isolated case reports of reactions, so safety cannot be reliably assumed, and there is no robust data defining risk. For line care, there are no alpha-gal-specific trials of alternatives, but standard catheter literature supports normal saline flushes using pulsatile technique and positive-pressure locking as a commonly used non-heparin approach to maintain patency and avoid potential exposure. When anticoagulation is required, alternatives such as bivalirudin or argatroban are commonly used in higher-risk patients, or heparin may be given with premedication, testing, or desensitization in controlled settings. Overall, management is individualized because the prediction of heparin reactivity in alpha-gal syndrome remains unreliable.

Background

A 2022 retrospective study (N= 133) examined the incidence of reactions to heparin products in patients with alpha-gal allergy based on self-reporting upon admission or documented reactions during care. Out of 158 total hospital visits, there were 57 visits where patients with alpha-gal syndrome received at least one heparin product, and 56 visits out of 57 resulted in heparin tolerability. The single patient who experienced a reaction had been administered two doses of unfractionated heparin (UFH) 5,000 units subcutaneously for venous thromboembolism prophylaxis, and the treatment was subsequently discontinued after allergy presentation. The patient had previously been tested for an alpha-gal allergy (24.20 kU/L, non-allergic reference range <0.10 kU/L) and had one of the highest antibody levels among previously tested patients within the study. The investigators note, however, that in comparison to another cohort study that looked at the use of high-dose UFH in patients with known alpha-gal allergy (Table 2), this patient had both a lower UFH dose and a lower alpha-gal titer, positing that measurement of antibody titers may not be the most ideal assessment of allergy risk. No reactions were reported in response to the use of low-molecular-weight heparin (LMWH). Although the study was conducted in an area endemic to alpha-gal syndrome, not all patients were tested to confirm this diagnosis prior to heparin use; additional studies are needed to confirm whether enoxaparin poses a lower risk for triggering a reaction in comparison to UFH. [1], [2]

A 2022 article investigates the risk of using heparin products in patients with alpha-gal allergy and the potential as a diagnostic option that heparin skin testing offers. One patient developed hypersensitivity reactions twenty minutes after administration of heparin flushes, with symptom improvement and resolution within three days. The patient was evaluated for serum alpha-gal IgE (> 100 kU/L) and reaction to intradermal skin testing (positive to heparin 100 U/mL and 5000 U/mL, and enoxaparin 1 IU/mL). Investigators analyzed the use of the same intradermal skin testing protocol in three additional patients with alpha-gal syndrome and one patient without to serve as a control. Out of the four total patients, including the first patient, one additional patient tested positive to heparin at 100 U/mL and 5,000 U/mL concentrations and had an antibody titer > 100 kU/L. The other two patients that had titers of 8.36 kU/L and 0.99 kU/L, respectively, were negative for skin testing and subsequently passed a heparin 5,000 U challenge with no symptoms. As a testing strategy to determine heparin tolerability in alpha-gal allergy has yet to be standardized, the investigators propose skin testing may show promise in determining whether patients may tolerate a challenge versus desensitization in settings where heparin is needed. [3]

Though not specific to patients with alpha-gal syndrome, one 2020 Cochrane review generally discusses the use of normal saline versus heparin for maintaining central venous catheter patency in pediatric patients. Across four small and heterogeneous trials, there was no clear difference between normal saline and heparin for preventing catheter occlusion or bloodstream infections, though the certainty of evidence was low due to inconsistency and methodological limitations (e.g., lack of blinding and potential confounding). Individual studies showed mixed results and were limited by small sample sizes, variable protocols, and potential confounding factors. Overall, the review concluded that there is insufficient evidence to determine whether heparin is necessary for catheter maintenance. A separate 2014 Cochrane review in adults similarly evaluated intermittent locking of central venous catheters with heparin versus normal saline across 12 trials. Overall, the results suggested that heparin may reduce occlusion rates compared to normal saline, but this finding was based on low-certainty evidence, with no clear difference in patency duration. There were also no clear differences in secondary outcomes, including catheter-related bloodstream infections, mortality, or bleeding, though studies were not powered to detect rare adverse events. Similar to the pediatric data, findings were limited by heterogeneity, imprecision, and methodological concerns. Importantly, despite not directly addressing alpha-gal syndrome, these findings may suggest normal saline (with appropriate flushing techniques) as a potential non-heparin alternative for line care when avoidance of heparin is desired; nonetheless, given the low quality of evidence, these results should still be interpreted cautiously when extrapolated to this population. [4], [5]

