“Healing the Heart First” – The Story of Mrs. XXYYZZ High-Risk CABG Case Study
This is the story of healing the heart first and the kidney next. Mrs. xxyyzz is a diabetic and hypertensive 59-year-old female who developed Chronic Kidney Disease as a complication of diabetes mellitus and hypertension. As per the past medical history, she was diagnosed with End-Stage Renal Disease. She has been on dialysis since the last one year and is waitlisted for a renal transplant.
During the pre-transplant cardiac evaluation as an inpatient, the patient complained of chest discomfort and dyspnea. The patient had a positive treadmill test, and a coronary angiogram revealed three-vessel disease, including the left main coronary artery.
The decision was made to staged the revascularization of her myocardium before her renal transplant because of her poor renal function. Her severely decreased kidney function made any major cardiac surgery seem relatively contraindicated and extremely high risk to some clinicians. The patient was not considered a good candidate for a renal transplant till her cardiac function was stabilized. At the same time, the CABG surgery also had potentially deleterious effects on the kidneys of the patient. The case was then discussed in a multi-disciplinary team consisting of nephrologists, cardiologists, anaesthetists, and cardiac surgeons. The consensus decision was to go for a high-risk bypass surgery to stabilize the patient’s condition and give her a chance at a renal transplant.
Dr. Srinath Vijayasekharan and Dr. Senthilkumar, expert cardiac surgeons, agreed to perform the surgery.
The patient came before us on the morning of the surgery and said, “Fix my heart so that I can one day wake up with a new kidney.”
A coronary artery bypass graft surgery was performed by Dr. Srinath and Dr.Senthilkumar. The surgery was performed off-pump to reduce the stress on the renal system. The left internal mammary artery was grafted to the left anterior descending artery, while venous grafts were fashioned and anastomosed to the right coronary artery and the circumflex artery. The bypass grafting took more than five hours. Anaesthetic agents were also administered in doses to avoid hypotension and fluid retention, which could have severely compromised the renal function.
Post-op, the patient’s kidney function was not at its best, leading to oliguria. Dialysis was initiated the following day due to rising serum potassium levels and fluid retention. The patient was managed with SLED dialysis and then transitioned to intermittent dialysis.
The patient’s post-operative period was complicated by several anticipated and unanticipated occurrences. However, no infections, arrhythmias, hypotension, or cardiopulmonary insufficiency occurred. She was noted to be responding well to the interventions by day two. The patient could sit up and talk to her family on the second day. Ms. xxyyzz was walking short distances in the ICU corridor and was discharged on the seventh day after the surgery. The patient was put back on dialysis. She was again placed on the renal transplant list three months later.
Currently, Ms. xxyyzz is leading a happy and healthy life, looking forward to receiving a new kidney.
