COVID-19 AND ACUTE CORONARY SYNDROME WITH MULTI-VESSEL DISEASE NEEDING CABG

Background

CAD increases the risk of COVID-19 mortality. Early reports have demonstrated higher fatality rates and increased post-surgical complications in patients undergoing CABG with symptomatic COVID-19 infection. We report a case demonstrating successful post-operative course in a patient with mild symptoms requiring urgent CABG.

Case

A 64-year-old female with hypertension and diabetes presented with three days of pressure-like substernal chest pain radiating to her jaw and shortness of breath. Based on non-specific ECG changes and an elevated troponin, she was diagnosed with an NSTEMI. Her shortness of breath was thought to be related to her acute coronary syndrome. She tested positive for COVID on an asymptomatic admission swab.

Medical management for an NSTEMI with a patient with a highly contagious and deadly disease should be considered in this situation. However, given her ongoing anginal symptoms, medical management was not an option, and angiography was performed the next day. Angiography showed severe multi-vessel disease.

Decision-making

Should this patient undergo CABG with a positive COVID 19 infection? The lack of experience and ever-changing guidelines for treating patients with COVID-19 added layers of complications to this case and a debate can be made as to whether surgery is beneficial or harmful. It is unclear how major cardiac surgery alters the normal disease process of COVID-19. On one hand, revascularization would provide survival mortality from her ACS and possibly from COVID-19. On the other hand, major thoracic surgery is immunocompromising and may make her more susceptible to her viral infection. We felt her infection was mild and the benefits would outweigh the risks.

Conclusion

The patient underwent 3-vessel bypass. Afterwards, she developed ARDS related to severe COVID infection. She was treated with guideline support for ARDS, including proning, as well as steroids, remdesivir, and convalescent plasma for COVID. She was successfully extubated on post-operative day 12, and was able to be discharge home thereafter. Multidisciplinary care and understanding the individual patient risks and benefits shows that urgent CABG is possible in COVID patients.