2025 FSA Podium and Poster Abstracts

Coronary artery bypass grafting (CABG) is a crucial surgical intervention for patients with severe coronary artery disease (CAD). However, the presence of concomitant ophthalmologic conditions such as macular degeneration, complicates management due to the risk of intraocular hemorrhage associated with anticoagulation. This case report describes the decision to postpone CABG in a patient with advanced macular degeneration due to the patient nearing the end of her anti-VEGF injection cycle, necessitating careful coordination between the cardiothoracic and ophthalmology teams to minimize the risk of intraocular hemorrhage while ensuring optimal cardiac care.

Introduction: Patients undergoing CABG require systemic anticoagulation during cardiopulmonary bypass to prevent thrombotic complications. Age-related macular degeneration (AMD) is a leading cause of vision loss in older adults and exists in two primary forms: dry and wet. The wet (neovascular) form is more severe and is characterized by the growth of abnormal blood vessels beneath the macula, leading to fluid leakage and bleeding. This condition can result in rapid vision deterioration and is commonly managed with anti-vascular endothelial growth factor (anti-VEGF) injections. Perioperative anticoagulation, which may include heparin, direct oral anticoagulants (DOACs), and antiplatelet agents, increases the risk of spontaneous retinal or vitreous hemorrhage, particularly in patients with active neovascularization.

Case Presentation: A 74-year-old female with a history of hypertension, type 2 diabetes mellitus, and severe triple-vessel CAD was scheduled for elective CABG. The patient had a longstanding diagnosis of neovascular age-related macular degeneration (AMD) since 2008 and had been receiving Faricimab-svoa (Vabysmo), an intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections. Initially, the injections were administered every eight weeks; however, due to disease progression, the interval was shortened to every four weeks. The patient was due for a routine Faricimab-svoa injection the day after the planned CABG. Given that she was nearing the end of his injection cycle, there was concern that the increased risk of intraocular hemorrhage could be exacerbated by the required systemic anticoagulation for surgery. A discussion between cardiothoracic surgery, retinal ophthalmology, anesthesiology and the patient resulted in a consensus decision to defer CABG to optimize the patient’s ophthalmologic condition before reconsidering surgery. The patient was advised to complete anti-VEGF therapy and was resecheduled CABG to the following week to enhance protection from potential complication. We will continue to monitor and report on the intraoperative course and postoperative outcome.

Discussion: This case highlights the challenges of managing CABG patients with coexisting conditions that contraindicate anticoagulation. Neovascular AMD, particularly in patients requiring frequent anti-VEGF injections, poses a risk of intraocular hemorrhage during the perioperative period. The patient’s inability to take aspirin per ophthalmologist recommendation further complicated her management, eliminating percutaneous coronary intervention (PCI) as an alternative treatment. Future cases may benefit from standardized protocols for managing similar scenarios, particularly in balancing the timing of anti-VEGF therapy with surgical interventions that require anticoagulation.