Abstract

A 60-year-old female patient presented with breathlessness (NYHA grade II), retrosternal chest pain, and postprandial fullness, alongside heartburn symptoms. Clinical evaluation revealed prominent Q waves and ST-segment depression on ECG, while chest X-ray showed a raised right-sided hemidiaphragm with bowel loop shadows, suggesting a diaphragmatic hernia or eventration. Pulmonary function tests were unremarkable. An echocardiogram indicated a dysfunctional left ventricle with an ejection fraction of 45%, apical septal akinesia, inferior wall hypokinesia, and mild mitral regurgitation. CT imaging of the chest and abdomen confirmed a diaphragmatic defect with herniation of omental fat and a large portion of the transverse colon, causing atelectasis of the medial right middle lobe. Coronary angiography revealed lesions in the left anterior descending artery, left circumflex artery, and right coronary artery. The patient was diagnosed with both coronary artery disease and diaphragmatic hernia and was recommended for coronary artery bypass grafting (CABG) along with diaphragmatic hernia repair. Intraoperatively, the patient was managed with standard ASA monitors, rapid sequence induction, and a left-sided double-lumen tube for single-lung ventilation. The hernia was repaired with polypropylene mesh, and CABG was performed offpump after achieving adequate anticoagulation. Postoperatively, the patient showed improvement with a significant reduction in airway pressure and was extubated 8 hours post-surgery. Bowel sounds were audible by postoperative day 1, and the patient was discharged on the 7th postoperative day without complications. This case highlights the complexity of managing concomitant coronary artery disease and diaphragmatic hernia, emphasizing a multidisciplinary approach to treatment and anesthesia.

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