While also not specific to alpha-gal syndrome, a 2026 scoping review systematically evaluated the use of alternative anticoagulants for carotid artery interventions in patients with heparin hypersensitivity. The review included studies assessing major adverse cardiovascular events and excessive bleeding associated with nonheparin anticoagulants—specifically bivalirudin, argatroban, and low-molecular-weight heparin (LMWH)—used during carotid endarterectomy (CEA) and carotid artery stenting (CAS). A total of 21 studies met inclusion criteria, including case reports, randomized controlled trials, and retrospective cohort studies. Findings indicated that bivalirudin was the most frequently studied agent and appeared to be a safe alternative to unfractionated heparin (UFH), with less associated bleeding and no significant increase in periprocedural complications. Argatroban, evaluated in several case reports, was also associated with no reported adverse events, although available data were limited. Overall, these findings suggest that bivalirudin may be a suitable alternative anticoagulant for carotid procedures in patients with heparin hypersensitivity, while argatroban may represent additional options based on available evidence. [6]

Relevant Prescribing Information

Heparin Sodium Injection, USP is a sterile solution of heparin sodium derived from porcine intestinal mucosa, standardized for anticoagulant activity, in water for injection. [7]

Literature Review

A search of the published medical literature revealed 8 studies investigating the researchable question:

Level of evidence

C - Multiple studies with limitations or conflicting results Read more→

Please see Tables 1-8 for your response.

Heparin desensitisation prior to cardiopulmonary bypass in a patient with alpha-gal allergy
Design	Case report
Case presentation	A 67-year-old male with a past medical history significant for coronary artery disease (CAD) and alpha-gal syndrome presented with newly diagnosed gastric adenocarcinoma. His most recent medical records reported IgE titers as very high for beef and moderately high for pork; this also confirmed IgE titers against alpha-gal. This alpha-gal allergy was found after developing hives following chemotherapy flushed with heparinized saline. During the present workup, he was found to have multivessel CAD, requiring revascularization. Due to the patient's previous reaction to heparin and laboratory values showing continued alpha-gal syndrome, the patient was considered at high risk for anaphylaxis to heparin required for cardiopulmonary bypass. After consulting immunology, they recommended using an established institutional protocol for rapid desensitization, specifically developed for heparin-allergic patients. Upon admission to the intensive care unit (ICU), the patient received famotidine 20 mg and cetirizine 10 mg PO BID. The evening before surgery, the desensitization protocol was completed (see below) without any adverse reactions. No steroids were administered to mask the signs of hypersensitivity. After the successful desensitization, the patient was continued on heparin infusion to a target-activated partial thromboplastin time (aPTT) of 40-60s. During bypass, the patient was given an initial heparin bolus of 30,000 IU and two additional boluses of 5,000 IU to achieve an activated clotting time of 462s. The patient also received a single dose of IV diphenhydramine 50 mg at the time of intraoperative heparinization. Following surgery, the heparin was fully reversed with IV protamine 300 mg, in divided doses, to a normal activated clotting time. Upon arrival to the ICU (90 minutes post-protamine), the patient was given subcutaneous heparin 5,000 IU q8h to prevent desensitization. He remained on this regimen until discharge 5 days later. His postoperative course was unremarkable, never experiencing urticaria, hives, or facial or tongue angioedema.
Protocol for Heparin Desensitization	Bag/Dose Number	Rate	Volume infused	Heparin dose given	Time infused
	Bag 1 (5 IU in 250 mL NS) Dose 1 Dose 2 Dose 3 Dose 4	4 mL/h (0.08 IU/h) 8 mL/h (0.16 IU/h) 16 mL/h (0.32 IU/h) 32 mL/h (0.64 IU/h)	1 mL 2 mL 4 mL 8 mL	0.02 IU 0.04 IU 0.08 IU 0.16 IU	15 min 15 min 15 min 15 min
	Bag 2 (50 IU in 250 mL NS) Dose 5 Dose 6 Dose 7 Dose 8	6.4 mL/h (1.28 IU/h) 12.8 mL/h (2.56 IU/h) 25.6 mL/h (5.12 IU/h) 51.2 mL/h (10.24 IU/h)	1.6 mL 3.2 mL 6.4 mL 12.8 mL	0.32 IU 0.64 IU 1.28 IU 2.56 IU	15 min 15 min 15 min 15 min
	Bag 3 (500 IU in 250 mL NS) Dose 9 Dose 10 Dose 11 Dose 12 Dose 13	10.2 mL/h (20.4 IU/h) 20.5 mL/h (41 IU/h) 41 mL/h (82 IU/h) 81.9 mL/h (163.8 IU/h) 163.8 mL/h (327.6 IU/h)	2.55 mL 5.125 mL 10.25 mL 20.475 mL 40.95 mL	5.1 IU 10.25 IU 20.5 IU 40.95 IU 81.9 IU	15 min 15 min 15 min 15 min 15 min
	Bag 4 (5000 IU in 250 mL NS) Dose 14 Dose 15	32.7 mL/h (654 IU/h) 50 mL/h (1,000 IU/h)	8.175 mL 50 mL	163.5 IU 1,000 IU	15 min 60 min
	The patient must be in an intensive care unit with continuous monitoring and 1:1 nursing. An anaphylaxis kit is kept at the patient's bedside throughout the process. The cumulative unfractionated heparin dose administered was 1,327.3 IU, and the total time to desensitize was about 4.5 h. If the patient successfully tolerates desensitization, then maintenance dosing can begin.
Study Author Conclusions	This case suggests heparin desensitization should be considered in alpha-gal allergic patients prior to cardiac surgery. The risks for severe reactions during desensitization in a highly controlled environment appear to be minimal, and without desensitization, the risk for severe reactions even when pre-treated with antihistamines and steroids remains unpredictable. Because the alpha-gal content of heparin solutions varies depending on the manufacturer and lot, skin testing has been proposed to determine the risk of reaction; however, this has yielded inconsistent results. Because the patient in this report had a history of heparin allergy, a rapid desensitization protocol was used to induce a temporary tolerance to heparin. Once the desensitization portion of the protocol was completed without complication, a standard heparin infusion at a maintenance rate was continued until surgery.

