ROUTINE CABG WITH A TWIST - PowerPoint Presentation

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ROUTINE CABG WITH A TWIST

DR ASHISH DOLAS

CASE SCENARIO

35 Year old male patient an

autodriver

.

Dyspneoa

on exertion : NYHA CLASS III Since 2months.

Chest pain radiating to back since 3 hours.

H/o sweating.

H/o Alcohol addiction.

Past H/o PTCA (stent) to LAD 3 months back.

ECG :

T wave inversion lead 2,3,

aVf

, V5 and V6.

ST elevation in V1 to V3.

2D ECHO

Mid and Distal anteroseptal akinesia.

Severely compromised LVEF =30%.

Inferior and Septal hypokinesia.

Coronary angiogram

100 % occlusion of proximal LAD within the stent, with impression of in stent restenosis.

HRCT :

Mild pericardial effusion

Few enlarged mediastinal lymph nodes.

PLAN:

SURGERY CABG

Single graft

ON INDUCTION:

BP : 102/60

mmhg

PA catheter at RA 20cm was exceptionally high at 34 (CVP).

Intraoperative:

Pericardial adhesions with SEVERE CONSTRICTIVE PERICARDITIS.

Performed pericardial

adhesiolysis

(pericardiectomy).

Patient was put on Cardiopulmonary bypass due to severe

haemodynamic

instability.

Single graft was done to LAD.

Challenging post operative period

CHALLENGE I:

Due to pericardiectomy bleeding was expected.

In the first 48 hours patient bleed around 2.5 liters.

Total of 9 PCVs , 2 SDPs, 6 RDPs and 6 FFPs were transfused in first 48 hours.

CHALLENGE II :

Low Cardiac Output.

Low Ejection Fraction due to sudden release of compression.

As EXPECTED COMLICATIONS (CHALLENGE III) FROM TRANSFUSION IN THE FORM OF :

HEPATORENAL DYSFUNCTION

:

High bilirubin went

upto

6.

High RFTS with creatinine GOING UPTO 2.8.

TRALI

(TRANSFUSION RELATED LUNG INJURY ) WAS ALSO EXPECTED .

Pericardial and pleural drains were removed on day 4 but reinserted on day 6 due to respiratory complications and low cardiac output.

COMPLICATIONS WERE MANAGED BY :

High inotropic support for longer duration of time (Due to low Cardiac Output).

Giving higher antibiotics ( to avoid post operative septicemia and SIRS)

Keeping close eye on fluid balance.

Good post operative rehabilitation.

Post op 2d echo

EF= 30%

NO additional RWMA.

No MR

NO TR.

Intercostal drains were removed on day 14 and patient discharged on post op day 16.

Now came for 2

nd

follow up in 3weeks and doing well ready to drive autorickshaw again.

disscussion

Complications :

OVERALL MORTALITY DUE TO PLANNED PROCEDURE ITSELF IS 14 TO 20 %.

Bleeding 10%

Arrythmias :

Atrial and ventricular 8 %

Prolonged intubation ( > 48

hrs

) 4 %

Prolonged chest tube output (> 6 Days) 4%

Renal and hepatic insufficiency

Wound infection 6 %

Systemic infection 4 %

Low cardiac output 4%

Cerebrovascular accident. 2 %.

Morbidity remains high for pericardiectomy. In addition to age, gender, and comorbidities, attention should be given to

Etiology

during surgical planning or referral.

This significantly influences the requirement for cardiopulmonary bypass, chances of bleeding complications, and transfusion requirements.

Reduced LVEF and right ventricular dilatation were independent predictors for early mortality.

CAD, chronic obstructive pulmonary disease and renal insufficiency were risk factors for late mortality.

Thus, an optimal timing for surgery on CP remains crucial to avoid secondary morbidity with an even worse natural prognosis.

Conclussion:

Our patient presented with surprise , as a case of constrictive pericarditis with low cardiac output with low LVEF.

It was challenging to manage patient postoperatively as a surprise on table was tackled.

It is always a team work with all the specialties coming together to bring out these type of challenging patients.

THANK YOU!!