Very Delayed Surgical Bleeding after Coronary Artery Bypass Graft Causing Cardiac Tamponade and Cardiogenic Shock: A Rare Case Report
DOI:
https://doi.org/10.59958/hsf.7125Keywords:
delayed bleeding, coronary artery bypass grafting, extracorporeal membrane oxygenationAbstract
Delayed surgical bleeding from the left internal mammary artery (LIMA) bed following coronary artery bypass grafting (CABG) is a rare yet potentially fatal condition that can lead to cardiac tamponade and life-threatening cardiogenic shock. We present a case of extremely delayed active bleeding from the LIMA bed, occurring 5 weeks after conventional CABG, resulting in cardiac tamponade and cardiogenic shock. The 73-year-old patient presented to the emergency room with a 2-day history of general weakness and hypotension. He had undergone CABG 5 weeks ago. Optimal inotropic agents and vasopressors were used for the treatment of shock. In the emergency room, real-time bedside echocardiography showed severe external compression of the right ventricle by a homogeneous, hyperechoic mass. Veno-arterial (V-A) mode extracorporeal membrane oxygenation (ECMO) was promptly instituted to stabilize hemodynamics. Subsequent chest re-exploration, involving blood clot evacuation, was performed, and the bleed from the distal LIMA bed was ligated. Delayed LIMA bed bleeding causing cardiac tamponade and cardiogenic shock is an infrequent occurrence, and the use of V-A mode ECMO successfully provided a window of time for chest exploration.
References
Hsu PS, Yang HY, Chen JL, Tsai YT, Lin CY, Ke HY, et al. The implication of seniority of supervising attending surgeon on the reexploration rate following elective coronary artery bypass grafting. Journal of the Formosan Medical Association = Taiwan Yi Zhi. 2019; 118: 354–361.
Mehta RH, Sheng S, O'Brien SM, Grover FL, Gammie JS, Ferguson TB, et al. Reoperation for bleeding in patients undergoing coronary artery bypass surgery: incidence, risk factors, time trends, and outcomes. Circulation. Cardiovascular Quality and Outcomes. 2009; 2: 583–590.
Miyata H, Tomotaki A, Motomura N, Takamoto S. Operative mortality and complication risk model for all major cardiovascular operations in Japan. The Annals of Thoracic Surgery. 2015; 99: 130–139.
Karthik S, Grayson AD, McCarron EE, Pullan DM, Desmond MJ. Reexploration for bleeding after coronary artery bypass surgery: risk factors, outcomes, and the effect of time delay. The Annals of Thoracic Surgery. 2004; 78: 527–34; discussion 534.
Čanádyová J, Zmeko D, Mokráček A. Re-exploration for bleeding or tamponade after cardiac operation. Interactive Cardiovascular and Thoracic Surgery. 2012; 14: 704–707.
Hansson EC, Jidéus L, Åberg B, Bjursten H, Dreifaldt M, Holmgren A, et al. Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel: a nationwide study. European Heart Journal. 2016; 37: 189–197.
Tehrani S, Rathore S. Successful percutaneous treatment of a catastrophic left internal mammary artery graft avulsion occurring 4 weeks post-coronary artery bypass grafting surgery: a case report. European Heart Journal. Case Reports. 2020; 5: ytaa524.
Biancari F, Mariscalco G, Gherli R, Reichart D, Onorati F, Faggian G, et al. Variation in preoperative antithrombotic strategy, severe bleeding, and use of blood products in coronary artery bypass grafting: results from the multicentre E-CABG registry. European Heart Journal. Quality of Care & Clinical Outcomes. 2018; 4: 246–257.
Nouraei SM, Gholipour Baradari A, Emami Zeydi A. Does Early Post-operative Administration of Aspirin Influence the Risk of Bleeding After Coronary Artery Bypass Graft Surgery? A Prospective Observational Study. Medical Archives (Sarajevo, Bosnia and Herzegovina). 2015; 69: 381–383.
Wang D, Huang X, Wang H, Le S, Yang H, Wang F, et al. Risk factors for postoperative pneumonia after cardiac surgery: a prediction model. Journal of Thoracic Disease. 2021; 13: 2351–2362.
Mubashir T, Balogh J, Breland E, Rumpel D, Waheed MA, Lai H, et al. Risk Factors and Outcomes of Protein-Calorie Malnutrition in Chronic Heart Failure Patients Undergoing Elective Cardiac Surgery. Cureus. 2022; 14: e30378.
Tasbulak O, Guler A, Duran M, Sahin A, Bulut U, Avci Y, et al. Association Between Nutritional Indices and Long-Term Outcomes in Patients Undergoing Isolated Coronary Artery Bypass Grafting. Cureus. 2021; 13: e16567.
Keskin M, İpek G, Aldağ M, Altay S, Hayıroğlu Mİ, Börklü EB, et al. Effect of nutritional status on mortality in patients undergoing coronary artery bypass grafting. Nutrition (Burbank, Los Angeles County, Calif.). 2018; 48: 82–86.
McLean AS. Echocardiography in shock management. Critical Care (London, England). 2016; 20: 275.
Combes A, Leprince P, Luyt CE, Bonnet N, Trouillet JL, Léger P, et al. Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock. Critical Care Medicine. 2008; 36: 1404–1411.