References:
[1] [1] McRae AS, Tidwell WP, Patel S, Lombard FW. Heparin desensitisation prior to cardiopulmonary bypass in a patient with alpha-gal allergy. Anaesth Rep. 2022;10(2):e12203. Published 2022 Dec 16. doi:10.1002/anr3.12203

Safety of Intravenous Heparin for Cardiac surgery in Patients with Alpha-Gal Syndrome
Design	Retrospective cohort study N=17
Objective	To analyze the safety of administering intravenous heparin in cardiac surgery patients with alpha-gal syndrome.
Study Groups	Reaction (n=4) No reaction (n=13)
Inclusion Criteria	Cardiac surgery patients undergoing cardiopulmonary bypass or TVAR, tested positive for alpha-gal prior to surgery, received high-dose heparin
Exclusion Criteria	N/A
Methods	Patient data from an academic medical center were collected and analyzed based on their alpha-gal IgE blood test. Patients were stratified based on whether they had a positive alpha-gal test prior to surgery and were stratified based on whether a reaction occurred or not. Some patients were premidcated with a combination of steroid (hydrocortisone 100 mg or methylprednisolone 500 mg), H1 blocker (diphenhydramine 50 mg), and H2 blocker (famotidine 20 to 40 mg).
Duration	2007 to 2019
Outcome Measures	Primary: Anaphylaxis or allergic reaction around the time of surgery (reported to 4 that experienced a reaction versus 13 that did not) Secondary: Mortality, stroke, renal failure, atrial fibrillation, transfusion, post-operative length of stay
Baseline Characteristics		Reaction (n=4)	No Reaction (n=13)	p-value
	Age, years	63 (46 to 74)	67 (59 to 71)	-
	Female	0	1 (8%)	1.00
	Prior stroke	2 (50%)	1 (8%)	0.121
	Diabetes	2 (50%)	5 (38%)	1.00
	Hypertension	3 (75%)	10 (77%)	1.00
	Pre-medication	2 (50%)	6 (46%)	0.733
	Heparin loading dose, IU Heparin total dose, IU	35,000 (15,000 to 36,000) 40,000 (35,000 to 56,000)	30,000 (17,500 to 31,500) 37,500 (26,00-46,000)	0.507 0.539
	Alpha gal IgE, kU/L	75 (61 to 96)	6 (3 to 18)	0.0006
	Total IgE, kU/L	360 (182 to 465)	343 (28 to 528)	0.774
Results	Endpoint	Reaction (n=4)	No reaction (n=13)	p-Value
	Alpha-gal IgE levels, kU/L	75 (61 to 96)	8 (3 to 18)	0.006
	Mortality	0	0	1.00
	Stroke	0	0
	Renal failure	0	1 (8%)
	Atrial fibrilation	1 (25%)	3 (23%)	1.00
	Transfusion	2 (50%)	2 (15%)	0.219
	Post-operative length of stay	7 (6 to 11)	5 (4 to 6)	-
	While patients with reactions experienced severe dermatologic, pulmonary, and cardiac events; patients were successfully treated with combinations of vasopressors, steroids, and H1/H2 blockers.
Adverse Events	N/A
Study Author Conclusions	Although alpha-gal is rare in patients undergoing cardiac surgery, there is up to a 50% risk of serious allergic reaction to heparin for cardiopulmonary bypass. Higher preoperative alpha-gal titers may confer a higher risk of severe allergic reaction. For patients with a clinical suspicion of alpha-gal syndrome, we recommend pre-screening with IgE levels and pre-medicating prior to receiving high doses of intravenous heparin.
InpharmD Researcher Critique	Due to the rarity of alpha-gal syndrome, the study was only able to identify a small subgroup with confirmed levels prior to surgery. Those who were identified with alpha-gal syndrome after surgery were excluded for analysis.

