Possible causes of death (Multiorgan failure) VT/VF intraoperatively Acute on chronic Heart failur Respiratory failure Acute Liver failure Acute renal failure Sepsis with septic shock Concern for Intestinal infarction

1. Autopsy Conference
03/02/2016
Khushboo Gandhi, MD
PGY 1, St Luke’s Hospital IM residency program

2. History of Present Illness:
79-year-old WM presents with chest pain and SOB on exertion.
Ten days ago - chest pain, tightness on anterior chest, with palpitation, resolved with sublingual nitroglycerin.
Past three to four days - chest pain continued despite NTG now radiating to left arm.
Shortness of breath on exertion and feeling tired easily.
Ten days ago - took Pseudoephedrine for allergy.
He went to Salem Township hospital, Troponins mildly elevated 0.15, BNP 180. Received NTG sublig, Lasix 80 mg, Nitro-
patch and heparin bolus, transferred to St Luke's' telemetry as his cardiologist was here.
Past Medical and Surgical history:
CAD s/p CABG x 5 in 1982, attempt at a PCI in 2008 with balloon angioplasty, MI in 2011
Recent cardiac catheterization in December 2014 - total occlusion of the native circulation and patent but severely
diseased 2 out of 3 venous grafts
Infrarenal AAA 5.4 X 4 cm, follows vascular surgeon, USG every 6 months
Transient ischemic attack in 12/2014
left subclavian arterial aneurysm and an aberrant right subclavian artery s/p bilateral carotid-subclavian bypass and TEVAR
with stent placement and embolization of the bypassed segments of the bilateral subclavian arteries in January 2015.
Hypertension
Hyperlipidemia
Chronic Kidney Disease

3. OSA on CPAP during night
History of gastric ulcers
Osteoarthritis
Hernia repair
Family History:
heart disease and hypertension in father
Social Hx:
Tobacco Use - Quit in 2008
Alcohol Use - occasional beer per week or 2 weeks.
Recreational Drug Use - Never drug user
Home meds:
Crestor 40 mg, Metoprolol Succinate ER 25 mg, Nitrostat 0.4 mg sublingual, Norco 5 mg-325 mg, Plavix 75 mg, Viagra 100
mg, amLODIPine 5 mg, aspirin 81 mg, cloNIDine 0.1 mg, fluticasone nasal spray, furosemide 20 mg as needed, omeprazole
20 mg.

4. Physical Exam:
VITAL SIGNS: Temperature 36.6, heart rate 80, respiratory rate 18, O2 saturation 96% on room air, blood pressure 137/89.
Height 177 cm, weight 97.2, body mass index 31.03.
CONSTITUTIONAL: No fever or chills.
GENERAL APPEARANCE: Looks appropriate for his age. Well-built, well-nourished appearance.
HEAD: Normocephalic, atraumatic.
MOUTH AND NOSE: Normal mucosa.
EYES: Anicteric sclerae. Normal conjunctivae. Pupils equal, round, and reactive to light and accommodation. No sinus
tenderness with palpation. Normal ears and hearing.
NECK: Supple. No visible jugular venous distention. No palpable mass or thyromegaly. No carotid bruits heard.
HEART: Irregularly irregular. Unable to appreciate any audible murmur, gallop, or rub.
LUNGS: Clear to auscultation bilaterally without any added sounds currently.
CHEST WALL: No tenderness with palpation.
ABDOMEN: Positive bowel sounds. Soft and nontender.
EXTREMITIES: Very trace edema bilaterally. Palpable weak pedal pulses. No calf tenderness. No tremors.
BACK: No spine tenderness. No costovertebral tenderness.

5. Labs:
Troponins: 0.15 → 0.82 → 1.70 → 1.58

6. EKG: Atrial fibrillation, Rightward axis, Nonspecific ST abnormality
Compared to prior on 11-Dec-2014: ST abnormality is new

7. CHEST 2 VIEWS 11/11/2015 - unremarkable
Small left pleural effusion or pleural scar, Postoperative changes.
No definite infiltrate.

