Very Severe Hypertriglyceridemia Prior to CABG: Successful Preparation and Sustainable Triglycerides Level

Presentation Number: LB MON 68
Date of Presentation: April 3rd, 2017

Carla Sawan*1, Bassam Abou Khalil2 and Daniel J Rader3
1University of Balamand, Beirut, Lebanon, 2University of Balamand, Lebanon, Beirut, Lebanon, 3University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA

Abstract

Introduction

Very severe hypertriglyceridemia corresponds to a TG level > 1000 mg/dL. In addition to the known association with acute pancreatitis, elevated triglycerides are an independent risk factor for CAD (1,2) and hypercoagulability (3,4,5). This poses a life threatening risk of hyperviscosity, thrombosis and complications following major procedures such as CABG. Outside the setting of acute pancreatitis, the literature shows no indication to use IV insulin for lowering of TG levels in asymptomatic patients, and no reports of CABG surgeries on patients with TG > 1000 mg/dL.

Case presentation

Our patient was a 67 year old Caucasian female with a long history of very severe hypertriglyceridemia, uncontrolled type 2 DM in need for CABG surgery for active CAD. Family history was negative for any lipid disorders. Her BMI was 21 kg/m2, she was not a smoker, and had rare alcohol intake. Since her diagnosis with hypertriglyceridemia at the age of 30, she was treated with combinations of fibrates and statins, and despite medical compliance and adherence to a strict low fat diet over the years, her TG level remained between 3000 mg/dL and 8000 mg/dL, triggering 2-3 episodes of pancreatitis yearly. Her diabetes was managed with basal bolus insulin along with metformin.

During the preoperative evaluation, the lipid profile was: triglycerides 2201 mg/dL, total cholesterol 344 mg/dL, LDL-C 28 mg/dL, HDL 26 mg/dL. The physical exam was negative for skin eruptions or tendinous xanthomas.

3 days prior to the scheduled surgery, the patient's TG level was 1219 mg/dL despite optimal oral therapy. She had no clinical or biochemical evidence of acute pancreatitis. Because of concerns regarding the immediate risk of hypercoagulability and hyperviscosity, the patient was hospitalized for administration of IV insulin, since plasmapheresis was not available on site. The patient was kept NPO and continued to take her oral lipid lowering drugs. The insulin IV infusion was titrated to maintain glycemia below 180 mg/dL. On the day of surgery, the TG level was 271 mg/dL.

The operation went successfully and consisted of CABG with total arterial revascularization using the left mammary and the left radial arteries. The postoperative course was uneventful and the patient’s TG level upon discharge was 318 mg/dL. It remained below 500 mg/dL up to 4 months later.

Discussion

The challenge in our case consisted of lowering the triglyceride level from > 1200 mg/dL to < 300 mg/dL in less than 72 hours prior to CABG surgery, given the significant morbidity and the risk of hypercoagulable state. Plasmapheresis was unavailable, and the patient had no active pancreatitis to require IV insulin infusion as it would be traditionally indicated. We had rapid and successful lowering of the TG level with our unconventional use of IV insulin leading to a smooth postoperative course, and a sustainable improvement in the patient’s TG level up to 4 months later.

 

Nothing to Disclose: CS, BA, DJR