Title : An unusual case of post-thrombolysis emergency Coronary Artery Bypass Graft surgery (CABG) with postoperative complication of hemothorax in a young patient
Abstract:
We present a case of a 43-year-old man, a known case of hypertension, who was diagnosed with acute myocardial infarction for which he was given streptokinase (Fibrinolytic drug).He presented to the hospital with exertional dyspnoea and chest pain. Angiogram showed triple-vessel disease, Ejection-fraction– 45% and hypokinesis of the anterior wall on echocardiogram. He had a euroscore of 5 and was unsuitable for PCI. Therefore, a decision to perform an off-pump Coronary bypass graft surgery (CABG) was made.Emergency CABG is indicated for patients with left-main coronary stenosis, 3-vessel disease, a history of failed percutaneous coronary intervention(PCI) or unsuitable for PCI.[2] CABG is the proven treatment for coronary artery disease ideally done 4-6 weeks after thrombolysis for MI due to hemorrhagic risk.[1] Little information currently exists describing the management of patients with an evolving acute myocardial infarction (AMI) treated with infusion of streptokinase (SK) followed by emergency CABG. Problems related to the surgical and anesthetic care of these high-risk patients involved: (1) management of resuscitation of AMI patients, (2) SK-induced coagulopathy, ongoing thrombolysis, (3) timely CABG to preserve myocardial salvage.In post-operative period, left pleural effusion ensued the insertion of Intercostal chest drain. Chest X-ray showed a left sided white-out. Bronchoscopy showed obstruction of the expanding lung. An emergency left thoracotomy was then performed, wherein blood clots were evacuated. The patient successfully recovered and subsequent visits were normal.
Conclusion:
Any emergency surgical procedure on a patient who is thrombolysed is a high risk for hemorrhage, reexploration and DIC. However, to save the patient's life, the risk is considered necessary.
Audience Take Away Notes
- Surgical Evacuation of the clot from left hemithorax was the most important step which was taken that saved the patient. The clot was consuming all the clotting factors leading the patient to DIC and therefore reopening was necessary.
- Despite thrombolysis, the patient had accumulation of clots
- In limited cases like this where CABG is high risk due to thrombolysis and acute MI, surgery must be undertaken
- Young patient with MI is at high risk of death due to poor collateral circulation and therefore emphasis on primary angioplasty should be done
- After an age of 35, patient with diabetes and hypertension, high risk for coronary artery disease should undergo yearly medical checkups