8. Assessment and plan:
Symptomatic new onset of atrial fibrillation with moderate ventricular response heart rate around 90s, likely secondary to
recent OTC medication, pseudoephedrine and Claritin-D. Before transfer, he received 25 mg of metoprolol and heparin bolus.
Seen by cardiologist, and on subcutaneous Lovenox, metoprolol
Elevated troponin - non-ST elevated myocardial infarction
History of coronary artery disease - known complex coronary anatomy with bypass surgery more than 30 years ago and attempt
at a percutaneous intervention in 2008, stents could not be deployed, but he did have balloon angioplasty. On aspirin, Plavix,
statin, metoprolol, nitroglycerin patch.
Cardiac catheterization in December 2014 - showed total occlusion of the native circulation and patent but diseased grafts to
marginals, patent graft to the LAD, and a patent graft to the right coronary artery with disease in the posterior descending
distal to it.
History of abdominal aortic aneurysm, 5.2x4 cm in size, follows vascular surgeon, usg q 6 months
Dyslipidemia, on statin.
Chronic diastolic congestive heart failure on small dose of furosemide.
chronic kidney disease stage II.
Hypertension on Imdur and metoprolol, amlodipine
History of recent transient ischemic attack in 12/2014, on aspirin, Plavix, and statin.
History of right subclavian bypass surgery January 12, 2015, and Left carotid subclavian artery bypass, thoracic aortic stent graft
placement, bilateral subclavian artery embolization 01/19/2015.
History of gastric ulcers status post upper endoscopy, colonoscopy in September 2011 for melena, on omeprazole.
Ex-tobacco use, quit in 2008, No COPD.

9. Day 2 11/12/2015
Patient still in A. fib with moderate ventricular response, HR 80s/min
Angina, currently controlled
Elevated troponin trending down (1.70 → 1.58 → 0.82)
Repeat EKG - No Significant Changes compared t0 11/11/2015
Decided against cardiac cath - as troponin trending down and according to patient wish.
if symptoms persist, he would need cardiac cath and possible CABG redo
Dyspnea, resolved. Decided against CT chest or USG of lower ext for suspected PE, as pt already received 2-3 dose of Lovenox, and in
the absence of calf pain, lovenox discontinued later that day.
Echo 11/12/2015
1.The rhythm during the study was atrial fibrillation.
2.Mild to moderate concentric left ventricular hypertrophy.
3.Normal left ventricular diastolic function for age as measured by tissue Doppler/Mitral Doppler indices.
4.Normal left ventricular cavity size and systolic function. The left ventricular ejection fraction is measured at 54%.
5.There is mild left atrial enlargement.
6.Mild focal thickening of the anterior mitral valve leaflet.
7.Mild mitral regurgitation.
8.Tricuspid aortic valve. Trace aortic regurgitation. No significant aortic stenosis.
9.Tricuspid regurgitant jet velocity envelope is inadequate for determination of RVSP.
10.Compared to prior study of 12/12/2014, there is no significant change.

10. Day 3 11/13/2015
Pt felt “great”
Labs unremarkable
Discharged home
DISCHARGE MEDICATIONS:
1. Acetaminophen/hydrocodone 5 mg/325 mg 1 tablet oral every 4 hours p.r.n. for pain.
2. Loratadine 10 mg oral daily.
3. Amlodipine 5 mg oral daily.
4. Eliquis 5 mg oral b.i.d. for 30 days.
5. Clonidine 0.1 mg oral p.r.n. for high blood pressure.
6. Plavix 75 mg oral daily.
7. Fluticasone, 1 spray nasal b.i.d.
8. Furosemide 20 mg oral as needed.
9. Imdur 30 mg oral daily.
10. Metoprolol 25 mg oral daily.
11. Nitroglycerin 0.4 sublingual as needed p.r.n. for chest pain.
12. Omeprazole 20 mg oral daily.
13. Crestor 40 mg orally at bedtime.

