Successfully navigating emergency coronary artery bypass surgery in an older female with severe hypothyroidism

We report a case of an 60-year-old frail female presenting to us with anterolateral wall myocardial infarction (MI). She had a history of hypothyroidism for the last 10 years and was on Thyroxine 25 µg daily (mcg). A coronary angiogram revealed a distal left main coronary artery having 40-50% occlusion with proximal left anterior descending artery (LAD) and circumflex artery critical stenosis and the lesions were not suitable for percutaneous coronary intervention (PCI). In view of ongoing chest pain with ST elevation in the anterior chest leads, an intraaortic balloon pump (IABP) was inserted. At admission, her thyroid function tests were severely deranged: Thyroid Stimulating Hormone (TSH) was 89.57 mIU/L. Endocrinology consultation prompted an increase in Thyroxine dosage from 25 to 75 mcg per day, with the addition of Triiodothyronine (T3) 20 mcg/day, as intravenous thyroxine was unavailable at our centre. After five days of optimization with thyroid medications and IABP support, emergency On Pump coronary artery bypass graft (CABG) surgery was performed with two grafts. As anticipated, the patient's postoperative course was prolonged due to congestive heart failure and recurrent bilateral pleural effusion, which was managed medically. On literature search at Google and PubMed, regarding Successful CABG surgery with such a high level of TSH, we did not find any study. This case demonstrates that emergency CABG can be successful in severe hypothyroidism with meticulous preoperative optimization and multidisciplinary care.