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 Ho sweating Ho Alcohol addiction ID: 935683
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Slide1
ROUTINE CABG WITH A TWIST
DR ASHISH DOLAS
Slide2CASE 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.
Slide3Past 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.
Slide42D ECHO
Mid and Distal anteroseptal akinesia.
Severely compromised LVEF =30%.
Inferior and Septal hypokinesia.
Slide5Coronary angiogram
100 % occlusion of proximal LAD within the stent, with impression of in stent restenosis.
HRCT :
Mild pericardial effusion
Few enlarged mediastinal lymph nodes.
Slide6PLAN:
SURGERY CABG
Single graft
ON INDUCTION:
BP : 102/60
mmhg
PA catheter at RA 20cm was exceptionally high at 34 (CVP).
Slide7Intraoperative:
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.
Slide8Challenging 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.
Slide9CHALLENGE II :
Low Cardiac Output.
Low Ejection Fraction due to sudden release of compression.
Slide10As 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.
Slide11COMPLICATIONS 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.
Slide12Post op 2d echo
EF= 30%
NO additional RWMA.
No MR
NO TR.
Slide13Intercostal 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.
Slide14disscussion
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%
Slide15Renal and hepatic insufficiency
Wound infection 6 %
Systemic infection 4 %
Low cardiac output 4%
Cerebrovascular accident. 2 %.
Slide16Morbidity 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.
Slide17Reduced 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.
Slide18Conclussion:
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.
Slide19THANK YOU!!