11. Day 4 11/14/2015
Pt presented to ER with worsening chest discomfort associated with some nausea and minimal diaphoresis.
Physical examination:
Elderly white male, currently in no acute distress, alert, oriented, and cooperative.
Vitals: afebrile. Pulse 96, atrial fibrillation, respirations 18, blood pressure 120/90.
Neck is supple without jugular venous distention.
Lungs are clear.
Heart is irregularly irregular. There is a grade 2/6 systolic ejection murmur. No diastolic murmur and no gallop. Radial, carotid, and
femoral pulses are palpable. Pedal pulses are diminished.
Abdomen is unremarkable.
EXTREMITIES: No significant edema.
EKG: Course Atrial fibrillation, Rightward axis, Nonspecific ST abnormality , probably digitalis effect
Compared to prior on 12-Nov-2015: No Significant Changes
CHEST SINGLE VIEW: No acute process or significant change in the chest.
Labs: CBC unremarkable, BUN 22, Creatinine 1.4, Troponin 1.64
Serial troponins: 1.64 → 11.80

12. Plan: Admitted to telemetry, However as chest pain was relieved, plan was made to continue medical management.
In case of recurrent angina, consider catheterization. Imdur and metoprolol dose doubled.
Day 5 11/15/2015
Pt asymptomatic, 2 episodes of NSVT (6 beats) during night
Troponin trending down to 1.64 → 11.8 → 8.57 → 3.53
A fib. rate controlled, HR in 70s-80s
Same day @ 1716
On call resident was called for chest pain, HR 110s/min, BP 160/112
Chest pain resolved after two sublingual NTG.
Trop stat 3.53
Repeat EKG:
Atrial fibrillation with rapid ventricular response
Rightward axis
Marked ST abnormality, possible inferolateral subendocardial injury
Compared to prior on 14-Nov-2015: HR is faster and ST changes are more pronounced
Serial troponins: 3.53 → 3.69 → 2.59

13. Day 6 11/16/2015
Pt was taken for cardiac catheterization
Report:
1. Normal left ventricular ejection fraction approximately 55% with anterolateral hypokinesia.
2. Moderately elevated LVEDP of 17 mmHg.
3. No mitral regurgitation.
4. Severe native 3-vessel coronary artery disease.
5. Left internal mammary artery to the left anterior descending is patent and visualized by a nonselective ascending aortogram.
6. The saphenous vein graft to the right posterior descending artery is patent with an ostial posterior descending artery stenosis of
80%.
7. The saphenous vein graft to the first diagonal branch of the left anterior descending has a 60% to 70% ostial stenosis.
8. The saphenous vein graft to the second obtuse marginal branch has a 99% ostial stenosis and 60% stenosis at the vein graft
anastomosis.
Decision was made to proceed with redo coronary artery bypass grafting. Plavix and eliquis discontinued and Heparin drip was
started.
Day 7-9
Transferred to the cardiovascular step down unit and cardiothoracic surgery was consulted for redo sternotomy, redo coronary
artery bypass grafting, and possible left atrial appendage excision and pulmonary vein isolation for atrial fibrillation.
Surgery was planned on November 20, 2015. Waiting for eliquis, plavix washout and improvement of creatinine.
STS risk score was approximately 7.085%.

14. PFT: Flow volume loop demonstrated moderate reduction of FVC, No airflow obstruction consistent with a restrictive impairment.
Recommend lung volume measurement to evaluate this abnormality.
Carotid BL duplex scan
1.The right internal carotid artery disease is consistent with a 50-69% stenosis per Doppler, closer to 69% per image.
2.The left internal carotid artery disease is consistent with a 50-69% stenosis by Doppler, closer to 69% per image.
3.Tandem lesions in the bilateral internal carotid arteries may underestimate the degree of stenosis by Doppler.
4.Abnormal flow is noted in the left vertebral artery.
5.Patent bilateral common carotid to subclavian artery bypass grafts with PTFE.
6.Consider vascular consultation. Consider CTA over MRA if clinically indicated.
Had some chest pain overnight (11/18/2015), started on integrilin drip
Repeat EKG:
Atrial fibrillation with rapid ventricular response, Rightward axis
Marked ST abnormality, possible inferolateral subendocardial injury
Compared to prior on 15-Nov-2015: No Significant Changes
Serial troponins: 1.77 → 2.30 → 1.81

