The patient signed informed consent for reporting his case.
A 42-year-old male smoker, who hadn’t sought medical care before,
presented to the emergency department with a two-day-history of
persistent chest pain. Electrocardiogram (ECG) showed ST-elevation in
precordial leads along with negative T-wave in inferior leads.
Troponin-T level was high (1.92 ng/ml). He had tachycardia (130
beats/min) and low blood pressure (90/50 mmHg). Coronary angiography
showed total occlusion of both the right coronary artery (RCA) and the
left anterior descending artery (LAD) (figure 1); no signs of arterial
dissection were found. An Intra-Aortic Balloon Pump (IABP) was inserted
to stabilize the patient’s hemodynamic status and PCI was attempted but
failed. Cardiac ultrasound revealed apical, septal and inferior left
ventricular (LV) wall akinesia with a left ventricular ejection fraction
(LVEF) of 30%, and no associated valvular disease. The patient was
referred to us for surgical treatment. He was admitted to the operating
room in a stable hemodynamic status under IABP. CABG was performed under
cardio-pulmonary bypass and aortic cross-clamping. During the procedure,
both mammary arteries were harvested (both were pedicled to their
corresponding subclavian arteries).
The RCA contained an organized
clot adherent to the vascular wall; it was kept and the arteriotomy
closed. The posterior descending artery (PDA) contained fresh clots.
These were thrombectomized, then an end-to-side anastomosis with the
RIMA was done. The RIMA, still pedicled to its origin, had enough length
after adequate skeletonization. The LAD was found to be large (2.5 mm in
diameter). The LAD-II arteriotomy uncovered a fresh clot that was
thrombectomized. The proximal clot was inaccessible through this
mid-segment arteriotomy; another arteriotomy was done at the LAD-I level
(video 1), and the whole clot was removed. We anastomosed LIMA to LAD-I,
side-to-side, then LIMA to LAD-II, end-to-side. Weaning of the
cardio-pulmonary bypass, needed high doses of intravenous inotropes in
addition to the active intra-aortic balloon pump (IABP). The patient was
transferred to the cardiac surgery unit in a stable condition with
adequate urine output. On the first post-operative day (POD), inotropes
started progressive titration and the patient remained stable. The IABP
was removed on POD4. The patient became fully autonomous on POD12 and
was discharged home. One month later, echocardiography showed
antero-apical left ventricular hypokinesia with an improvement of the
LVEF reaching 55%. Haematological workup including factor V-Leiden,
protein C, protein S, fibrinogen, anti-thrombin III, Factor
Von-Willebrand, and a cardiovascular panel for mutations was completely
normal. A follow-up coronary scan (figure 2) performed ten months after
surgery showed complete occlusion of RCA, patent RIMA to PDA graft,
patent native LAD bed, and patent LIMA to LAD graft.