Preoperative Therapeutic Plasma Exchange for Severe Hypertriglyceridemia-Associated Myocardial Infarction in a Chronic Hemodialysis Patient Undergoing Urgent Coronary Artery Bypass Grafting: A Case Report

Severe hypertriglyceridemia (HTG) is a well-recognized cause of acute pancreatitis, but its role as a precipitant of acute myocardial infarction (MI) and a barrier to urgent surgical intervention is less frequently documented, especially in patients with end-stage renal disease (ESRD). We report a unique case of a 68-year-old male on chronic hemodialysis who presented with an inferior wall myocardial infarction. Coronary angiography revealed severe triple vessel disease necessitating urgent coronary artery bypass grafting (CABG). However, laboratory investigations identified critical hypertriglyceridemia (1943 mg/dL), posing significant risks for hyperviscosity and extracorporeal circuit failure. To mitigate these perioperative risks, the patient underwent four sessions of preoperative Therapeutic Plasma Exchange (TPE), which successfully reduced serum triglycerides to 355 mg/dL. Following this stabilization, the patient underwent a successful off-pump CABG and was managed postoperatively with sustained low-efficiency dialysis. This case highlights the clinical utility of TPE as a rapid and effective "therapeutic bridge" to enable safe, urgent cardiac surgery in patients with severe HTG. It demonstrates that preoperative lipid-lowering apheresis can safely manage metabolic barriers to surgery in complex ESRD patients, potentially expanding the management options for high-risk cardiovascular cases where medical therapy alone is insufficient.