15. Day 10, 11/20/2015, Day of surgery
CTS: Redo CABG, Right pulmonary vein isolation, Insertion of an IABP.
Details: SVG → marginal of circumflex, SVG → diagonal, SVG → RPD, LIMA found and preserved
Right pulmonary vein isolation done, but posterior pericardium very "stuck", so LAA excision and left PVI not done.
Just before sternal closure, he went into VT/VF and could not be cardioverted. Replaced on CPB and successfully converted.
Some RV dysfunction was noted after sternotomy. IABP placed for hemodynamic support.
Very oozy after second pump run.
Blood products replaced: 8u prbc, 5u FFP, 3u SDP, 10u cryo, Factor 7.
Sternal closure caused hypotension, so chest left open.
CHEST SINGLE VIEW 11/20/2015 @19:40 Post open heart surgery.
Cardiac operative changes with support system as described, Left perihilar infiltrates and possible tiny basal pleural effusion.
Pt was transferred to SICU intubated, with IABP 1:1, on epi, NE, milrinone, DBA, vaso, amiodarone, inhaled flolan. Cardiac index ~2.5
and MAP in 70's on arrival.

16. Plan:
Sedated and intubated.
Postoperative Cardiogenic shock, cont IABP 1:1, epinephrine, milrinone, dobutamine. Amiodarone for AF.
Inhaled flolan for RV support.
Postoperative AKI, cont Foley, monitor UOP, trend Creatinine.
Ancef for periop Abx.
Day 11, 11/21/2015, Postop day 1
Patient condition relatively unchanged overnight. Slight increase in epi requirement.
He remains intubated/sedated, followed commands & moved ext x4, requiring IABP (1:1), epi, levo, vaso, dobutamine, amio, and
inhaled flolan for inotropic and pressor support.
He continues to make adequate urine, CT w/ 350 cc bloody output overnight, receiving 2nd unit of pRBC for Hgb=7.9.
Plan for return to OR later in the week for closure
CHEST SINGLE VIEW 11/21/2015 0600
Extensive postoperative changes, as described.
Increasing left hemithorax opacification (presumably from hemorrhage or fluid) and right basilar infiltrate or atelectasis.

17. Renal USG for Acute AKI
Small left renal cyst, otherwise normal sonographic exam of the kidneys.
Day 12-13, Postop day 2-3:
Develops severe acute kidney injury with anuria, hyperkalemia and acidosis
Creatinine: Potassium:
Right femoral venous double-lumen hemodialysis catheter placed - HD
started

18. Labs: AST, ALT after 10 hours

19. CHEST SINGLE VIEW Postop day 3:
● Essentially unchanged left-sided infiltrates.
● Small bilateral pleural effusions.
● Rounded area of mildly consolidative
atelectasis/infiltrate in the right perihilar
and basilar location.
● likely lap sponge overlying the inferior
sternum.

20. Some new Assessments on postop day 3:
Postoperative cardiogenic shock, requiring vasopressors
Postoperative respiratory failure requiring mechanical ventilatory support.
Acute renal injury requiring daily hemodialysis.
Postoperative ischemic hepatitis.
Chronic atrial fibrillation.
Leukocytosis.
Postoperative thrombocytopenia.
Day 14, 15, Postop day 4, 5:
The patient remained fairly stable on milrinone and dobutamine and epinephrine drips.
Vasopressin has been on and off. Remains on dialysis.
He was taken back to the OR, to clean of the left pleural space and see if closure is possible.
Operative report: Mediastinal exploration and sternal closure
Returns to the SICU intubated and sedated. The sternum was closed; a negative pressure dressing was placed over the skin.
Continues to be on Flolan, Hemodynamics stable on the Amiodarone, dobutamine, epinephrine, milrinone, Precedex, and
vasopressin.
HIT ELISA negative 11/25

