High-Risk Coronary Artery Bypass Grafting in a 74-Year-Old Patient with Multiple Comorbidities

Abstract: This case study explores the successful management and treatment of a 74-year-old female patient who presented with multiple comorbidities, including severe coronary artery disease, acute coronary syndrome, and other systemic complications. The patient underwent a high-risk Off-Pump Coronary Artery Bypass (OPCAB) surgery at Vadamalayan Hospital, Dindigul. This report highlights the expertise of the surgical team, the pre- and post-operative management, and the critical role of a multidisciplinary approach in achieving a successful outcome.

Introduction:

Coronary artery bypass grafting (CABG) in elderly patients with multiple risk factors poses significant challenges due to their vulnerability to perioperative complications. This case involved a 74-year-old woman with a range of pre-existing conditions, including coronary artery disease, acute coronary syndrome, type II diabetes mellitus, and bilateral peripheral vascular disease. The patient underwent surgery at Vadamalayan Hospital in Dindigul, under the expert care of Dr. Sathiya Selvam M., MS, MCh., Cardiothoracic Surgeon, and Dr. Dhev Anand M., MD, PDCC, leading to a remarkable recovery despite the high perioperative risk.

Case Presentation:

A 74-year-old female from Dindigul was admitted to Vadamalayan Hospital on 30.08.2024, after presenting with breathlessness and chest pain. Her medical history was significant for a variety of conditions, including:

• Coronary Artery Disease (CAD) with Left Main and Triple Vessel Disease
• Acute Coronary Syndrome (ACS)
• Acute Inferior Wall Myocardial Infarction (MI)
• Moderate Left Ventricular (LV) Dysfunction
• Acute Pulmonary Oedema
• First-degree AV Block
• Bilateral Pneumonia
• Chronic Kidney Disease (CKD)
• Bilateral Peripheral Vascular Disease (PVD)
• Bilateral Carotid Stenosis
• Systemic Hypertension
• Type II Diabetes Mellitus
• Obesity
• Urinary Tract Infection (UTI)

Her clinical condition was deteriorating, requiring urgent intervention. Given the complexity of her condition and high risk of complications, it was decided that she would undergo Off-Pump Coronary Artery Bypass (OPCAB) surgery.

Preoperative Evaluation and Risk Assessment:

The patient’s preoperative condition was severe, marked by her significant coronary artery disease and other systemic comorbidities, including Chronic Kidney Disease (CKD) and Bilateral Peripheral Vascular Disease (PVD). The preoperative evaluation, which included assessments of her cardiovascular, respiratory, renal, and metabolic statuses, indicated a high perioperative mortality risk of over 50%. Her HbA1c was elevated at 8.6%, pointing to poorly controlled diabetes, which further increased the complexity of the case.

Treatment and Surgical Intervention:

On 31.08.2024, the patient was stabilized and underwent Off-Pump Coronary Artery Bypass Grafting (OPCAB). The procedure was carried out by Dr. Sathiya Selvam M., MS, MCh, a highly experienced cardiothoracic surgeon with expertise in high-risk cardiac surgeries. The surgical team performed a triple bypass using the following grafts:

• LIMA (Left Internal Mammary Artery) to the LAD (Left Anterior Descending artery)
• RSVG (Reverse Saphenous Vein Graft) sequentially to the PDA (Posterior Descending Artery) and PLB (Posterior Left Branch)

This technique of off-pump surgery was selected to reduce the risks associated with cardiopulmonary bypass, such as systemic inflammation, renal complications, and stroke, particularly given the patient's bilateral carotid stenosis and chronic kidney disease.

Postoperative Course:

Despite the high-risk nature of the surgery, the patient’s postoperative recovery was remarkably smooth. She was extubated on the first postoperative day, with no signs of respiratory distress. Contrary to expectations, common postoperative complications such as:

• Sepsis
• Renal failure
• Stroke
• Arrhythmias
• Prolonged ventilation

were notably absent. The patient’s renal function remained stable, as demonstrated by creatinine levels rising only slightly from 0.8 mg/dl preoperatively to 1.3 mg/dl postoperatively. This stabilization was largely attributed to the diligent care provided by Dr. Dhev Anand M., MD, PDCC, and the Cardiothoracic Intensive Care Unit (CTICU) nursing team.

Hospital Facilities and Postoperative Care:

The CTICU at Vadamalayan Hospital, Dindigul, played a pivotal role in the patient’s recovery. Equipped with advanced monitoring systems and staffed by a team of specialized critical care nurses, the unit provided round-the-clock surveillance for any signs of postoperative complications. Under the guidance of Dr. Dhev Anand, a seasoned intensivist, the team ensured that the patient’s hemodynamics remained stable throughout her recovery period. The early mobilization and continuous care offered by the multidisciplinary team were crucial in the patient's rapid and uneventful recovery.

The patient remained under observation until her discharge on 13.09.2024, after a thorough assessment confirmed that she was hemodynamically stable and ready for discharge. Her creatinine levels, monitored throughout her stay, showed minimal fluctuations, confirming that her renal function had remained stable post-surgery despite the initial risks posed by her chronic kidney disease.

Discussion:

The success of this case highlights several critical aspects of modern cardiothoracic surgery in high-risk patients:

1. Expertise in High-Risk Surgeries: The technical expertise of Dr. Sathiya Selvam M., particularly in OPCAB techniques, was a key factor in the patient’s successful outcome. Avoiding the cardiopulmonary bypass in this high-risk patient helped mitigate risks such as stroke and renal failure.
2. Comprehensive Preoperative Management: The meticulous preoperative evaluation and stabilization of the patient were essential in ensuring her suitability for surgery. The team carefully assessed her cardiac, renal, and respiratory functions, optimizing each system before proceeding.
3. Multidisciplinary Approach: The coordination between the cardiothoracic surgeon, the intensivist, and the CTICU team played a central role in the patient’s recovery. This highlights the importance of a multidisciplinary approach in managing complex cases, especially in smaller hospitals like Vadamalayan Hospital in Dindigul.
4. State-of-the-Art Facilities: Vadamalayan Hospital’s CTICU and post-operative care facilities were instrumental in monitoring and managing potential complications. The presence of a dedicated team and advanced technology enabled continuous monitoring, early detection of issues, and prompt intervention.

Conclusion:

This case study underscores the importance of specialized care, advanced surgical techniques, and comprehensive postoperative management in the successful treatment of high-risk cardiac patients. The outcome in this 74-year-old patient with multiple comorbidities, including severe coronary artery disease, chronic kidney disease, and peripheral vascular disease, demonstrates that, with the right expertise and hospital facilities, even the most challenging cases can be managed effectively.

Vadamalayan Hospital, Dindigul, under the leadership of skilled professionals like Dr. Sathiya Selvam and Dr. Dhev Anand, continues to provide exceptional care for high-risk patients, contributing to improved outcomes even in the most complex cardiovascular surgeries.