Urgent CABG With Recent TIA, Recent DES, and Moderate Ischemic Mitral Regurgitation
A 68-year-old man with insulin-treated diabetes (HbA1c 9.4%), eGFR 38 mL/min/1.73 m², and a transient ischemic attack 3 weeks ago presents with 30 minutes of rest angina. Angiography shows 90% left main, 80% proximal LAD, and 70% circumflex disease; the right coronary artery is occluded. Echocardiography shows LVEF 32% and moderate ischemic mitral regurgitation (vena contracta 0.5 cm, EROA 0.25 cm²). Carotid duplex shows a 60% asymptomatic right internal carotid stenosis. He is on aspirin and clopidogrel after a drug-eluting stent was placed in the circumflex 6 weeks ago. The heart team is asked to decide urgency, operation, and antiplatelet management.
1. What is your revascularization plan, including urgency, conduits, and management of the moderate ischemic mitral regurgitation?
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This is urgent rather than elective: rest angina with left main and proximal LAD disease plus LVEF 32% warrants prompt CABG despite the recent TIA and recent DES. I would use cardiopulmonary bypass with aortic cross-clamping for reliable revascularization. LIMA to LAD plus additional vein grafts is appropriate; a skeletonized single LIMA is safer than bilateral ITA given insulin-dependent diabetes and sternal infection risk. For moderate ischemic MR with EROA 0.25 cm², CABG alone is reasonable, especially because LV dysfunction may improve after revascularization. I would not routinely add mitral repair unless the valve is clearly repairable and the added cross-clamp time is acceptable. If repair is performed, use an undersized annuloplasty ring and test the result. The 60% asymptomatic carotid stenosis does not warrant endarterectomy before CABG; avoid intraoperative hypotension.
2. How would you manage antiplatelet therapy around surgery given the DES placed 6 weeks ago?
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The patient has a recent circumflex DES at 6 weeks and now needs urgent CABG. Continuing clopidogrel increases bleeding; stopping it increases stent thrombosis. Because surgery is urgent for left main/rest angina, I would continue aspirin, stop clopidogrel, and operate after 3–5 days if angina remains controlled. If symptoms are unstable, operate sooner on aspirin alone and accept bleeding risk. I would not routinely bridge with glycoprotein IIb/IIIa inhibitors because of bleeding; if stent thrombosis risk is judged very high, a heart-team discussion and a short tirofiban bridge under a verified protocol could be considered. Postoperatively restart aspirin within 6–24 hours and clopidogrel as soon as bleeding risk allows. Avoid NSAIDs, maintain hemoglobin, and avoid hypotension given the recent TIA.
3. The family asks why left main PCI is not preferred. How do you counsel them?
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Left main PCI is an option in selected patients, but this man has diabetes, multivessel disease including proximal LAD and circumflex disease, LVEF 32%, and moderate ischemic MR. CABG offers more durable revascularization and is preferred when surgical risk is acceptable. Recent DES and DAPT also complicate immediate PCI. His renal dysfunction, diabetes, and recent TIA make risk high but not prohibitive; the heart team should explain that the choice is not “surgery versus no risk,” but balancing stroke, bleeding, stent thrombosis, and incomplete revascularization. If he declines surgery or is judged inoperable, PCI could be reconsidered, but not as the default strategy here.