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Coronary Artery Bypass Grafting in ST-Segment Elevation Myocardial Infarction: Option of Reperfusion (Still)

Author : M. Puspitasari, Y.E. Sembiring, M.Y. Alsagaff
Upload Date : 19-04-2018

Introduction: Coronary artery bypass grafting (CABG) is considered for reperfusion in ST-segment elevation myocardial infarction (STEMI) if coronary anatomy is not amenable to percutaneous coronary intervention.

Case report: Coronary angiography of 61-years-old male infero-anterolateral STEMI diabetic patient revealed critical stenosis of left main coronary artery (LMCA), acute total occlusion of left circumflex (LCx), chronic total occlusion of left anterior descending (LAD) and right coronary artery (RCA). Due to these complex anatomy, CABG was chosen as reperfusion method. The patient had pneumonia the third day which postponed the surgery. Day by day non-invasive hemodynamic monitoring were performed to differentiate hypotension aetiology (septic and or cardiogenic). At the sixth day when cardiogenic shock was marked, intra-aortic balloon pump (IABP) was inserted. Surgery was carried out at the seventh day. Postoperative echocardiography revealed left ventricle thrombus. Dual antiplatelet and dabigatran were administrated. The patient experienced recurrent pneumonia, atrial fibrillation, and melena during stabilization. Dose and drugs adjustment were made and he was discharged 19 days after CABG with clopidogrel and dabigatran.

Discussion: CABG in STEMI is associated with high mortality and adverse event rates. Adverse events especially focus on bleeding and ischemic events related on antiplatelet discontinuation. In this case, the patient’s coronary anatomy was unsuitable for PCI. Therefore, he underwent urgent CABG at the seventh day, after DAPT discontinuation 24 hours prior to CABG. Since postoperative melena occurred after warfarin initiation, clopidogrel and dabigatran were given as discharge therapy to prevent another bleeding event.

Conclusion: CABG may be considered as reperfusion strategy on acute STEMI with special attention on timing and patient preparation prior to procedure.

KEYWORDS : STEMI, revascularization, CABG


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