Emergent Coronary Artery Bypass Grafting For a Patient With Hemophilia
Bob Tagalakis, M.D., Felipe Urdaneta, M.D.
Department of Anesthesiology, University of Florida, Gainesville, FL
Case Report
Presentation
A 67-year-old male with a history of hemophilia, presented for
cardiac catheterization due to unstable angina. His past medical
history included hemophilia that was resistant to Factor VIII.
Currently, he was receiving Recombinant Factor IX. Otherwise,
his past medical history included obesity, hypercholesterolemia,
and Hepatitis C. We were called emergently to the cardiac
catheterization suite when his left anterior descending artery
ruptured during attempted angioplasty. At that time, the patient
was removed to the operating room to undergo emergent coronary
artery bypass grafting.
The patient underwent uneventful induction of general anesthesia
with fentanyl, midazolam, and pancuronium. Emergency cardiac
bypass grafting was performed under cardiopulmonary bypass.
During this case, the patient was maintained on isoflurane,
fentanyl, and pancuronium. Aprotinin was used to reduce
hemorrhage. The patient remained hemodynamically stable
throughout his surgery. Blood loss was approximately equivalent
to that observed during routine coronary artery bypass grafting
on patients without coagulation abnormalities. The patient
underwent uneventful separation from cardiopulmonary bypass.
After protamine administration for heparin inactivation, the
activated clotting time (ACT) remained greater than 600 s.
Following completion of surgery, the patient was transferred to
the cardiac intensive care unit. Within six hours of surgery,
the patient was extubated in the intensive care unit.
Approximately six hours after extubation, he complained of
excruciating, mid-sternal chest pain and had a cardiac arrest
due to ventricular fibrillation. Although a sternotomy was
performed emergently, the patient was unresponsive to
resuscitative measures and perished.
Discussion
The treatment of patients with hemophilia who undergo cardiac
procedures can be quite complex. As more patients with
hemophilia live longer lives, it is likely that
anesthesiologists will encounter greater numbers of patients
with such coagulopathies undergoing cardiac surgeries. The
implications of hemophilia on this patient’s management, review
the pathophysiology of hemophilia, and a brief literature review
will be presented.
References:
1. Donahue BS, Emerson CW, Slaughter TF: Elective and emergency
cardiac surgery on a patient with hemophilia B. J Cardiothoracic
Vasc Anesth 13:92-97, 1999.
2. Palanzo DA, Sadr FS: Coronary artery bypass grafting in a
patient with haemophilia B. Perfusion 10:265-270, 1995.
3. Scharfman WB, Rauch AE, Ferraris V, Burkart PT: Treatment of
a patient with factor IX deficiency (hemophilia B with coronary
bypass surgery. J Thorac Cardiovasc Surg 105: 765-766, 1993.
