Brief Answer:
I would explain as follows:

Detailed Answer:
Hello,

Welcome back on HCM!

I carefully passed through your uploaded medical data.

I would explain that atrial fibrillation occurs in around 30% of perioperative patients.

Regarding your concern, I would like to explain that:

- when comparing those two ECGs (pre and post-op) it seems like are two different patients (different QRS axis [frontal and horizontal planes], voltage, QRS duration, new T wave inversion in DI, aVL, V2-V6).

Nevertheless, when judging the postoperative and one year prognosis of the patient hospitalised for an ACS or even exertion angina we consider the presence or absence of ST deviation on ECG, which in fact is absent.

Also other markers implicated in prognosis are: elevated cardiac enzymes (elevated troponin not related to surgery), CHF (Killip class), systolic blood pressure, creatinine and cardiac arrest on admission.

By using GRACE score we could stratify patients according to their prognosis.

So additional variables are necessary to make a prognostic estimation.

But as you refer that his in-hospital clinical course was uneventful, his calculated risk is between low to intermediate.

- when dealing with healing of surgical sternotomy wound, it is very important that the surgical site hasn't persistent inflammation due to any microbiological agent invasion, which could lead to mediastinitis (one of the most three dangerous complication after cardiac surgery).

Also, persistent coughing should be supressed as it may be an source for sternal fixation instability, leading to dehiscence and also inflammation/infection.

The first couple of weeks (around six weeks) are very important to allow sternal stabilization and healing process.

I recommend to check markers of imflammation (like PCR, complete blood count [leucocytes count and differential] with ESR, etc. especially their trend, to confirm an uneventful process of healing.

Please. provide me wit hfurther clinical information (average BP values, creatinine, CHF class, in-hospital major arrhythmia or cardiac arrest,etc) to be able in quantifying more precisely his prognosis.

Hope to have been helpful to you.

Kind regards,

Dr. Iliri

---

Brief Answer:
My opinion:

Detailed Answer:
Hello again dear colleague,

I didn’t doubt that they are the same patient ECGs (but the aspects are quite different that may lead to such a thought).

I would explain that when comparing two consecutive ECGs it is important (for a better accuracy of interpretation) that both be done on the same conditions (both of them be resting ECGs, or stress test ECGs, possibly be done by placing electrodes on the same positions [chest leads], ideally be the same technician and equipment, etc).

It would not be correct to compare a stress test ECG with a resting one.

Nevertheless, as a college asks me to do that, I will try to give my opinion as follows:

1. There is a leftward QRS axis deviation in the post op ECG (compared to the previous one); also there is a new T wave inversion in DI, aVL, V2-V6; new QS wave in DIII, aVF; a shifting of precordial transitional zone (R/S) to the left in the horizontal plane.

2. Now let me explain that the possible reasons of these ECG changes besides a real myocardial ischemia by any graft circulation disorder may be related also to:

a) Myocardial injury by suture placement or manipulation of the heart,
b) Coronary dissection
c) Global or regional ischemia related to inadequate intra-operative myocardial protection,
d) Microvascular events related to reperfusion
e) Failure to reperfuse areas of the myocardium that are not subtended by graftable vessels,
f) Myocardial injury that induced by oxygen free radicals generation

The best answer whether a possible new cardiac ischemia event (even myocardial infarction) post-op is present (as may be suggested by new QS waves in DIII, aVF and negative T wave in DI, aVL, V2-V6) would be to review together with new ECG changes:

- also the increase in cardiac troponin within 48 hours after CABG (by convention > 10 fold greater than the normal pre-op troponin level),
- angiographically documentation of new graft or native coronary artery occlusion,
- new regional wall motion abnormality by cardiac ultrasound,
- new loss of viable myocardium,

Besides cardiac ultrasound, angiography, for studying a possible post-op myocardial infarct a cardiac MRI would be an excellent tool (clear evidence of the presence and distribution of infarcted tissue).

If myocardial infarction or cardiac ischemia is confirmed, then prognosis would be decided by the level of myocardium involved (severity of cardiac function impairment [LVEF and other indices]).

3. So, only from those uploaded ECGs would not be possible to conclude professionally on a new myocardial infarct. (if no troponin level is measured post-op, then cardiac ECHO and MRI could give the right answer regarding this issue).

4. In my experience ECG changes after CABG are common, influenced in the majority of cases by causes other than a clear myocardial infarction (due to a graft or native coronary artery occlusion).

It is necessary a careful review (by using the above mentioned techniques) to confirm myocardial injury.

When facing with an acute coronary syndrome a useful scoring tool would be GRACE score (I mentioned previously), which helps in predicting the risk of death or death/myocardial infarction following an initial acute coronary syndrome.

