PeRIOPeRaTIve evaluaTION aNd MaNageMeNT OF a PaTIeNT WITH CONgesTIve HeaRT FaIluRe

case presentation: Male, 57 years old. Until one week before admission had asymptomatic history, no angina or CHF symptoms. In the last week described complaints of upper respiratory symptoms with influenza-like fever. Risk factors: Dyslipidemia, NIDDM, smoker. The patient arrived to the ER with severe dyspnea a week after initial symptoms. Extensive anterior wall MI was diagnosed. Echocardiography on arrival: Severe LV dysfunction. Due to hemodynamic instability: low BP & pulmonary edema, IABP was inserted. Medications: Continuous diuretics infusion, low dose MO, dobutamine and noradrenalin in escalating doses. Worsening renal function was evident: reduced urinary output, creatinine 2.0 & worsening liver function with elevated enzymes. The patient’s condition required a semielective intubation & mechanical ventilation. The patient was taken to the cath lab and underwent coronary angiography revealing totally occluded proximal RCA, significant OM stenosis and 70% occlusion of the left main coronary artery. PA catheter was inserted and the patient underwent a triple coronary CABG with LIMA and two vein grafts. The LV function was still poor, although some improved function was observed by TEE in the septum and inferior wall. Pulmonary pressures seemed to be high by palpation. Weaning from bypass was a challenge, and was supported by his previous medical support, dobutamine and noradrenalin and additional infusion of milrinone and inhaled NO.