How should I treat a post-CABG patient who presents with myocardial infarction within two months of surgery?
A 78-year-old diabetic male with chronic stable angina had undergone a coronary arterial angiogram four months before. He was diagnosed as having triple-vessel disease and had undergone CABG about three months previously. One arterial (left internal mammary artery [LIMA] to left anterior descending [LAD]) and three venous grafts (to the diagonal, obtuse marginal [OM] and right coronary artery [RCA]) were used for CABG. He had no other comorbid conditions. About 15 days before, he developed severe retrosternal chest pain at rest lasting for four hours and since then was having angina and dyspnoea on minimal exertion. His electrocardiogram showed new Q-waves with T-wave inversion in the inferior leads, and echocardiography showed new regional wall motion abnormality (RWMA) in the inferior wall of the left ventricle. We then carried out a coronary arterial angiogram of the native and graft vessels (Figure 1-Figure 6, Moving image 1-Moving image 4) which showed a proximal LAD 95-99% lesion, proximal RCA 100%, proximal OM1 50% lesion, proximal to mid saphenous vein graft (SVG) to RCA long segment lesion 95% (TIMI 2 flow), variable degrees of stenosis of the other graftnative vessel anastomotic points.
Should we go for repeat revascularisation or keep the patient only on medical management?
If revascularisation is planned, considering the type of lesion, should we plan for redo CABG or PCI?
Moving image 1. LAO caudal view of venous graft to diagonal.
Moving image 2. LAO caudal view of venous graft to obtuse marginal (OM).
Moving image 3. LAO view of SVG to RCA.
Moving image 4. Lateral view of LIMA to LAD.
Moving image 5. LAO view showing distal embolic protection device (filter) placement.
Moving image 6. LAO view of SVG to RCA after stenting.
Moving image 7. Final LAO view after stenting and retrieval of the filter.