CASE REPORT

CABG
Identitas Pasien
NAMA Tn. Rudya Ateng
USIA 70 tahun
JENIS KELAMIN Laki-laki
NO. MR 10713366

Keluhan Utama:
Sesak nafas sejak 1 bulan SMRS
Riwayat Penyakit Sekarang:
Sesak nafas sejak 1 bulan SMRS, sesak diperberat saat pasien beraktivitas ringan seperti
berjalan dan mandi, diperingan saat pasien beristirahat
Pasien menyangkal sesak saat pasien tidur dan hanya menggunakan satu bantal untuk
tidur
Pasien mengeluhkan bengkak pada kedua kaku hilang timbul sejak 6 bulan lalu.
Nyeri dada (-), sulit tidur (-), keringat malam (-), demam (-).
Tekanan darah tinggi sejak 5 tahun lalu, sebelumnya rutin pengobatan amlodipine lalu
candesartan namun sejak 1 tahun ini tidak konsumsi lagi.

Riwayat Pengobatan:
Sesak nafas sehingga pasien berobat ke Mitra Keluarga →dirawat inap dan dikonsulkan
ke Sp JP → dilakukan USG jantung dan ditemukan jantung pasien terendam →diberikan
obat diuretik→ keluhan membaik →Pasien kemudian berobat kembali ke dr Antono Sp.JP
dan dilakukan CTA → ditemukan penyempitan 3 lokasi dan direkomendasikan tindakan
CABG
Riwayat Penyakit Dahulu:
Dislipidemia (+), Hiperurisemia (-), DM (-)

Riwayat Penyakit Keluarga:

Tidak ada keluhan serupa pada keluarga pasien

Riwayat Operasi:
Riwayat operasi DJ Stent dekstra dan cholelithiasis

Riwayat Alergi:
Tidak ada alergi pada substansi dan obat tertentu.
Pemeriksaan Fisik
Status Generalis Head-to-Toe
KU : Tampak Sakit Ringan Kepala : Normosefali
Mata: CA (-), SI (-)
GCS : E4M6V5 Compos Mentis
Leher: Massa (-)
BB : 55 kg Thorax:
TB : 160 cm Paru :
I : Dada mengembang simetris
Tanda-tanda Vital P : Chest expansion simetris
P : Sonor pada seluruh lapang paru
TD : 100/70
A: VBS (+/+). Rh (-/-), Wh (-/-)
HR : 98
Jantung:
RR : 16 I : Ictus cordis tidak tampak
Sat : 99% on RA P : Thrill (-), heave (-)
A: S1S2 regular, murmur (-), gallop (-)
Abdomen: Supel, BU (+), NT (-)
Ekstremitas: CRT <2detik, edema (-/-), Nadi teraba
regular, kuat angkat
Pemeriksaan Penunjang
PT
Laboratorium (02/10)
Patient: 12 (H)
Hb: 11 (L) INR : 1.07 Ureum 34
WBC: 7.66 APTT Creatinin 1.46 (H)
Diff Count: 0/7/0/51/34/8 Kontrol : 24.7 eGFR 48.04
ESR: 20 (H) Patient: 31.6 (H) Natrium 136
RBC 4.75 Albumin: 3.4 (L) Kalium 4.4
Ht 32.9 (L) Globulin 3.6 (H) Clorida 107
MCV: 69.3 (L) Bilirubin Kalsium total 9.3
MCH 23.2 (L) Total 1.47 (H) Magnesium 1.7 (L)
MCHC 33.4 Indirek 0.65 (H)
PLT: 128 (L) Direk 0.82 (H) Anti HIV non reaktif
SGOT 47 (H) HbsAg non reaktif
SGPT 24 Anti HCV non reaktif
Kolesterol total 158 Anti Hbs 7.54
LDL 86 (revaksinasi)
Pemeriksaan Penunjang
Urinalisis (02/10)
Wanra Kuning muda pH 6.0
Kejernihan Jernih Berat Jenis 1.008
Albumin (-) Bilirubin (-)
Glukosa (-) Urobilinogen (-)
Eritrosit 0 Keton (-)
Leukosit 0 Eritosit (-)
Silinder 0 Lekosit (-)
Sel epitel (+) Nitrit (-)
Kristal (-)
Lain (-)
Pemeriksaan Penunjang
Catheter Angiography 11/09

