Cardiovascular Journal of Africa: Vol 28 No 6 (November/December 2017)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 1, January/February 2018 e6 AFRICA
Case Report
Coronary artery bypass grafting and paraparesis;
is there a correlation?
Ilias Samiotis, Nikolaos G Baikoussis, Vasileios Patris, Michalis Argiriou, Panagiotis Dedeilias,
Christos Charitos
Abstract
Adult cardiac surgery is associated with significant peri-
operative morbidity and mortality rates, mainly in elder-
ly patients with co-morbidities. A series of postoperative
complications may arise and delay the recovery of patients
undergoing cardiac surgery. Such complications also increase
the burden of resource use and may affect late survival rates.
Neurological complications appear mainly as stroke of vary-
ing degrees, with impairment of mobility and ability of the
patient. We describe a rare case of progressive paraparesis
after on-pump coronary artery bypass grafting, and review its
aetiology, diagnosis and management.
Keywords: coronary artery bypass grafting, CABG, stroke, extra-
corporeal circulation, neurological complications in cardiac
surgery, paraparesis, spinal cord ischaemia, transient ischaemic
attack
Submitted 8/11/16, accepted 26/1/17
Cardiovasc J Afr 2018; 29: e6–e8
DOI: 10.5830/CVJA-2017-014
Neurological complications after cardiac surgery may occur in
the post-operative period. Stroke and transient ischaemic attack
are major adverse cardiac events following coronary artery
bypass grafting (CABG) and markedly reduce patient short-
and long-term survival rates. The causes of these complications
are hypoxia, metabolic abnormalities, emboli or haemorrhage.
These complications are associated with increased mortality
rates, prolonged intensive care unit (ICU) stay and decreased
long-term survival rates.1-7 The main risk factors for neurological
complications in cardiac surgery are haemodynamic instability,
diabetes mellitus, advanced age, complex procedures, prolonged
cardiopulmonary bypass time (CPB > two hours), previous stroke,
hypertension, hyperglycaemia, hyperthermia, hypoxaemia, aortic
atheromatosis and peripheral vascular disease. 1,2,5
Case report
A 65-year-old man was admitted to our department for a routine
CABG due to left main coronary artery disease. The patient’s
medical history included smoking, family history of early
coronary artery disease, hypertension, diabetes, hyperlipidaemia,
percutaneous transluminal coronary angioplasty to the left
descending artery (LAD) and to the right coronary artery (RCA)
12 years earlier, and myocardial infarction 11 years earlier due
to in-stent stenosis. In his past medical history, there was an
unclear history of sensory or motor impairment after coccyx
cyst surgery.
All laboratory data were within normal limits except for
the erythrocyte sedimentation rate (521st, 1 132nd) and a
C-reactive protein (CRP) > 2 mg/l. Echocardiographic findings
were left ventricular ejection fraction (LVEF) of 45% and mild
left ventricular hypertrophy. Coronary artery CT-angiography
was performed and stenosis of three coronary arteries was
established.
The induction of anaesthesia was performed with Dormicum
5 mg, Propofol 150 mg, Esmeron 60 mg and Sevoflurane.
The patient underwent triple coronary artery bypass grafting
as follows: left internal mammary to left anterior descending
artery (LIMA–LAD), a saphenous vein graft to the first obtuse
marginalis (SVG–OM1) and another saphenous vein graft to the
right coronary artery (SVG–RCA). During surgery his vital signs
were stable and the arterial blood gasses (ABGs) were within
normal limits.
After surgery the patient was moved to the cardiac ICU while
intubated and unconscious, with a blood pressure of 110/60
mmHg, heart rate of 77 beats/min and normal sinus rhythm,
central venous pressure of 8 cm H2O and peripheral capillary
oxygen saturation of 100%. After admission to the ICU, his
primary vital signs were normal. The patient was successfully
weaned and extubated on the same day. The post-surgery drugs
were: enoxaparin 40 mg daily, furosemide 20 mg daily, metoprolol
100 mg twice daily, clopidogrel 75 mg daily, atorvastatin 20 mg
daily and acetylsalicylic acid 100 mg daily.
On the first postoperative day, laboratory findings in the
ICU were: haemoglobin 10 g/dl, haematocrit 30.5%, platelets =
242 000 cells/l, white blood cell count = 9 100 cells/l, prothrombin
time = 15.3 sec, activated partial thromboplastin time = 32 sec,
INR = 1.47, sodium = 139 mEq/l, potassium = 4.9 mmol/l, blood
Cardiovascular and Thoracic Surgery Department,
Evangelismos General Hospital of Athens, Athens, Greece
Ilias Samiotis, MD, MSc
Nikolaos G Baikoussis, MD, PhD,
Vasileios Patris, MD, MSc
Michalis Argiriou, MD, MSc, PhD
Panagiotis Dedeilias, MD
Christos Charitos, MD, PhD