Coronary artery bypass graft for stent occlusion in a patient with essential thrombocythemia
A 38-year-old man known case of hyperlipidemia, hypertension and ET diagnosed 5 years previously by bone marrow biopsy with JAK2 mutation (Janus Kinase 2) presented with angina. He was on hydroxy urea therapy since that time. He underwent multiple percutaneous coronary interventions to left anterior descending artery (LAD) and first diagonal artery (D1) for past 5 years. He presented with unstable angina. He had no past surgical history and no family history of ischemic heart disease. He was non-smoker. Coronary angiography showed total occlusion of LAD and D1 arteries with normal right coronary and circumflex arteries (). Echocardiography showed ejection fraction of 50% with no significant valve disease. Hemoglobin was 16 g/l and platelet count was 495 * 109 per litter with normal renal and liver function tests. His hydroxyurea medication was continued at a dose of 500 mg orally daily until day of surgery.\nHe underwent total arterial coronary artery bypass graft surgery with left internal mammary artery anastomosed to LAD and radial artery anastomosed to D1. The procedure was performed on cardiopulmonary bypass with cardioplegic arrest. The operation was uneventful and he was extubated 9 hours post-operatively. His total drainage from mediastinal and pleural drains were 500 cc over 24 hours. He required no blood or blood product transfusion. He was commenced on dual antiplatelet treatment (DAPT) using aspirin and clopidegrol Day 1 post-operative. Immediate post-op platelet count was 295 * 109 per litter and Day 1 platelet was 464 * 109 per litter. Hydroxyurea was increased Day 1 post-operatively to a dose of 500 mg orally twice daily. His platelet counts on Day 2 until Day 6 were 489 * 109, 365 * 109, 395 * 109, 650 * 109 and 780 * 109 per litter, respectively. He was discharged home Day 6 post-op with no complication. At 3 weeks post-operatively, his platelet count was 750 * 109 per litter on same treatment and dose. Patient was then seen at 4 months post-operatively with platelet count is 467 * 109 per litter and hemoglobin was 147 g/l. He was back to all daily activities and walking daily for one and half hour with no symptoms. He remained on the same dose of hydroxyl urea (500 mg orally twice daily) and DAPT.