Emergency CABG for young female patient with critical coronary artery disease

T Jasmine Rajareegam Princely

Non-Critical Ward Supervisor, Kauvery Heart city, Trichy, India

Abstract

Emergency CABG refers to a surgical procedure performed in urgent situations to bypass blocked or narrowed coronary arteries in patients with acute myocardial infarction (MI), unstable angina, or other life-threatening coronary conditions. Performing CABG in younger patients is less common than in older adults but can be necessary for several reasons.

Coronary artery bypass graft surgery is the mainstay cardiac operation for the treatment of severe atherosclerotic coronary disease. The surgery is founded on harvesting vascular conduits from select anatomic sites in the arterial and venous circulation to serve as bypass grafts. Degenerative bypass graft disease involves relentless pathologic processes causing failure of these vascular structures following coronary artery surgery.

Background

Coronary artery bypass grafting (CABG) remains the Gold Standard for excessive coronary artery disease involving three vessels or the left main stem1. CABG is more durable than percutaneous coronary intervention, especially when using arterial grafts only2-4. There is abundant literature regarding risks of elderly patients undergoing cardiac surgery5-7. However, reports about younger patients undergoing CABG are sparse. D’Errigo et al. recently reported the multicenter data concerning patients below 50 years of age receiving CABG with a mortality rate of 0.9% overall8. However, no details about the used grafts were given in that study. A low postoperative mortality rate has also been reported by Khawaja et al.9 in patients aged <50 years treated by percutaneous coronary intervention (0.86%). However, percutaneous coronary interventions were performed in 41% of cases in patients with single vessel coronary artery disease, which is significantly different from surgical series8.

Coronary artery disease (CAD) is one of the most prevalent cardiac diseases in industrialized countries and is associated with high rates of mortality and morbidity10. It mainly affects older adults, the reported incidence among young adults being only 3–6%11. Since Yater described the presence of CAD in autopsy reports of young soldiers in 1948, the data about outcomes in young people are relatively scarce12. Although coronary bypass grafting (CABG) is one of the most extensively studied surgical techniques for the treatment of the disease, only a few studies have been performed to characterize and compare the risk factors and outcomes of this young group with those of older patients12.  Our goal was to analyze the perioperative results and long-term survival after CABG in a young adult patient. Young patients undergoing CABG often face the challenge of needing lifelong follow-up to manage their coronary health, as they are at increased risk of future atherosclerosis or graft failure

Outcome

Young patients having coronary bypass surgery had low rates of peri-operative death and morbidity. Nonetheless, these patients have a significant chance of experiencing long-term, serious adverse events that are of cardiovascular origin13.

Indications for emergency CABG

  • Left main coronary stenosis
  • 3-vessel disease
  • A history of failed PCI or an anatomy unsuitable for PCI
  • Ongoing ischemia despite maximal non-surgical therapy.
  • Ruptured Vessel
  • Cardiogenic shock with unsuitability for PCI

Case presentation

A 35 years aged female came to OPD with C/O intermittent chest pain for 1 month. TMT Tread Mill Test) was positive. She was admitted on 10.11.24 for CAG. She was known to have CAD and Hypothyroidism.  She had high lateral MI on 24.12.23 for which underwent primary PTCA to Ostio proximal LAD at Chennai Kauvery and she was having her regular follow up at Chennai and Trichy.

She was shifted to cath lab on 11.10.24 for CAG procedure and the report was Coronary Artery Disease – critical LMCA, with double vessel disease. During Angiogram BP dropped and  was managed with inotropes. Immediately CTVS opinion obtained as per cardiologist advice. She was seen by CTVS surgeon and posted for emergency CABG.

Clinical Signs

Patient was having intermittent chest pain for 1 month.

Symptoms

  • Chest pain
  • Fatigue
  • Palpitation
  • Abnormal heart rhythm
  • Shortness of breath
  • Nausea and vomiting

ECG

Pre OP ECG

Post OP ECG

ECHO Report

CAG Report

Diagnosis

  • Coronary Artery disease
  • Effort angina II
  • TMT Positive
  • Old high lateral MI
  • S/P PTCA to Ostio proximal LAD (24.12.23) out side
  • CAG – LM + double vessel disease (11.10.24)
  • Severe LV Dysfunction
  • Hypothyroidism

Management

Pre OP Nursing Management

  • Patient shifted critical care unit for continuous cardiac monitoring.
  • Nurses maintained every one hour’s vital signs and intake / output chart.
  • Blood sampling done for pre OP investigation under aseptic technique to prevent thrombophlebitis that is CBC, blood grouping, serum electrolytes, RFT, Serology and USG abdomen.
  • Doctors explained about risk and benefits of procedure to the attender and informed consent obtained.
  • Skin preparation was done and patient was given a povidone bath to minimize the risk of infection.
  • NPO instructions were explained to the patient and maintained to ensure an empty stomach.
  • The patient was shifted to OT for emergency CABG.

Post OP Nursing Management

  • The patient was transferred from the OT to the CTICU for continuous cardiac monitoring with IABP monitor and connected to ventilator.
  • Nurses monitored and maintained vital signs every 15mins, blood pressure stabilized with inotropes IV fluids and IABP.
  • Nurses trained in intravenous infusion and blood sampling techniques, collected samples for CBC, ABG, RFT, Electrolytes etc., using sterile technique to prevent thrombophlebitis
  • The doctors explained the patient condition to attenders.
  • Early up right position – up right position in and out of the bed as soon as possible after patient is woken up with endotracheal tube still in place.
  • Inotropes tapered according to blood pressure and IABP machine removed after stabilization of the patient on 14.10.24.
  • Early ambulation and mobilization done with the help of physiotherapist to prevent from deep vein thrombolysis.
  • All the bundles care followed properly to prevent from hospital acquired infection.
  • Prior to discharge, off ventilator and encouraged the patient for deep breathing exercise by using spirometer.
  • All the drains were removed and shifted to ward for further management on 5th POD and prepare for discharge.
  • On 10th POD patient condition improved and she was discharge in a stable hemodynamic status.

Advice on Discharge

  • Educated about personal hygiene, wound care and positioning.
  • Educated about to take high protein, high fibre and Vitamin – C food.
  • Explained about importance of walking and deep breathing exercise.
  • Avoid weight lifting for three months.
  • Advised to watch for any signs and symptoms of infection like – fever, redness, oozing from the operated site (pus or serous discharge).
  • Advised to take medicine properly and regularly.

Medications

DrugDoseFrequency
Tab. Clavix AS150mg0-1-0
Tab. Aztor40mg0-0-1
Tab. Flavedone MR35mg1-0-1
Tab. Dytor10mg1-1-0 (8am, 4pm)
Cap. Pantoprazole40mg1-0-1 (Before Food
Tab. Dolo650mg1-1-1
Cap. Becosules-0-1-0
Tab. Alprax0.5mg0-0-1
Tab. Dulcolax5mg0-0-1 (For Constipation)
Tab. Ivabrad5mg1-0-1
Tab. Cordarone100mg1-0-1
Tab. Thyroxine50mcg1-0-0
Tab. Oflox200mg1-0-1
Syp. Mucolite10ml1-1-1
Syp. Ulgel10ml1-1-1

Conclusion

While emergency CABG in young patients is relatively uncommon, it can be life-saving in situations involving severe coronary artery disease, acute myocardial infarction, or other serious coronary conditions. The approach to surgery and postoperative care needs to be tailored, considering both the patient’s age and the underlying pathology. The focus should be on not only the immediate surgical intervention but also on long-term cardiovascular health and rehabilitation.

References

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