Discussant: John Harper, MD
Presenter: Maryam Zamanian, MD
HPI: 66 y.o. male with h/o occasional chest pain that he has related to indigestion was in his usual state of health when on a routine physical at his PCP’s office, he had a positive stress test. Subsequently, a nuclear stress test at the cardiologist’s office was consistent with inferior-posterior ischemia. Patient underwent a cardiac catheterization on 8/6/02. Results showed left main stenosis of 50-60% with LAD stenosis of 40%, multiple lesions in the circumflex (ostial 80%, mid 70%, and distal 65%), total occlusion of right coronary artery and significant left to right collateralization. There was mild anterior hypokinesis with left ventricular ejection fraction of 60%. Patient was referred to a cardiothoracic surgeon and a CABG procedure was scheduled for 8/12/02.
PMH:
Parkinson’s disease x 30 yrs
Kidney stone- many years ago
Allergies: Penicillin and Tylenol
Medications:
1. Sinemet (carbidopa/levodopa) 25/100 (I tab q am)
2. Requip (ropinirole 2 mg (ii tabs qd)
3. Comtan (entacapone) 200 mg qid)
4. Amantadine 100 mg bid
5. Seroquel (quetiapine) 25 mg qd
6. Prozac (fluoxetine) 20 mg qd
Family History: negative for CAD, HTN, or DM
Social History: married, in propane business but he is not significantly exposed
ROS: no other pertinent positives
Physical Examination:
Pulse 70 BP 130/70
HEENT: PERLA, otherwise normal
Neck: supple, trachea midline, carotid pulses full and equal without bruits
Cardiac: RRR, no m/r/g
Chest: CTA bilaterally
Abdomen: no organomegaly, no mass, non-tender
Extremities: no clubbing/cyanosis/or edema, rash from poison ivy, good pedal
pulses, no varicose veins
Neurologic: speech pattern consistent with Parkinson’s disease, otherwise
non-focal
Labs (including CBC, chem-14, PT,PTT,INR): all were within normal limits on the day of surgery.
Hospital Course: Off-pump CABG x4 with internal mammary x2 (right mammary to 1st obtuse marginal and left mammary to 2nd obtuse marginal) and saphenous vein x2 (to left anterior descending and posterior descending arteries) performed on 8/12/02. He tolerated surgery well and was immediately extubated. He did not require any blood transfusions and was transferred out of CCU after 24 hours. He did well on 8/13 and 8/14 and on the morning of 8/15 his lab work was as follows: Hgb 12.6, Hct 35.8 (compared to 14.3/40.6 on 8/12 post-op), WBC 9.8, plts 174, Cr 0.9, sodium 141, potassium 4.3, chloride 110, bicarbonate 26, calcium 7.7. Pt was seen at 6 pm on 8/15/02 (post-op day #3) and was stable except that the patient complained of some mild neck pain. At 9:30 pm, patient had a seizure witnessed by his wife. He was initially in sinus rhythm but within a couple of minutes went into a junctional rhythm for 2 minutes and then became asystolic. Routine ACLS protocol was started and his temporary pacemaker, placed at the time of CABG, was noted to be firing but electromechanical dissociation was present. Resuscitation efforts were continued for 45 minutes without ever achieving a pulse or blood pressure, and the patient expired.
An autopsy was performed.