References:
[1] [1] Hawkins RB, Wilson JM, Mehaffey JH, Platts-Mills TAE, Ailawadi G. Safety of Intravenous Heparin for Cardiac Surgery in Patients With Alpha-Gal Syndrome. Ann Thorac Surg. 2021;111(6):1991-1997. doi:10.1016/j.athoracsur.2020.07.050

Successful implementation of a multidisciplinary safety protocol in patients with alpha-gal syndrome receiving parenteral anticoagulation: A case series
Design	Retrospective case series N= 20
Objective	To assess the safety of implementation of the previously recommended protocol for heparin administration in patients with alpha-gal syndrome (AGS)
Study Groups	All patients (n= 20)
Inclusion Criteria	Patients with a documented history of AGS who underwent procedures from February 2022 to January 2024 with potential administration of intravenous heparin
Exclusion Criteria	Not specified
Methods	Patients were risk stratified based on alpha-gal severity and urgency of intervention. The protocol involved using alpha-gal specific IgE levels to guide therapeutic decisions. High-risk patients received bivalirudin or argatroban, or underwent heparin desensitization. Lower-risk patients received a heparin challenge after premedication. Data were collected from electronic medical records
Duration	February 2022 to January 2024
Outcome Measures	Primary: Safety of heparin administration protocol Secondary: Incidence of adverse reactions, delays in surgical procedures
Baseline Characteristics		All patients (n= 20)
	Age range, years	39 to 84
	Gender - Male	15
	Gender - Female	5
Results		Result
	Adverse reactions	None
	Protocol deviations	8 patients
	Surgical delays due to AGS	None
Adverse Events	No adverse reactions to parenteral anticoagulation were reported
Study Author Conclusions	Implementation of a therapeutic intervention protocol for patients with known or suspected AGS undergoing procedures requiring systemic parenteral anticoagulation can safely and efficiently risk stratify patients by likelihood of reaction to heparin and help guide therapy.
Critique	The study is limited by its retrospective design, small sample size, and single-center setting. The protocol deviations and reliance on electronic medical records may affect the reliability of the findings. Further studies with larger sample sizes are needed to confirm the safety and applicability of the protocol.

