Alpha-gal syndrome (AGS) is an immunoglobulin E -mediated allergy to the mammalian oligosaccharide galactose-α-1,3-galactose (α-gal) that can trigger delayed anaphylaxis after exposure to nonprimate mammal products. Although its perioperative impact is well described in cardiac surgery, guidance for spine surgery is lacking. We investigated common hemostatic agents, dural substitutes, and grafts used in spine surgery at our institution located in Suffolk County, NY, which has the highest prevalence of AGS nationwide, and classified them as safe or unsafe based on the presence or absence of mammal products. Additionally, we discuss anesthetic considerations and the workup and pretreatment of AGS patients, as well as present an illustrative case of an AGS patient who experienced intraoperative anaphylaxis during a deformity correction surgery. A review of 25 commonly used agents showed that 64% were potentially unsafe for AGS patients. In contrast, plant-based polysaccharide powders, oxidized cellulose, human recombinant thrombin, and synthetic dural sealants are safe alternatives. AGS poses unique risks in spine surgery because the use of many hemostatic, graft, and dural-repair agents that contain mammal products is commonplace. A structured pathway that includes preoperative allergy consultation, α-gal immunoglobulin E testing, premedication, pharmacy-verified product lists, and real-time team communication can prevent life-threatening reactions. As AGS incidence rises, spine surgeons must recognize high-risk patients, substitute for safe biomaterials when able, and coordinate perioperative care to avoid anaphylaxis.
Alpha-gal syndrome is an allergic condition in which individuals develop an immune-mediated hypersensitivity response when consuming red meat and its derived products. Its diagnosis is important in individuals undergoing cardiac surgery, as patients frequently require large doses of unfractionated heparin or the insertion of surgical implants, both of which are porcine or bovine in origin. There are currently no guidelines for heparin administration in alpha-gal patients, with even less knowledge regarding the long-term clinical implications of these patients after receiving bioprosthetic valve replacements or other prostheses. We present the case of a 31-year-old male who underwent cardiac surgery in the setting of alpha-gal syndrome for a large atrial septal defect (ASD) and mitral valve prolapse (MVP). The patient continues to do well one year after undergoing a mitral valve repair, tricuspid valve repair and an ASD closure using bovine pericardium. He sustained no adverse reaction to the use of heparin products or the presence of a bovine pericardial patch. This rare case was managed by a multidisciplinary team consisting of cardiothoracic surgery, cardiac anesthesiology, and allergy/immunology that led to an optimal outcome despite the patient's pertinent allergic history. This case highlights that the use of bovine pericardium and porcine heparin to close septal defects in patients with milder forms of alpha-gal allergy can be considered if other options are not available. Further studies are warranted to investigate the long-term outcomes of such potential alpha-gal containing prostheses and heparin exposure and establish the optimal decision making algorithm and prophylactic regimen.