21. Day 16 - 18 Postoperative day 6-8:
Hemodynamically, he seemed to be tolerating sternal closure reasonably well.
Clinically, remained in anasarca despite of daily hemodialysis Platelets trend:
His liver function was getting worse with a bilirubin up to 11.6.
hematologist was consulted for persistent thrombocytopenia
Recommendations: majority of his thrombocytopenia is due to peripheral destruction
from intra-aortic balloon pump - IABP removed
Day 19 Postop day 9:
Pt remains intubated, failed SIMV 'trial', Pulmonary consult made, respiratory culture obtained
Still requiring vasopressors
RUQ US for persistently elevated LFTs
Remains on daily HD
Empirically receiving Vanc and Ceftazidime
Improved thrombocytopenia, not actively bleeding
US abdomen:
Gallbladder is normal in size. There is a moderate amount of sludge within the gallbladder, this may be secondary to fasting. There
is slight gallbladder wall thickening, this is nonspecific. The bile ducts are normal. Small right pleural effusion.

22. Day 20 - 27 Postop day 10-17:
Started on TPN as not tolerating tube feedings very well
Continued to have leukocytosis, respiratory culture grew Klebsiella pneumoniae and a diagnosis of tracheobronchitis made,
Continued on IV ceftazidime, planned for tracheostomy later that week
Blood culture remained negative
Also had loose bowel movements after suppository, C diff was negative.
Tunneled dialysis catheter was placed into the right internal jugular vein for dialysis
BP remained low requiring pressor support, CVP remained elevated at 15-17 mmHg.
ceftazidime changed to ceftriaxone later in the week due to persistent low-grade temperature and worsening leukocytosis
Later linezolid and micafungin was added as patient was at risk for nosocomial bloodstream pathogens.
Percutaneous tracheostomy was placed on day 24, postop day 14 for his inability to wean from mechanical ventilation
Later in the week, His pressor support requirement decreased and he received epinephrine only during hemodialysis.
Repeat Echo: Distal septal, anteroapical and apical dyskinesia and LVEF reduced
Day 28 - 31, Postop day 18 - 21:
Overnight developed abdominal distention, KUB - diffuse dilatation of intestine consistent with ileus.
Zyvox was discontinued and course of ceftriaxone completed
Micafungin discontinued due to severe jaundice and hepatocellular dysfunction.
Right upper quadrant USG repeated: No evidence for main hepatic or portal vein thrombosis, 2.5 cm complex right renal cyst, small
right pleural effusion, Inadequate visualization of the entire pancreas.
Tube feeding restarted on 12/09/2015
Pt was off the vasopressors support, LFTs trending down but bilirubin still very high at 33

23. Additional tests:
Ammonia 21
Anti smooth muscle IgG - Negative
Antimitochondrial antibody - Negative
Day 32, postop day 22
WBC count - 29.7
Chest X Ray - Mild left lower infiltrates and small pleural effusion.
C. diff and blood culture remained negative
As he remained afebrile and in the absence of any source of infection, no antibiotics were started
CT chest abdomen pelvis - due to marked rise in leukocytes and persistently elevated LFTs and bilirubin
1. Patchy bilateral pulmonary infiltrates, suggesting infection or low-grade pulmonary edema. There are small bilateral pleural
effusions.
2. Collapsed gallbladder, without intrahepatic or extrahepatic biliary duct dilation.
3. Colonic wall thickening involving the right colon and possibly the sigmoid, nonspecific, possibly seen with colitis. No evidence of
bowel obstruction.
4. Infrarenal aortic aneurysm.
CT head w/o contrast due to worsening mental status - essentially unremarkable

24. Day 33 - 34, Postop day 23 - 24
Had hypotension overnight and had to be started on vasopressors
WBC - 34.6
Started empirically on broad spectrum antibiotics and Rx for c. diff colitis.
Virtually unresponsive to verbal or physical stimuli.
Diagnosis of sepsis with sepsis shock was made with suspicion for ischemic colitis. C. Diff remained negative.
Day 35, Postop day 25
Family decided to withdraw care.
Code status changed to level 3 comfort care.
Levophed was not restarted after the last bag, dialysis was discontinued, ventilator discontinued @ 1952
Day 36, Postop day 26, 12/16/2015 @ 0113 patient expires.