References:
[1] [1] Rutherford ME, Stone CA Jr, Kahwash BM, Brazil MS, Siegrist KK. Successful implementation of a multidisciplinary safety protocol in patients with alpha-gal syndrome receiving parenteral anticoagulation: a case series. JCA Adv. 2024;1:100074. doi:10.1016/j.jcadva.2024.100074

Impact of Newly Emerging Alpha-Gal Allergies on Cardiac Surgery: A Case Series
Design	Case series study N= 4
Objective	To assess the impact of alpha-gal allergies on cardiac surgery and to demonstrate that pre-treatment with diphenhydramine and steroids can help attenuate serious allergic reactions during surgery
Study Groups	All patients (n= 4)
Inclusion Criteria	Patients with known alpha-gal allergies undergoing cardiac surgery
Exclusion Criteria	Not specified
Methods	Four patients with known alpha-gal allergies underwent cardiac surgery. Pre-treatment with diphenhydramine and steroids was administered to mitigate allergic reactions. Heparin was used during cardiopulmonary bypass, and patients were monitored for allergic responses. Skin testing for heparin was performed preoperatively in some cases. In particular, one patient received a 5000-unit IV test dose of heparin.
Duration	Not specified
Outcome Measures	Primary: Successful completion of cardiac surgery without severe allergic reactions Secondary: Incidence of mild allergic reactions, management of allergic responses
Baseline Characteristics		All patients (n= 4)
	Age, years	49, 63, 71, 87
	Gender	3 males, 1 female
	History of alpha-gal allergy	All patients
Results		Result
	Successful surgery without severe allergic reactions	4/4 patients
	Mild allergic reactions managed	2/4 patients
Adverse Events	Mild urticarial rash in two patients; one patient experienced a significant perioperative myocardial infarction potentially related to an IgE-mediated allergic reaction.
Study Author Conclusions	With careful observation and planning, heparin can be safely used for cardiopulmonary bypass in patients with alpha-gal allergies. Prophylaxis with steroids and histamine receptor blockers can improve surgical outcomes without severe IgE-mediated immune responses.
Critique	The study provides valuable insights into managing alpha-gal allergies during cardiac surgery, but is limited by its small sample size and lack of a control group. The variability in heparin lots and the absence of a standardized test for alpha-gal content in medications are notable limitations. Further research is needed to establish standardized protocols and to quantify alpha-gal in medications.

References:
[1] Sell-Dottin KA, Sola M, Caranasos TG. Impact of newly emerging alpha-gal allergies on cardiac surgery: a case series. Clin Surg. 2017;2:1477.

MANAGING HEPARIN-INDUCED ANAPHYLAXIS RISK IN ALPHA-GAL SYNDROME THROUGH PREOPERATIVE HEPARIN DESENSITIZATION PROTOCOL AND PRETREATMENT
Design	Case report
Case presentation	A 69-year-old male undergoing CABG was described as being at great risk for adverse reactions if administered heparin, due to his past medical history and elevated serum IgE level of alpha gal <100 kU/l. Thus, a fifteen-step heparin desensitization protocol, with a target dose of 1300 IU, was administered and stopped 6 h prior to the procedure, per institutional protocol, in addition to a premedication protocol with corticosteroids and antihistamines. The patient was bolused with 31,000 IU of heparin without sequelae.
Study Author Conclusions	This case reports successful administration of heparin during cardiopulmonary bypass using a combined approach of heparin desensitization and medication pretreatment in a patient with AGS and an extremely high sIgE to alpha gal that was greater than that generally reported in previous publications.

References:
[1] [1] Farooqui Z, Dykewicz M. MANAGING HEPARIN-INDUCED ANAPHYLAXIS RISK IN ALPHA-GAL SYNDROME THROUGH PREOPERATIVE HEPARIN DESENSITIZATION PROTOCOL AND PRETREATMENT. Ann Allergy Asthma Immunol. 2025 Nov;135(5):S218. doi:10.1016/j.anai.2025.08.672

