Dual surgical intervention in cardiac disease: A case study on CABG with AVR

Prathyusha

Staff Nurse – ICU, Kauvery Hospital, Hosur, Tamil Nadu

Abstract

Coronary Artery Bypass Grafting (CABG) combined with Aortic Valve Replacement (AVR) is a complex cardiac surgical procedure performed in patients who present with both significant coronary artery disease and severe aortic valve pathology. This combined approach allows simultaneous revascularization of ischemic myocardium and correction of valvular dysfunction, thereby improving hemodynamic stability, myocardial perfusion, and long-term functional outcomes.

The procedure involves cardiopulmonary bypass, harvesting of conduits (commonly the internal mammary artery and saphenous vein), grafting of obstructed coronary arteries, and replacement of the diseased aortic valve with either a mechanical or bioprosthetic valve. Performing CABG and AVR together reduces the need for multiple surgeries, lowers cumulative operative risk, and offers better symptom relief for patients with concurrent diseases.

Its benefits, the combined procedure carries higher perioperative risk compared to isolated surgeries, including increased chances of bleeding, arrhythmias, renal impairment, and prolonged recovery. Advances in surgical techniques, myocardial protection strategies, and postoperative critical care have significantly improved survival and outcomes.

Overall, CABG with AVR remains an effective and often essential surgical option for patients with coexisting coronary and aortic valve disease, offering improved quality of life and long-term survival when performed by experienced multidisciplinary teams.

Introduction

Coronary Artery Bypass Grafting (CABG) combined with Aortic Valve Replacement (AVR) is a major open-heart surgical intervention performed in patients presenting with coexisting coronary artery disease (CAD) and significant aortic valve pathology. This combined approach provides simultaneous revascularization of ischemic myocardium and correction of valvular dysfunction, resulting in improved myocardial perfusion, enhanced cardiac function, symptom relief, and long-term survival outcomes. Given the high incidence of severe aortic stenosis accompanied by CAD, CABG with AVR remains a recommended and effective surgical strategy. The use of advanced grafting techniques, including internal mammary artery conduits, further contributes to improved graft patency and patient prognosis.

A 45-year-old male, presented with progressive breathlessness, chest pain, palpitations, excessive sweating, and intermittent headaches for two months. Following clinical evaluation and coronary angiography performed ouside hospital, he was diagnosed with significant CAD and severe aortic valve disease. His comorbidities included Type II Diabetes Mellitus for 10 years and long-standing hypertension.

The patient underwent CABG with AVR using a 23 mm metallic valve on 11/11/2025 under general anaesthesia and cardiopulmonary bypass. Three units of blood were transfused intraoperatively. Postoperatively, he was managed in the Intensive Care Unit (ICU) with ventilatory and inotropic support and remained hemodynamically stable.

InvestigationResults
pH7.38
PCo233
PO289
HCO325.4
Sodium140
Potassium4.6
Hb9.0 g/dl
Calcium1.07
Lac5.0
WBC 16,530 /mm3
RBC3.24 million/mm3
Platelets20,000/mm3

Pre-operative X-ray

Post-operative X-ray

Postoperative Clinical Course

Postoperative Day 1 (POD-1)

  • Successfully weaned from ventilator support and extubated.
  • Shifted to face mask oxygen; ABG values acceptable.
  • Later transitioned to nasal mask based on clinical improvement.
  • Continued minimal inotropic support.

Postoperative Day 2 (POD-2)

  • Stable vitals on 4 L/min oxygen via face mask, maintaining SpO₂ at 95%.
  • Laboratory investigations:

Postoperative Day 3 (POD-3)

  • Hemodynamically stable on face mask oxygen at 4 L/min.
  • Initiated incentive spirometry, chest physiotherapy, and early mobilization.

Postoperative Day 4 (POD-4)

  • Stable on 1 L/min oxygen; SpO₂ at 99%.
  • Surgical drains removed.
  • Patient shifted to the general ward.

Postoperative Day 5 (POD-5)

  • Fully off ventilatory support; stable hemodynamic.
  • Tapered off inotropes and progressing toward recovery.

Echocardiographic Findings

  • Trivial aortic regurgitation, no paravalvular leak
  • Aortic valve gradient: 10/5 mmHg
  • Mild LV dysfunction, EF ~50%
  • Concentric LVH
  • Trivial MR and TR
  • No pulmonary arterial hypertension
  • Adequate RV function
  • IVC diameter: 1.8 cm
  • No pericardial effusion, clot, or vegetation

Final Diagnosis

  • Coronary Artery Disease – Single Vessel Disease
  • Degenerative Aortic Valve Disease
  • Severe Aortic Stenosis with Moderate Aortic Regurgitation
  • Left Ventricular Ejection Fraction: 50%
  • Type II Diabetes Mellitus and Hypertension

Nursing Assessment

Comprehensive nursing assessment included:

  • Evaluation of presenting symptoms and CAD risk factors
  • Physical examination and interpretation of ECG findings
  • Continuous monitoring of vital parameters and laboratory values
  • Review of past medical history, particularly diabetes and hypertension
  • Assessment of patient and family understanding, anxiety levels, and coping strategies

Nursing assessment guided individualized care planning and early identification of complications.

Surgical Overview

A median sternotomy provided access for the combined CABG and AVR procedure. Following initiation of cardiopulmonary bypass and cardiac arrest:

  • Suitable graft conduits (saphenous vein or internal mammary artery) were harvested and prepared.
  • The diseased aortic valve was excised and replaced with a mechanical prosthesis.
  • Distal and proximal anastomoses were completed to bypass obstructed coronary arteries.
  • The heart was gradually re-perfused and weaned off bypass.
  • Haemostasis was secured and surgical closure performed.

