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Case reports Journal

International Case Reports Journal (ISSN: 2770-9647)

International Case Reports Journal (ISSN: 2770-9647) (DOI: 10.5281) is an open access international journal

Introduction
Specific management of post coronary bypass graft ischemia in patients presenting with ST-Elevation Myocardial Infarction (STEMI) is not well defined. We present a case of Post CABG STEMI (anterior wall) successfully managed by PCI to LIMA graft.
Case Report
A 56 Years old male, Hypertensive, smoker presented with complaints of angina on exertion Class III. His biochemistry was within normal limits. His ECG showed normal sinus rhythm, no significant st-t changes and echo revealed mild concentric LVH, NO RWMA, LVEF 60%. Coronary angiography was done which revealed triple vessel disease with SYNTAX score 28 and CABG was planned. He underwent CABG with LIMA to LAD/diagonal and SVG to PDA and OM. Post CABG (day 0), there was excessive drainage from mediastinal drains, and re-exploration was done which showed-bleeding from LIMA-diagonal anastomosis and Redo-side to side parallel LIMA anastomosis on D1, LAD done. On post CABG day 1 patient developed hypotension with ECG showing ST elevation in anterior leads and ECHO revealed RWMA in LAD territory with LVEF 35%. Urgent cardiology consultation taken by CTVS team and after discussion with attendants of the patient coronary angiography was done which revealed subtotal occlusion in mid part of LIMA graft with thrombus. As native LAD was a CTO so revascularization with PTCA/Stenting o LIMA was planned. Successful PTCA and stenting to LIMA to LAD done using two drug eluting stents. Patient became hemodynamically stable and extubated the next day and discharged post op day 7 (Figure 1 and 2).
Discussion
Postoperative MI occurs in 2%-15% of patients following cardiac surgery. It leads to reduced survival both short and long term, longer hospital stays and results in a greater burden on hospital finances.
Establishing a definite diagnosis of postoperative MI is not an easy task. A wide range of lesions varying from transient myocardial ischemia to complete necrosis can occur. The classical clinical approach using elements such as chest pain, ECG changes and increased cardiac enzymes (CK-MB, troponin) can be misleading and inadequate, missing numerous coronary events albeit less severe but requiring intervention. Typical chest pain may be absent due to postoperative analgesia. Q waves are frequently absent and non-specific ECG modifications following cardiac surgery can blur clinical presentation. Finally, elevation of enzymes especially post- surgery CK-MB can further complicate the interpretation of biomarkers in the diagnosis of MI. Current recommendations suggest that biomarker values above ten times the 99th percentile of the normal reference range during the initial 72 hours following CABG, when associated with the appears of new pathological Qwaves or new LBBB, or angiographically documented new graft or native coronary artery occlusion, or imaging evidence of new loss of viable myocardium, should be considered as diagnostic of CABG-related myocardial infarction. In general, Type 5 MI is mainly due to an ischemic event because of either new graft occlusion, new native artery occlusion or inadequate cardioprotection.
The causes are endothelial injury due to surgical manipulations and endothelial activation due to hemodynamic stress or transient ischemia leads to release of prothrombotic/proinflammatory molecules leading to graft occlusion.

Post CABG Stemi: A Clinical Challenge?

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