B64-50 CTEPH-CABG Combined: Curious Case of Recurring Dropping Hemoglobin and Postop Delayed Complications

Introduction Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is characterized by fibrotic thromboemboli that persistently obstruct the pulmonary arteries, leading to increased pulmonary vascular resistance and RV failure. CTEPH is classified as Group 4 pulmonary hypertension by WHO, defined as precapillary pulmonary hypertension with an mPAP> 20 mmHg & a PAWP < 15mmHg. Current treatments include pulmonary thromboendarterectomy, balloon pulmonary angioplasty (BPA), or medical management with riociguat. Description A 58-year-old male with a history of HTN, T2DM, and CTEPH presented to the hospital for shortness of breath (SOB). Extensive pulmonary artery thromboembolism was found. Further workup, including PFTs, 6-minute walk test, VQ scan, and right- and left-heart catheterization, was consistent with CTEPH & Coronary Artery Disease (CAD). A scheduled pulmonary thromboendarterectomy along with 2-vessel Coronary Artery Bypass Graft (CABG) is performed. During surgery, he had difficulty coming off bypass due to reperfusion injury. After surgery, he was able to wean off of vasopressors relatively quickly; however, his hemoglobin (Hb) dropped about 3 grams over 48 hours and required 3pRBC without any obvious sourc,e including chest tubes. Repeat ECHO reported no pericardial effusion or hematoma. CT chest showed no significant effusions. Hb stabilized, anticoagulation per CTEPH protocol resumed, and the patient was eventually weaned off dobutamine & iNO. As hemodynamics & Hb remained stable, the patient was transferred to the floor. He complained of SOB a week after surgery again. Repeat CT showed a pericardial hematoma and a large left pleural effusion. Thoracentesis was performed for bloody effusion, and the patient’s symptoms subsided. He was eventually discharged without any further complications. Discussion This case highlights the complex management of CTEPH in a middle-aged male with multiple CAD who underwent PTE with CABG. Peri & postop complications included reperfusion injury and acute anemia WITHOUT an obvious source of bleeding, which resolved with recovery of heart & pulmonary function. A week delayed pericardial hematoma and large pleural effusion underscore the need for proactive and relatively prolonged postop vigilance, particularly in CTEPH combined with CABG complex patients.