Monday, April 22, 2019

Iris Publishers- Open access Journal of Cardiovascular Research | Systemic Thrombolyis within 24 Hours of Major Cardiac Surgery; When the Risk to Life outweighs the Haemorrhage


Authored by Mahmoud M Abdelaziz
 
Ischaemic stroke after cardiac surgery is well recognised devastating complication. The incidence of stroke usually varies based on patients’ risk factors and peri-operative related factors and can be as high as 6% [1]. Due to the high risk of Intracerebral and systemic haemorrhage, systemic thrombolysis is contraindicated within 14 days after any major surgery including open heart surgery [2]. Given the high risk of bleeding, unsurprisingly there has not been any research articles into the bleeding rate of systemic thrombolysis after major surgery.
We present a case of using systemic thrombolysis within 24 hours post major open-heart surgery for treating acute ischaemic stroke.
An 81-year-old man presented with increasing shortness of breath and previous hospital admission with congestive heart failure and pulmonary oedema. Echocardiography confirmed severe mitral and tricuspid valve regurgitation, moderately elevated pulmonary artery pressures (PASP 56mmHg) and preserved left ventricular function. His risk factors of heart disease included primary hypertension and hypercholesterolaemia. He underwent median sternotomy, cardiopulmonary bypass with systemic cooling to 30⁰C, Mitral valve and Tricuspid valve repair. He was transferred to the intensive care unit as per routine and immediate postoperative recovery was unremarkable. 13 hours after the operation the patient suddenly became unresponsive with poor respiratory effort and Glasgow coma score (GCS) deteriorated from normal to 3 for which he required emergency re-intubation and ventilation. His Pupils were unequal.
Computer Tomography angiography (CTA) scan of the brain did not show any obvious areas of infarcts or bleeding, but clinical assessment by expert neurology physician concluded the likelihood of major brain stem stroke which carried very high risk to life and poor prognosis if left untreated. Targeted cerebral intra-arterial thrombolysis was not feasible based on CT findings and the anatomy of the affected area. Upon discussion with the surgical team, cardiac anaesthetic team and patient’s family, the decision was made to treat the patient with systemic thrombolysis given the likelihood of not surviving this insult if left untreated and accept the risk of major bleeding event.

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