RCA: Proximal RCA has 90 % stenosis, mid

RCA has diffuse 70-80% stenosis, calcified,
Proximal RPL is occluded, collateral from LCX

LAD: First diagonal is more proximal than first

septal branch. Proximal to mid LAD has 70-
80% stenosis, calcified. Distal LAD has diffuse
70-80% stenosis, calcified. Diagnonal 2 is
occluded

Ramus Int: Ostial LCX has 90-95% stenosis.

Distal LCX has diffuse 70-80% stenosis. Small
OM
Pemeriksaan Penunjang
Echocardiography 15/09
Dimensi ruang jantung LV dilatasi
dengan LVH eksentrik
Fungsi sistolik LV menurun EF
46%, disfungsi diastolik grade 2
Terdapat RMWA pada LV
Fungsi sistoli RV baik
Katup mitral dan aorta sklerotik
dengan MR mild
Status volume euvolemik
Pemeriksaan Penunjang
EKG 02/10
HR: 75 bpm regular
Sinus rhythm
normal axis
P wave: 0.12 s
PR interval : 0.28 s
QRS : 0.12 s
ST : elevasi (-), depresi (-)
T wave :
Diagnosa Intervensi
CAD, 3 VD CABG

Tatalaksana
Atorvastatin 20 mg 1x1 PO
Furosemide 4 mg 1x1 PO
Spironolactone 25 mg 1x1 PO
Monecto 10 mg 1x1 PO (Isosorbide mononitrate)
Angintriz MR 35 mg 2x1 PO (Trimetazidine)
Concor 2.5 mg 2x1 PO
Jardiance 10 mg 1x1 PO (Emplaglifozin)
Intraoperation
Operative Report
Pasien posisi terlentang, induksi anestersi, Anastomosis Vena ke RCA (endarterektomi)
dipasang AL dan CVP Anastomosis Vena ke OM distal
Preparasi kulit drapping braunderm (endarterektomi)
Vena kedua kaki diambil untuk graft Anastomosis Vena ke LAD (endarterektomi)
Insisi median sternotomy; LIMA dibebaskan Vena ke aorta 2 buah
Pericardium dibuka, Heparin diberikan Klem aorta dilepas, jantung berdenyut
Kanulasi aorta, atrium kanan spontan, variasi sinus.
CPB dimulai, suhu tubuh pasien diturunkan - 32 C Setelah suhu normal, CPB diberhentikan.
Perlu inotropik, epinephrine, dll.
Hemostais, Protamin diberikan, dekanulasi
aorta.
Dipasang drain substernal 1 buah.
Pasien dirawat ke ICCU.
Lama aorta klem 116, CPB 148
LITERATURE
REVIEW
ANATOMI
ANATOMI
CORONARY ARTERY DISEASE

condition in which there is an inadequate supply of blood and oxygen to the myocardium
results from occlusion of the coronary arteries and results in a demand-supply mismatch of
oxygen
Non-modifiable risk factor History
Gender (male) Chest pain and relation to physical
Age activity
Family History Radiation of pain
Genetic Dyspnea on rest and on activity
Syncope, palpitation
Modifiable risk factor Tachypnea
smoking Lower extremity edema
obesity Orthopnea
Lipid level Exercise capacity
Psychological variables Family history
Lifestyle (diet, smoking)

Physical Exam
Inspection (jugular venous distension,
peripheral edema)
Palpate (fluid thrill, heave)
Auscultate (heart and lung)
ARTHEROSCLEROSIS

