A case report: Myeloproliferative Neoplasms (MPNS) with CABG

Ms. Estharrani S1*, Ms. Kanimozhi A2, Ms.Pushpa3

1Nursing Superintendent, Kauvery Heartcity, Trichy, India

2OT Assistance Manager, Kauvery Heartcity, Trichy, India

3OT Incharge, Kauvery Heartcity, Trichy, India

*Correspondence: M: +91 8508698000; email: [email protected]

Abstract

Coronary artery bypass grafting (CABG) is a major surgical operation where atheromatous blockages in a patients coronary arteries are bypassed with harvested venous or arterial conducts. The bypass restores blood flow to the ischemic myocardium, which in turn, restores the functions, viability and relieves angina symptoms.

Almost 4,00,000 CABG surgeries are performed each year making it the most commonly performed major surgical procedure, but surgeries have decreased, as the use of alternative options such as medical treatment and Percutaneous Coronary Intervention (PCI) have increased.

This activity highlights the role of the inter-professional team in the management of patients with CAD.

Myeloproliferative neoplasms are considered to increase the risk in cardiac surgery. In patients with myeloproliferative neoplasms, increased rates of perioperative infections and thromboembolic complications can be expected but studies analyzing the impact of myeloproliferative neoplasms on outcomes after cardiac surgery are lacking.

Background

Myeloproliferative neoplasms (MPNS) are hematopoietic stem cell neoplasms with a high risk of thrombosis, including acute myocardial infarction (AMI), however, outcomes after AMI have not been thoroughly characterized.

Case Presentation

A 55 years old male patient came to the emergency department with history of chest pain. He had previous history of ACS in 2020 and had undergone PCI to RCA and LAD. The recent admission was on 24/10/2023 when he had presented with complaints of chest pain. He was diagnosed as recent IW- PW- LW MI and was lysed with Inj. Streptokinase in the ER.

Echo indicated moderate LV dysfunction, grade I, diastolic dysfunction, Aortic sclerosis and mild concentric LVH. EF was 35%. His coronary angiogram revealed triple vessel disease and was advised CABG. However he needed hematologist and nephrologist opinions in view of abnormal hemoglobin and renal parameters. Hemoglobin, PCV and Creatinine were elevated.

Other symptoms

  1. Fatigue
  2. Weakness
  3. Weight loss
  4. Splenomegaly
  5. Brushing and bleeding
  6. Night sweats
  7. Pain in bones or joints

Symptoms pertaining to Polycythemia Vera

  1. Headache
  2. Dizziness
  3. Fatigue
  4. Blurred or double vision

 

Pre – Operative Lab Investigations

S No

Investigation Name

Patient Value

Normal Value
1 Hemoglobin 18.4g/dl 13-17g/dl
2 Packed Cell Volume (PCV) 57.7% 40-54%
3 Total WBC count 15200 cells/cumm 4000-10000

Differential Count WBC
5 Neutrophil 83.8% 40-75%
6 Lymphocyte 8.6% 25-40%
7 Monocyte 5.6% 1-8%
8 Eosinophil 1.7% 1-6%
9 Basophil 0.3% 0-1%
10 Red Blood Cell Count 8.28 ml/10 4.5-6.0
11 MCV 69.6fl 80-96
12 MCH 22.2pg 27-32
13 MCHC 31.8 g/dl 32-36
14 Platelet Count 366000cells/cum 140000-400000
15 Urea Serum 30.5 mg/dl 10-50
16 Creatinine serum 1.72mg/dl 0.5-1.4

Activated Partial Thromboplastin Time
18 Test 140.2sec 20.76-29.84
19 Control 25.3sec

X-Ray

Myeloproliferative-1

Serology

  1. HIV (1 and 2) Serum by ECLIA
  2. HCV antibody (ECLIA) – Non-reactive
  3. HBsAg (ECLIA) – Negative

USG Abdomen

  1. Moderate splenomegaly
  2. Bilateral renal parenchymal changes

Molecular Cytogenetics Report

Negative for BCR/ABLI fusion

Myeloproliferative-3

JAKV2 V617F Mutation Study by real time PCR

Result: Detected

 

Myeloproliferative-2

In view of the above Myeloproliferative Neoplasm (MPNS) was diagnosed

But in view of the high-risk CAD, CABG was offered

Hematologist Oncologist Opinion

In view of the Laboratory findings, the patient was diagnosed with Polycythemia Rubra Vera and the patient was advised for

  1. Venesection of 450 ml if required
  2. Proceed for the surgery
  3. Post-surgery if no infection to restart with C. Hydroxyurea 500 mg

Nephrologist Opinion

  1. Patient can be taken for CABG
  2. Moderate High risk
  3. Kindly avoid NSAID/Aminoglycosides to avoid intraop hypotension
  4. I/O chart to be strictly monitored
  5. Fluids 1.5L/day
  6. To review in postop period

Hence patient was taken up for CABG.

