Very Delayed Surgical Bleeding after Coronary Artery Bypass Graft Causing Cardiac Tamponade and Cardiogenic Shock: A Rare Case Report

Delayed surgical bleeding from the left internal mammary artery (LIMA) bed following coronary artery bypass grafting (CABG) is a rare yet potentially fatal condition that can lead to cardiac tamponade and life-threatening cardiogenic shock. We present a case of extremely delayed active bleeding from the LIMA bed, occurring 5 weeks after conventional CABG, resulting in cardiac tamponade and cardiogenic shock. The 73-year-old patient presented to the emergency room with a 2-day history of general weakness and hypotension. He had undergone CABG 5 weeks ago. Optimal inotropic agents and vasopressors were used for the treatment of shock. In the emergency room, real-time bedside echocardiography showed severe external compression of the right ventricle by a homogeneous, hyperechoic mass. Veno-arterial (V-A) mode extracorporeal membrane oxygenation (ECMO) was promptly instituted to stabilize hemodynamics. Subsequent chest re-exploration, involving blood clot evacuation, was performed, and the bleed from the distal LIMA bed was ligated. Delayed LIMA bed bleeding causing cardiac tamponade and cardiogenic shock is an infrequent occurrence, and the use of V-A mode ECMO successfully provided a window of time for chest exploration.