Successful intravenous heparin administration during coronary revascularization surgery in a patient with alpha-gal anaphylaxis history
Design	Case report
Case Presentation	A 45-year-old male with a history of alpha-gal anaphylaxis reaction presented with a referral for cardiac catheterization. However, further investigation revealed obstructive coronary artery disease in multiple vessels, leading to coronary artery bypass graft with IV unfractionated heparin (UH) as the intraoperative anticoagulation of choice. Alpha-gal anaphylaxis was diagnosed based on reaction to beef ingestion. While serum-specific IgE tests also revealed a possible pork allergy, the patient had not historically had reactions to port. At the present time of the study, the patient was consuming beef but avoided pork and had never received heparin formulation. As skin tests revealed negative reactions to beef and pork food extracts, along with the urgency of revascularization; it was decided that the patient would receive intraoperative heparin for anticoagulation. The patient was initiated on prednisone 60 mg daily, diphenhydramine 25 mg Q6H, and cetirizine 10 mg BID prior to surgery and IV UH administration. The patient had an uneventful intraoperative and postoperative period and IgE levels were not remarkable in relation to alpha-gal, beef, and pork.
Study Authors' Conclusions	In summary, described herein is a patient with alpha-gal anaphylaxis history who had successfully reintroduced dietary beef and exhibited declining or negative repeat alpha-gal and food-specific IgE levels.

References:
[1] [1] Mawhirt SL, Banta E. Successful intravenous heparin administration during coronary revascularization surgery in a patient with alpha-gal anaphylaxis history. Ann Allergy Asthma Immunol. 2019;123(4):399-401. doi:10.1016/j.anai.2019.05.017

Porcine or bovine valve replacement in 3 patients with IgE antibodies to the mammalian oligosaccharide galactose-alpha-1,3-galactose
Design	Case report
Case Presentation	A 75-year-old male experienced anaphylaxis while undergoing anesthesia in preparation for ascending aortic aneurysm repair. The moment of anaphylaxis occurred immediately after heparin was flushed into the central line. The patient had historically tolerated procedures in the past that required sedatives, anesthetics, and heparin and the patient's heparin-specific IgE levels were negative prior to surgery. Investigations showed IgE from bovine lung and porcine intestinal mucosa were correlated with positive levels; despite a lack of history. The patient ultimately completed surgery without complications and was healthy 6-months later without any restrictions to mammalian meat in the diet.
Study Author's Conclusions	At present, there is no way to predict the severity of reactions following valve replacement in patients with mammalian meat allergy.

References:
[1] [1] Mozzicato SM, Tripathi A, Posthumus JB, Platts-Mills TAE, Commins SP. Porcine or bovine valve replacement in 3 patients with IgE antibodies to the mammalian oligosaccharide galactose-alpha-1,3-galactose. J Allergy Clin Immunol Pract. 2014;2(5):637-638. doi:10.1016/j.jaip.2014.04.016

Perioperative Considerations for a Patient with Alpha-Gal Syndrome Undergoing Cardiac Surgery
Design	Case report
Case presentation	A 74-year-old male patient with Alpha-Gal Syndrome (AGS) undergoing cardiac surgery presented with a history of allergy to red meat, hypertension, and atrial fibrillation, necessitating surgical intervention for severe prosthetic aortic stenosis. Following the confirmation of AGS through elevated alpha-gal IgE levels, specific perioperative considerations were outlined to manage the potential allergic reactions associated with mammalian-derived products, such as heparin and bioprosthetic valves. In preparation for surgery, a mechanical aortic valve was selected to avoid exposure to alpha-gal residues, and a preoperative intravenous heparin challenge was performed. The patient was administered escalating doses of heparin, which he tolerated without incident, thereby allowing for safe heparinization during cardiopulmonary bypass. Intraoperative precautions included pretreatment with intravenous diphenhydramine, methylprednisolone, and famotidine to mitigate allergic responses. The patient underwent successful valve replacement with a #27 St. Jude mechanical mitral valve in the aortic position and experienced an uneventful recovery.
Study Author Conclusions	In summary, this case conference highlights the numerous perioperative considerations for patients with AGS sched- uled to undergo cardiac surgery. Ideally, these patients should be identified prior to the day of surgery, and an allergy to red meat should raise suspicion. A preoperative workup, including testing for AGS if the diagnosis is uncon- firmed and tolerance testing for heparin, can help avoid unexpected adverse events during surgery. Careful planning regarding cardiac surgical implants is also important to avoid unintended complications. Clinicians must be meticu- lous in checking whether commonly used medications are safe for administration. Although these measures require extra planning and vigilance, they can facilitate achieving an optimal outcome in the perioperative period.

References:
[1] Rinehart CD, Wang K, LoBue C, et al. Perioperative Considerations for a Patient with Alpha-Gal Syndrome Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth. 2025;39(9):2516-2523. doi:10.1053/j.jvca.2025.04.037