Operational notes

  1. LAD artery was 1.75mm diameter. LIMA was anastomosed to end to side with 8-0 prolene sutures.
  2. OM1 artery was 1.5mm diameter with mild plaque. The segment of the saphenous vein was anastomosed end to side with 8-0 prolene suture and the graft flushed well. The proximal end of the graft was anastomosed to the aorta with 6-0 prolene sutures.
  3. PDA artery was 1.5 mm diameter with mild plaque. The segment of the saphenous vein was anastomosed end to side with 8-0 prolene sutures and the graft was flushed well. The proximal end of the graft was anastomosed to the aorta with 6-0 prolene sutures.
  4. Mild line sternotomy division of thymus. Peri-cardiotomy, systemic heparinisation after harvesting of conducts. Grafting done as mentioned above with tissue stabilizers. Hemostasis and sternal closure with mediastinal and left pleural drains.

Post-Operative Management

On 30/10/2023 – 0 POD

On 02:00pm patient received from HCOT with ambu ventilation and then connected to mechanical ventilation. Pre-lateral air entry equal.

SIMV (PC+PS) with FW2 – 100%, RR – 16, PC – 15, PS – 10, PEEP – 5 in ET size of 8.5mm.

Patient chest drain was-290ml

Urine output-870ml

Supports are Inj. Adrenaline 0.1ml/hr – 2ml/hr

Inj. Noradrenaline 1.1ml/hr – 5.5ml/hr

Inj. NTG 0.1ml/hr

Blood withdrawal done-2 units (350ml + 350ml)

On 31/10/2023 I POD

Patient on extubation done connected to O2 mask

Ryles tube removed.

Chest drain – 420ml

Urine output – 1615ml

Supports are Inj. Adrenaline – 1ml/hr

Inj. Noradrenaline – 5ml/hr

Inj. Lasix – 4ml/hr

On 01/11/2023II POD

No chest drain

Urine output – 1480ml

Supports are Inj. Adrenaline – 1ml/hr

Inj. Noradrenaline – 5ml/hr

Inj. Lasix – 4ml/hr

Inj. Dopamine – 5ml/hr

On 02/11/2023 III POD

S/P left side ICD insertion done. Urea – 109, Creatinine – 3.36 so, advised to get nephrologists opinion sir ordered to do I/O chart fluid 1.5mll/day, to take a medication

Tab. Nefrosave – BD

Tab. Nodosis – BD to taper Lasix.

On 03/11/2023 IVPOD

On 4th POD patient antibiotic was changed to Inj. Magnex 1.5g. Supports were stopped.

Post-Operative Investigation

S N

Investigations

Patient Value

Normal Value
1 Hemoglobin 9.8g/dl 13-17g/dl
2 Packed Cell Volume 30.2% 40-54%
3 Urea Serum 119mg/dl 10-50mg/dl
4 Creatinine Serum 3.43mg/dl 0.5-1.4
5 Sodium Serum 134meg/l 136-145
6 Potassium Serum 4.02mmol/l 3.5-5

 

Post OP ECHO

 

  1. S/P CABG
  2. Moderate LV dysfunction
  3. No Pericardial effusion/clot

 

 

Discharge Medication Advice

 

 

S No

Medications

Dose

Frequency
1 Tab. Clavix AS 150mg 0-1-0
2 Tab. Aztor 40mg 0-0-1
3 Tab. Ivabrad 5mg 1-0-1
4 Tab. Prolomet XL 12.5mg 1-0-0
5 Tab. Flavedon MR 35mg 1-0-1
6 Tab. Dytor 10mg 1-1-0

(08:00am and 04:00pm)
7 Cap. Pan D 40mg 1-0-1
8 Tab. Dolo 650mg 1-1-1
9 Cap. Becosules – 0-1-0
10 Tab. Alprax 0.5mg 0-0-1
11 Tab. Dulcolax 5mg 0-0-1
12 Tab. Augmentin 625mg 1-0-1 ×5 Days
13 Tab. Bifilac 1-0-1
14 Syp. Mucolite 10ml 1-0-1
15 Syp. Ulgel 10ml 1-1-1
Dr. Balaji Advice
1 Tab. Nefrosave – 1-0-1
2 Tab. Nodosis 500mg 1-0-1

We scheduled his review after 2 weeks from the discharge date and he was advised to follow all instructions at his home.

Conclusion

Patient with coronary artery disease along with myeloproliferative neoplasm- polycythemia in thin instance – have higher risk of in hospital death as there is a higher risk of thrombosis post procedure CABG > PCI.

More case reports are needed to understand the significant of in-hospital mortality in this subset group of patients.

Esthar

Ms. Esthar Rani S

Nursing Superintendent

Kanimozhi

Ms. Kanimozhi

OT Asssitant Manager

Pushpa

Ms. Pushpa

OT Incharge

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