As you are a physician, I encourage you to use it by yourself entering the above mentioned variables (age, heart rate, systolic BP, creatinine, cardiac arrest at admission, cardiac enzymes, ST segment deviation in ECG, and other symptomatology, etc.).

You can find GRACE calculator in internet.

Dear colleague,

I hope to have been clear with my last explanations.

Nevertheless, I remain at your disposal in case of any further uncertainties about my opinions.

Please let me know!

I would be glad to discuss about these issues with you.

Sorry about my delayed response; it’s because of my professional commitments.

Greetings!

Dr. Iliri

---

Brief Answer:
You are welcome!

Detailed Answer:

Feel free to ask me whenever you need!

Greetings!

Dr. Iliri

---

Brief Answer:
I would explain:

Detailed Answer:
Hi again, dear XXXX!

Regarding your concern, I would explain that:

- The slightly increased heart rate at rest and even more during daily activity (example taking a bath) coupled with extreme weakness should be further investigated in several directions:

a) A persisting inflammation/ infection,
b) Heart failure (including also a pericardial effusion),
c) A pulmonary dysfunction (including also a pleural effusion),
d) Anemia,

Coming to this point, I recommend performing some new tests as follows:

a) A new complete blood count (investigating hemoglobin level, and leukocytes differential)
b) PCR, ESR,
c) Cardiac ultrasound,
d) Chest X ray study,
e) Arterial blood gas analysis

- The newly uploaded resting ECGs seems completely normal without any evidence of cardiac ischemia or infarction, no arrhythmias or conductance
disturbances. So, there is no adverse ECG implication in the patient prognosis.

- Considering the increased Troponin level, I recommend taking into account the above mentioned responsible causes, other than a true myocardial infarction due to a graft or native artery occlusion:

a) Myocardial injury by suture placement or manipulation of the heart,
b) Coronary dissection
c) Global or regional ischemia related to inadequate intra-operative myocardial protection,
d) Microvascular events related to reperfusion
e) Failure to reperfuse areas of the myocardium that are not subtended by graftable vessels,
f) Myocardial injury that induced by oxygen free radicals generation

Coming to this point, to correctly interpret the actual Troponin level, it is necessary to compare with pre-op and within 48 hours post-op Troponin levels, coupled with a new cardiac ultrasound (ECHO).

I believe that all the above medical tests I advised you above will be sufficient to clearly conclude the right responsible cause of your relative’s current complaints.

Please, let me know about his medical tests results whenever available.

Wishing you are having a pleasant weekend!

Regards,

Dr. Iliri

---

Brief Answer:
Furhter medical investigation is necessary.

Detailed Answer:
Dear XXXXXXX

Your newly uploaded ECGs seem the same ECG (uploaded 4 times).

It reveals QS waves in DIII and aVF; also biphasic T wave in V2, negative T wave in DI, DII, aVL, V4-V6.

Considering his actual clinical symptomatology and increased level of Troponin (no evidence of Troponin levels within 48 hours of coronary bypass surgery), these new EG changes raise suspicions of a peri-operative myocardial damage.

Coming to this point, a new cardiac ultrasound should be done, to find evidence of potentially new left ventricular myocardial kinetics abnormalities and evaluating the overall cardiac function (evidence of possible LV dysfunction).

If they are confirmed (new kinetics abnormalities), then a coronary angiogram should be done.

This is my opinion.

At least a new cardiac ultrasound should be done.

Best wishes,

Dr. Iliri

---

Brief Answer:
My opinion:

Detailed Answer:
Dear XXXXXXX

That elevation in Troponin level after coronary bypass surgery may be a myocardial injury of any kind (please read again the alternatives I wrote above), but an ischemic myocardial damage (myocardial infarction) could not be excluded.

As I explained you above, a cardiac ultrasound would shed valuable light on possible myocardial infarction by making evidence of left ventricular (LV) wall motion abnormalities and resulting LV ejection fraction.

Whether an irreversible damage (myocardial infarction) has occurred, important information would be achieved by contrast-enhancement MRI, which is able to reveal even small micro-infarctions (around 1-2 grams).

If enough data is gathered in favor of an ischemic myocardial damage (infarction), then coronary angiography should be repeated again.

Peri-operative myocardial infarction may occur in around 5% - 10% of patients undergoing CABG.

But, to properly predict any adverse effect of this presumably new myocardial damage in patient prognosis, it is necessary to quantify the cardiac performance by ECHO, and if available a contrast-enhancement MRI.

So, to conclude I would advise you: Please, do a cardiac ultrasound!

Greetings!

Dr. Iliri

---

Brief Answer:
You are welcome!

Detailed Answer:
I am glad to have been helpful!

If you have any other uncertainties, please feel free to ask me directly at any time at the link below:

http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=69765

Best wishes,

Dr. Iliri

---