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Patient initials or identifier number
Relevant clinical history and physical exam
A 57-year-old man, known hypertension, and smoker. He presented with worsening angina for 1 month and was referred to us for a coronary angiogram. PE noted displaced apex beat with a systolic murmur. COROS showed severe triple vessel disease. He was referred for CABG.
However, he developed PR bleed in the ward. Colonoscopy showed bleeding diverticulitis. Therefore, DAPT and heparin were withheld.
He remained well until he developed acute inferior MI in CCU, roughly 1 month after admission. DAPT was loaded.
Relevant test results prior to catheterization
hsTROP I positive.
Hb 15 g/dL, platelet 189 x 109 /L
Renal profile and liver function normal
ECG - Delta wave, no ischemic changes
CXR - Borderline cardiomegaly
Echocardiogram - LVEF 45-50%, AMVL prolapse with moderate eccentric MR, mild hypokinesia at anteroseptal wall
Relevant catheterization findings
LM - Normal
LAD - 80-90% ostio-proximal stenosis. 70-80% mid-segment stenosis, ostial D1 70-80% disease
LCx - 70-80% proximal-distal stenosis. 80% disease at ostial OM1
RCA - Proximal tendam lesion 80-90% stenosis. 70% stenosis distally.
Emergency COROS was performed and showed occluded RCA at mid-segment. 6Fr JR 4GC was used to engaged ostium RCA via a right radial artery. A PT2 MS guide wire was introduced into distal RCA. The lesion was dilated with a 2.0 x 10 mm SC balloon to 8 atm. However, a patient went into pulseless VT after reperfusion. Active resuscitation was initiated and he was intubated. Re-COROS then showed re-occluded RCA at mid-segment. At the meantime, he developed persistent refractory pulseless VT and VF despite active resuscitation. Therefore, emergency bypass system (EBS) was inserted via a right femoral artery and femoral vein. He was then referred to a cardiothoracic team for emergency CABG. While waiting to be transferred for CABG, further POBA to mid- and distal RCA with 2.0 x 10 mm SC balloon was done and achieved TIMI 3 flow. He was transferred to OT for an emergency on pump beating CABG. SVG to LAD, SVG to OM2, SVG to PDA were done. Post-operation there was uneventful, and he was successfully extubated on D2 post-op. However, on post-op D5, while halfway doing echocardiogram at the echocardiographic room, he developed VF and collapsed in the echo room. Active resuscitation was commenced and he was re-intubated. Unfortunately, he had never recovered from this episode. With prolonged intubation and CICU stay, he eventually developed nosocomial pneumonia, Pseudomonas infection, ARDS and passed away on post-op D28 due to severe sepsis.
There is always a debate whether a patient on DAPT and heparin should proceed straight for emergency CABG. And, there is also always a challenge on the transfer of a patient in hemodynamically unstable condition from cath lab to OT. This case illustrated the possibility of emergency CABG with the support of emergency bypass system (EBS) after PCI in such unstable patient.
Although, this patient succumbed eventually due to severe sepsis secondary to prolonged intubation, but the initial result of the surgery was great. Undoubted, achieving hemostasis is challenging in such case when a patient was loaded with DAPT and heparin, but the success of surgery can be achieved in good hands.