Coronary artery bypass grafting following COVID-19 infection
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Coronary artery bypass grafting following COVID-19 infection. https://www.jnhrc.com.np/index.php/jnhrc/article/view/3789
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Coronary artery bypass grafting following COVID-19 infection
- 1. Coronary artery bypass grafting following COVID-19 infection: Difficulties and Challenges A Case Report Dr. Dharmendra Joshi Cardiothoracic and Vascular Surgeon Nepal Mediciti Lalitpur, Nepal
- 2. INTRODUCTION • The COVID-19 pandemic has raised challenges and dilemmas to perform cardiac surgery in the patients following COVID-19 infection due to lasting adverse impacts of the disease on the lungs.
- 3. CASE REPORT - History • Age/Gender: 74 years / Male • C/C: Chest discomfort • Past history: 1. Post COVID infection status with low pulmonary reserve 2. Hypothyroidism 3. Hypertension 4. Diabetic mellitus 5. Previous smoker
- 4. History • Anterior wall Myocardial Infarction (2004). • Percutaneous coronary interventions (2004) in the left anterior descending artery (LAD). • Repeated PCI in 2012 following in-stent thrombosis in LAD. • Recently done exercise-induced ischemia test (treadmill): Positive. • Infected by COVID-19 (November 2020); not hospitalized.
- 5. Clinical Evaluation • Occasional basilar crepitation in the lungs; no other significant findings. • Oxygen saturation (SpO2): 88% in room air and 90-92% with 2 liters/minute of oxygen support.
- 6. Clinical Evaluation • Chest x-ray did not reveal any gross abnormality. • ABG: PaO2 (80 mmHg); PaCO2 (40 mmHg) with 2 liters/minute oxygen.
- 7. Clinical Evaluation • Echocardiography – LVEF 40% and RWMA with previous MI • Coronary angiogram: TVD 1. RCA: non dominant, 80% (mid RCA) 2. LAD: 70% (D1), 90% instent re-stenosis (mid LAD) 3. LCX: 80% (mid LCX), 90% (Osteal OM2), 100% (OM3) • EuroSCORE II: 4.08% • STS risk score: 3.37%
- 8. Operation • Coronary artery bypass grafting under cardiopulmonary bypass (15/04/2021). 1. Left internal mammary graft to LAD (2 mm) 2. Saphenous vein graft to large D1 (1.5 mm) and OM1 (1.75 mm). • Right coronary artery was diffusely diseased and small in calibre. • The lung recruitment maneuver was provided during the intra-operative period.
- 9. Postoperative • Ventilator support weaned off in 4 hours, accepting a SpO2 of 90% with the support of high flow oxygen in a re-breather mask, requiring up to 15 liters/minute.
- 10. Postoperative • With regular chest physiotherapy, bronchodilators, breathing exercises with an incentive spirometer the oxygen requirement continued to decrease over the postoperative period (SpO2 of 85% in room air and 92% with 1-2 liters/min of oxygen supplement).
- 11. Discharge • Discharged on the 9th postoperative day with the advice of domiciliary oxygen of 1-2 liters/min.
- 12. Follow-up 1. Over a period of 3-month, his oxygen requirement was gradually decreased. 2. At 6 months and one year of follow-up: asymptomatic, no oxygen supplement requirement (resting saturation of 90 - 95% in room air).
- 13. DISCUSSION • Dilemma regarding the timing of the surgery. • The “two-hit” model that may lead to acute lung injury. • Optimization of our patient and improved the lung function for better result.
- 14. DISCUSSION
- 15. DISCUSSION • Drastic decrease in cardiac surgical procedures. • About 50% to 75% reduction in cardiac surgery case volume, 5% of centers did not perform any cardiac surgery, and one-third of centers reported more than 50% reductions in an intensive care capacity. • The risk of mortality in 5864 patients waiting for elective or emergency CABG in Sweden has increased by 11% per month.
- 16. DISCUSSION • It is recommended that cardiac surgery should be deferred where possible until the patient tests negative. • The timing of surgery has been recommended once inflammatory markers normalize and the patient is tested negative. • Timing of surgery at least 2 months following infection and normalization of respiratory parameters.
- 17. DISCUSSION • Risk factors for mortality among patients awaiting coronary bypass: 1. The left main stem disease, 2. Atrial fibrillation, 3. Decreased ejection fraction, 4. Unstable angina
- 18. DISCUSSION • Further, there is an increased risk of acute kidney injury, stroke, acute respiratory distress syndrome, etc. following coronary bypass in post- COVID patients compared to non-COVID affected patients. Fortunately our patient did not have any such complications.
- 19. CONCLUSION • Coronary artery bypass grafting may be done with caution in patients who have had previous COVID-19 infection affecting pulmonary reserve. • A judicious approach of pre-operative assessment along with post- surgical pulmonary rehabilitation may result in improved outcomes.
Editor's Notes
- More than 10 lakh infections and more than 12 thousands death in Nepal.
- lung recruitment maneuver
- There is a dilemma regarding the timing of the surgery for the patients who are tested positive for COVID-19 infection as the risk of surgery in COVID-19 positive patients is high. Post-COVID surgery is also challenging due to lung issues like post-COVID pneumonia, pneumothorax, and decreased respiratory reserve. The cardiopulmonary bypass and COVID-19 infection itself may exacerbate the systemic inflammatory response syndrome according to the “two-hit” model that may lead to acute lung injury.4 We optimized our patient and improved the lung function with intraoperative lung recruitment maneuver and postoperative regular chest physiotherapy and incentive spirometry which resulted in an uneventful postoperative period without major pulmonary complications.
- Although there are few papers and systemic review available now, due to the lack of enough information and guidelines, there was dilemma about the decision for the appropriate course of management. With the available limited guidelines, we had to take huge risk and take him to operation as he was having chest pain.
- During the COVID-19 pandemic, there is a drastic decrease in cardiac evaluation procedures and thus surgical procedures as well.6 A survey conducted during the peak of the COVID-19 pandemic that included more than 60 cardiac surgery centers and more than 600 cardiac surgeons reported about a 50% to 75% reduction in cardiac surgery case volume, 5% of centers did not perform any cardiac surgery, and one-third of centers reported more than 50% reductions in an intensive care capacity.5 The risk of mortality in 5864 patients waiting for elective or emergency CABG in Sweden has increased by 11% per month.8 Thus a judicious mechanism to identify patients requiring cardiac surgical procedures during the pandemic is necessary to prevent morbidity and mortality.
- Although not validated completely due to lack of sufficient data, it is recommended that cardiac surgery should be deferred where possible until the patient tests negative due to a significant association of morbidity and mortality.5 The timing of surgery has been recommended once inflammatory markers normalize and the patient is tested negative. Some recommend performing the surgery at least 2 months following infection. Some have individualized that the timing of surgery should be based on the normalization of respiratory parameters.6,7 In our patient, although the resting saturation remained low, we performed the surgery as the patient had unstable angina, and chest x-ray, ABG, and other preoperative evaluation findings were normal.
- The left main stem disease, atrial fibrillation, decreased ejection fraction, and unstable angina is considered the risk factors for mortality among patients awaiting coronary bypass.6 Our patient had post-MI unstable angina, hence, considering the increased morbidity and mortality rate among patients awaiting cardiac surgery, we decided to perform the procedure.