# Perioperative management and inflammatory marker monitoring in a cardiac surgery patient treated with tocilizumab: a case report of successful surgical aortic valve replacement

## TL;DR

A 73-year-old man with Castleman disease successfully underwent heart surgery after stopping and later resuming tocilizumab, with careful monitoring of inflammation markers.

## Contribution

This case report provides insights into managing tocilizumab use during cardiac surgery and monitoring inflammatory markers.

## Key findings

- Tocilizumab was safely discontinued 26 days before surgery and resumed 30 days after, with no infection or disease flare.
- Vascular endothelial growth factor levels increased before C-reactive protein, suggesting it may predict disease exacerbation.
- Perioperative management with a multi-disciplinary approach was crucial for successful surgical outcomes.

## Abstract

Interleukin (IL)-6 is associated with wound healing and infection response. Tocilizumab (TCZ) is a monoclonal antibody against the IL-6 receptor, interfering with its signalling pathway. However, reports on patients treated with TCZ undergoing cardiac surgery are limited.

A 73-year-old man with Castleman disease, treated with TCZ, underwent surgical aortic valve replacement via median sternotomy for aortic valve regurgitation with exertional shortness of breath. Comprehensive measures for preventing surgical site infection along with close examination were implemented during the perioperative period. Tocilizumab was discontinued 26 days before surgery and resumed 30 days after surgery, during which plasma IL-6 levels decreased. There was no evidence of infection or exacerbation of Castleman disease. Vascular endothelial growth factor levels increased before an increase in C-reactive protein levels following hospital discharge and prior to TCZ resumption.

Meticulous perioperative management with a multi-disciplinary approach is crucial during the cessation of TCZ for cardiac surgery. Changes in vascular endothelial growth factor levels may serve as an early predictor of underlying disease exacerbation after TCZ cessation for surgery.

Graphical Abstract