This process affects medium and large-sized arteries and

is characterized by patchy intramural thickening of the
subintima that encroaches on the arterial lumen.
Atherosclerotic lesions are composed of three major
components.
→
First cellular component comprised predominately
of smooth muscle cells and macrophages.
Second → connective tissue matrix and extracellular
lipid.
Third→ intracellular lipid that accumulates within
macrophages, thereby converting them into foam
cells.
CORONARY ARTERY DISEASE
Evaluation

Electrocardiogram (EKG)
ACS : ST segment change and T wave changes
Arrythmia
Axis deviation, bundle branch block, ventricular
hypertrophy

Echocardiography
Wall motion, valvular regurgitation, stenosis
infective or autoimmune lesion
chamber size
diagnosis pulmonary embolism
pericardial cavity
Response to therapy

Stress Test
Exercise stress test where patient run until he achieves
85% of the age-predicted maximal heart rate. If a patient
develops exertional hypotension, hypertension (>200/110
mmHg), ST-segment elevations or depression, or
ventricular or supraventricular arrhythmias
CORONARY ARTERY DISEASE
Evaluation

Chest X-Ray
initial evaluation of lung, heart and vasculature

Blood Work
CBC
Metabolic panel
Cardiac enzyme (CK and troponin)
B-type natriuretic peptide (volume overload)
lipid panel
CRP and ESR
Liver function test

Cardiac Cathehterization
Gold standard
CABG - Coronary Artery Bypass Graft
Type of operation that improves blood flow to the heart. This surgery is
used to treat coronary artery disease (CAD).

Indications:
Left main disease greater than 50%
Three-vessel coronary artery disease of greater than 70% with or
without proximal LAD involvement
Two-vessel disease: LAD plus one other major artery
One or more significant stenosis greater than 70% in a patient with
significant anginal symptoms despite maximal medical therapy.
One vessel disease greater than 70% in a survivor of sudden cardiac
death with ischemia-related ventricular tachycardia
Contraindications:
Emergency CABG in a hemodynamically stable patient who has persistent
angina but only a small area of viable myocardium
Emergency CABG after PCI reperfuses the epicardium but not the
microvascular circulation (no reflow).
Emergency CABG after failed PCI but no active ischemia or imminent
occlusion
Patients with ventricular tachycardia and myocardial scar but no sign of
active ischemia
Stable ischemic heart disease with either <70% stenosis
RCA should not be grafted with an arterial graft unless stenosis is >90%.
Patients with end-stage kidney disease with limited life expectancy due
to non-cardiac conditions
REFERENCE
1. Ogobuiro I, Wehrle CJ, Tuma F. Anatomy, Thorax, Heart Coronary Arteries. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534790/
2. Shahjehan RD, Bhutta BS. Coronary Artery Disease. [Updated 2023 Feb 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK564304/
3. lo, J J Coughlan, Emanuele Barbato, Colin Berry, Alaide Chieffo, Marc J Claeys, Gheorghe-Andrei Dan, Marc R Dweck, Mary Galbraith,
Martine Gilard, Lynne Hinterbuchner, Ewa A Jankowska, Peter Jüni, Takeshi Kimura, Vijay Kunadian, Margret Leosdottir, Roberto
Lorusso, Roberto F E Pedretti, Angelos G Rigopoulos, Maria Rubini Gimenez, Holger Thiele, Pascal Vranckx, Sven Wassmann, Nanette
Kass Wenger, Borja Ibanez, ESC Scientific Document Group , 2023 ESC Guidelines for the management of acute coronary syndromes:
Developed by the task force on the management of acute coronary syndromes of the European Society of Cardiology (ESC),
European Heart Journal, 2023;, ehad191, https://doi.org/10.1093/eurheartj/ehad191
4. Rihal, C.S. et al. (2003) ‘Indications for coronary artery bypass surgery and percutaneous coronary intervention in chronic stable
angina’, Circulation, 108(20), pp. 2439–2445. doi:10.1161/01.cir.0000094405.21583.7c.
5. Eagle, K.A. et al. (1999) ‘ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery: Executive summary and recommendations’,
Circulation, 100(13), pp. 1464–1480. doi:10.1161/01.cir.100.13.1464.