31. Possible causes of death (Multiorgan failure):
VT/VF intraoperatively:
Could not be cardioverted. Replaced on CPB and then successfully converted, (Could not find the time required)
Required 8u prbc, 5u FFP, 3u SDP, 10u cryo, Factor 7
Significant Hypotension on sternal closure.
Acute on chronic Heart failure:
Cardiomegaly with marked left ventricular hypertrophy
Severe coronary artery disease, involving the native coronary arteries and two of three old vein grafts.
Recent coronary bypass grafts were intact and patent.
Myocardial infarction:
Remote myocardial infarction, small foci.
Subacute extensive myocardial infarction (3-6 weeks prior to death), involving the septum and much of the left ventricle.
Acute myocardial infarction (approximately 12 hours prior to death), involving the apex.
Respiratory failure:
Not able to wean from mechanical ventilation
Tracheobronchitis with Klebsiella pneumoniae
Autopsy:
Patchy bilateral edema and BOOP like changes
Well-organized thrombus in a single distal pulmonary artery, but no evidence of clinically significant embolism to the lungs.

32. Acute Liver failure:
Markedly elevated bilirubin level, AST and ALT
No evidence of hepatitis or cirrhosis, and no gross evidence of biliary tract obstruction on autopsy.
Cholestasis - likely secondary to ischemic injury and/or a pharmacologic agent.
Acute renal failure:
with anuria, hyperkalemia and acidosis requiring daily HD
Autopsy: Tubular atrophy and interstitial fibrosis, consistent with ischemic injury
Sepsis with septic shock:
Markedly elevated WBC
Persistent hypotension requiring vasopressor support
Possible source of infection - Tracheobronchitis with Klebsiella pneumoniae
Lactic acidosis, thrombocytopenia, hyperbilirubinemia
Multiorgan failure, Glasgow Coma Scale <6
C diff and Blood culture remained negative (Pt already received broad spectrum antibiotics)
Concern for Intestinal infarction: No evidence of intestinal infarction on autopsy
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Thank You

34. Autopsy Findings:
Cardiovascular System
A. Severe coronary artery disease.
1. Remote history of bypass grafting.
a. Severe atherosclerotic disease involving the native coronary arteries and two of three old vein
grafts.
b. Left inferior mammary artery graft patent.
2. Recent history of bypass grafting.
a. New vein grafts intact and patent.
3. Myocardial infarction.
a. Remote myocardial infarction, small foci.
b. Extensive subacute myocardial infarction (3-6 weeks prior to death), involving the septum and much
of the left ventricle.
c. Superimposed acute myocardial infarction (approximately 12 hours prior to death), involving the
apex.
B. Severe atherosclerotic disease of the aorta and great vessels.
1. Severe calcific atherosclerosis of the descending thoracic and abdominal aorta.
2. Abdominal aortic aneurysm, infrarenal, 5 cm, with narrowing of the aorta distal and immediately proximal to the
aneurysm.
3. Narrowing of the renal artery ostia, left mild, right severe.
4. Aneurysms of the bilateral subclavian arteries.
a. Status post bilateral subclavian-carotid bypass.
b. Status post coil-induced thrombosis of the bilateral aneurysms.
c. Status post endovascular aortic repair with stent present in the aortic arch / proximal descending

35. II. Respiratory System
A. Patchy bilateral edema.
B. Well-organized thrombus occluding a single small distal artery in the right upper lobe.
III. Hepatobiliary System
A. Cholate stasis of the liver, consistent with marked/prolonged cholestasis.
B. Gallbladder and biliary tract intact and patent.
IV. Genitourinary System
A. Tubular atrophy and interstitial fibrosis, consistent with ischemic injury.
B. Benign right renal cortical cyst, approximately 2 cm.