Pulmonary embolism after coronary artery bypass grafting.

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Case Presentation : A 76-year-old man developed increased fatigue during his daily 40-lap swim and daily 3-mile walk. His past medical history included use of hydrochlorothiazide for hypertension. His physical examination and baseline ECG were normal. An exercise treadmill test demonstrated ischemia, and cardiac catheterization showed left main and 3-vessel obstructive coronary artery disease. Echocardiography revealed normal left ventricular function. He underwent a 3-vessel coronary artery bypass grafting (CABG) with the left internal mammary artery grafted to the left anterior descending, and separate saphenous vein grafts, harvested endoscopically from the left leg, to the obtuse marginal branch and posterior descending coronary artery. The surgery was uncomplicated, with an aortic cross clamp time of 73 minutes and cardiopulmonary bypass time of 89 minutes. On the first postoperative day, he was transferred out of the intensive care unit. By the fifth postoperative day, he was walking 100 feet steadily without use of any assist device. He was discharged home on the sixth postoperative day on enteric-coated aspirin, hydrochlorothiazide, metoprolol, and atorvastatin. He presented to his community hospital on the 30th postoperative day, complaining of 5 days of increasing fatigue and 1 day of markedly increased shortness of breath. The ECG showed a heart rate of 79 beats per minute and nonspecific ST and T wave abnormalities. The D-dimer level was elevated (>8000 ng/mL). Contrast-enhanced spiral computed tomography (CT) of the pulmonary arteries, including additional sections of the lower extremities, acquired during venous phase of contrast enhancement (“indirect CT venography”) showed a large bilateral central pulmonary embolism (PE) and a right leg deep vein thrombosis (DVT), without DVT in the leg from which the saphenous vein had been harvested (Figure 1). He was transferred to Brigham and Women’s Hospital for further management, where he was hospitalized for 6 days, received enoxaparin as a …