Postoperative Nursing Management

1. Intensive Monitoring

  • Continuous observation of hemodynamic parameters
  • Assessment of cardiac rhythm, chest tube output, fluid balance, and perfusion

2. Pain and Respiratory Management

  • Timely administration of analgesics
  • Teaching sternal support during coughing and deep breathing
  • Use of incentive spirometry to prevent atelectasis and pneumonia

3. Early Mobilization

  • Assistance with sitting, dangling legs, and ambulation from POD-1
  • Reduced risk of thromboembolism and respiratory complications

4. Medication Management

Medications included:

  • T. Telmisartan 40 mg OD
  • T. Lasilactone 50 mg OD
  • T. Clopitab A 150 mg OD
  • T. Acitrom 2 mg OD
  • T. Rosuvastatin 20 mg OD
  • T. Amlodipine 5 mg OD
  • T. Pantoprazole 40 mg OD
  • T. Cefpodoxime 200 mg as prescribed
  • T. Paracetamol 650 mg PRN
  • T. Alprazolam 0.25 mg HS
  • Human Actrapid insulin as per sliding scale

5. Wound Care

  • Maintenance of clean, dry surgical site
  • Education on hygiene practices, dressing care, and infection signs

6. Dietary Support

  • Emphasis on heart-healthy diet:
    • High-fibre fruits and vegetables
    • Lean proteins
    • Restricted salt, refined sugars, and saturated fats

Patient Education: Warning Signs Requiring Immediate Medical Attention

  • Persistent or worsening chest pain
  • Sudden breathlessness
  • Wound redness, discharge, or fever
  • Rapid weight gains (>3 pounds in 2–3 days)
  • Dizziness, syncope, or neurological deficits
  • Palpitations or sustained arrhythmias

Outcome

The patient demonstrated steady postoperative improvement following the combined CABG and AVR procedure. Hemodynamic parameters stabilized early, respiratory function improved progressively with physiotherapy, and the patient achieved adequate oxygenation without ventilatory support by POD-5. Surgical wounds healed without signs of infection, chest drains were removed uneventfully, and mobility returned to baseline with assisted ambulation. Overall, the patient’s clinical status improved significantly with better symptom control, stable cardiac function, and satisfactory echocardiographic findings.

Discharge Summary

The patient was discharged from the hospital on Postoperative Day 7, following stable recovery and satisfactory progress in all clinical parameters.

Discussion

Medical Aspects

The management of combined CAD and severe aortic valve disease requires a multidisciplinary approach due to the complexity and elevated operative risk. The decision to perform CABG with AVR in a single surgical session is supported by positive evidence demonstrating reduced morbidity, avoidance of repeat sternotomy, and improved cardiac function.

In this case, the patient benefited from:

  • Early diagnosis using coronary angiography and echocardiography
  • Timely surgical intervention using a 23 mm mechanical prosthetic valve
  • Successful revascularization through bypass grafting
  • Effective cardiopulmonary bypass management
  • Appropriate postoperative hemodynamic support

Laboratory investigations showed initial postoperative changes consistent with major cardiac surgery, including leukocytosis and thrombocytopenia, which normalized during recovery. Echocardiographic findings were favorable, showing trivial regurgitation and an acceptable valve gradient.

Overall, surgical and medical management successfully stabilized cardiac function, improved symptoms, and prevented major complications.

Nursing Aspects

Nursing care played a pivotal role throughout the perioperative and postoperative phases. Key areas included:

1. Preoperative Nursing Care

  • Assessment of symptoms, comorbidities (diabetes, hypertension), and anxiety
  • Patient and family education regarding the procedure and postoperative expectations
  • Optimizing diabetes and blood pressure control

2. Postoperative ICU Care

  • Continuous monitoring of ECG, vitals, hemodynamic parameters
  • Ventilator management and timely extubation
  • Monitoring chest tube output, urine output, and fluid balance
  • Early detection of bleeding, arrhythmias, or respiratory compromise
  • Pain management and sedation weaning

3. Respiratory Care

  • Incentive spirometry
  • Chest physiotherapy
  • Positioning to improve lung expansion
  • Prevention of atelectasis and pneumonia

4. Wound Care and Infection Control

  • Regular inspection of sternal and graft sites
  • Sterile dressing techniques
  • Monitoring for erythema, discharge, or fever

5. Medication Management

  • Ensuring correct doses of anticoagulants and antiplatelets
  • Monitoring INR for Acitrom
  • Managing insulin therapy with sliding scale
  • Educating patients on medication adherence

6. Psychosocial and Educational Support

  • Addressing anxiety and fear
  • Teaching sternal precautions
  • Educating about diet, lifestyle changes, warning signs, and follow-up

Nursing care ensured smooth recovery, early mobilization, prevention of complications, and improved patient confidence before discharge.

Conclusion

The combined CABG and AVR procedure provided effective management for the patient’s concurrent coronary artery disease and severe aortic stenosis. The postoperative course demonstrated the crucial role of comprehensive nursing care—including vigilant monitoring, respiratory support, early mobilization, medication optimization, and patient education—in promoting recovery and preventing complications. This case highlights the significance of multidisciplinary collaboration in achieving favourable surgical outcomes and ensuring holistic postoperative rehabilitation.

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