(Chest. 2001;119:1941-1943.)
© 2001
American College of Chest Physicians
Lung Cancer Resection or Aortic Graft Replacement With Simultaneous Myocardial Revascularization Without Cardiopulmonary Bypass*
Amir Elami, MD;
Amit Korach, MD and
Ehud Rudis, MD
*
From the Department of Cardiothoracic Surgery, Hadassah University Hospital, Jerusalem, Israel.
Correspondence to: Amir Elami, MD, Cardiothoracic Surgery, POB 12000, Jerusalem 91120, Israel; e-mail: eamir{at}md2.huji.ac.il
 |
Abstract
|
|---|
Background: The concomitant occurrence of lung cancer
or other thoracic problems requiring surgical treatment in patients
with significant coronary artery disease is uncommon.
Methods: Three patients underwent revascularization of the
anterior descending artery, without cardiopulmonary bypass, with
simultaneous pulmonary lobectomy (two patients) or replacement of an
obstructed descending aortic graft (one patient).
Results: Postoperative ventilation time was < 3 h, and no
morbidity related to the combined procedure occurred during midterm
follow-up.
Conclusions: This one-stage approach
allowed the immediate solution of two intrathoracic comorbidities,
reducing expenses and suffering to the patients and minimizing the risk
of bleeding or tumor dissemination secondary to extracorporeal
circulation-induced coagulopathy and
immunosuppression.
Key Words: aortic coarctation • cardiac surgery • cardiopulmonary bypass • lung cancer
|
Introduction
|
|---|
Occasionally
, a patient with coronary artery disease may present with another
thoracic problem requiring surgical intervention. The opposite may also
happen; a patient presenting with a thoracic surgical problem may be
found to have a significant undiagnosed coronary artery disease.
Myocardial revascularization may be indicated in such patients to
eliminate symptomatic myocardial ischemia or to increase the safety of
the thoracic operation.
Myocardial revascularization without extracorporeal
circulation is increasingly accepted as an alternative to conventional
coronary artery bypass grafting (CABG), using cardiopulmonary
bypass.1
2
Minimally invasive CABG can be combined with
another thoracic procedure for the simultaneous solution of both
medical problems. We would like to share our experience with this
approach for the management of cardiac and thoracic comorbidities.
|
Materials and Methods
|
|---|
Between August 1997 and April 1999, three patients underwent
concomitant minimally invasive CABG and thoracic procedures. A
47-year-old woman with Turner’s syndrome complained of shortness of
breath during effort and recurrent syncope. Fourteen years earlier, she
had undergone repair of coarctation of the aorta with a bypass graft
(Dacron; Dupont; Wilmington, DE) between the origin of the left
subclavian artery and the descending aorta. The results of a
201Tl scan during exercise were positive, and
cardiac catheterization revealed a total obstruction of the proximal
left anterior descending (LAD) coronary artery and a significant
filling defect within the descending aorta bypass graft. Through a left
thoracotomy incision in the fourth intercostal space, the left
internal thoracic artery (LITA) was harvested under direct inspection.
The LAD coronary artery was exposed, and a segment was temporarily
occluded and stabilized to allow direct anastomosis of the LITA.
Diastolic flow in the graft was confirmed with a Doppler signal. The
distal aortic arch, the left subclavian artery, the graft, and the
descending aorta were then isolated. A temporary heparinized shunt was
placed between the ascending and descending aorta, and the graft was
excised and removed. The graft was found to be partially obstructed by
detached pseudointima. A new 16-mm graft (Dacron) was used to replace
the old graft. Massive bleeding from the cannulation site at the
ascending aorta during decannulation resulted in hemodynamic
instability and ventricular fibrillation. The patient was resuscitated
successfully and discharged to home after 8 days, with normal left
ventricular function seen on echocardiography. Coronary angiography
performed after 22 months for the recurrence of shortness of breath,
revealed a patent LITA graft and new 70% stenosis at the origin of the
first and second marginal branches of the circumflex coronary artery.
Two patients underwent lung resection in addition to CABG. A
66-year-old patient with worsening angina pectoris was found to have a
significant two-vessel coronary artery disease (ie, LAD and
a nondominant right coronary artery). A 2.5-cm shadow in the left upper
lung field attracted the attention of the patient’s cardiologist
during the catheterization. A further workup revealed this nodule to be
a squamous cell carcinoma with no metastatic spread (stage T1N0M0). At
surgery, through a left thoracotomy incision, a left upper lobectomy
and lymph node sampling was performed, followed by LITA-to-LAD coronary
artery anastomosis on the beating heart. The patient was discharged
home after 6 days and remained asymptomatic, with no evidence of
disease after 24 months of follow-up.
A 77-year-old woman, who had been on regular radiographic follow-up
since her sister had died 5 years earlier of lung cancer, was referred
with a 3-cm right upper lobe mass, which was found by fine-needle
aspiration to be an alveolar cell carcinoma. The patient had negative
results for CT and positron emission tomography scans for distant
metastases. She had been treated for hypertension and reported an
atypical episodic chest sensation. The results of a
thallium-dipyridamole scan was positive for reversible anterior
ischemia, and during cardiac catheterization a 90% stenosis was found
in the mid-LAD coronary artery. Through a median sternotomy incision,
she underwent a right-upper lobectomy combined with LITA-to-LAD
coronary artery grafting without cardiopulmonary bypass. The
postoperative course was uneventful, and she has been asymptomatic
without evidence of disease during 22 months of follow-up.
|
Discussion
|
|---|
The combination of medical problems illustrated by these patients
can be approached using a number of alternative therapies. When the
coronary anatomy is suitable for transcatheter intervention, it can be
dealt with in the catheterization laboratory. However, the adjunctive
pharmacotherapy that is required after such an intervention might
increase the risk of hemorrhagic complications and will delay surgical
correction of the thoracic problem.3
4
In patients with
malignant tumors, this may be regarded as a disadvantage. Also, staging
the treatment will usually make it more expensive and may double the
patient’s discomfort. Another option is to perform first a
conventional CABG operation, followed by a second thoracic operation
(through a separate incision). Although the surgical exposure for each
procedure will be optimal, allowing complete revascularization, it may
be more painful for the patient and more expensive. Also, alterations
in the immune system following cardiopulmonary bypass procedures may
enhance tumor growth and dissemination, adversely affecting long-term
survival.5
6
The alternative of a combined procedure,
particularly in the era of minimally invasive coronary surgery, has a
number of advantages. It confers adequate myocardial protection with
simultaneous, undelayed treatment of the thoracic problem. Depending on
the type of surgical incision, the following vessels other than
the LAD coronary artery can be bypassed on the beating heart:
circumflex marginal branches through a left thoracotomy incision or
through bilateral submammary anterior thoracotomy
incision7
; and the right coronary artery when median
sternotomy incision is employed. Residual coronary disease may be
treated subsequently in the catheterization laboratory (hybrid
approach).8
Most of the experience in concomitant lung
resection and coronary artery bypass surgery was obtained using
cardiopulmonary bypass procedures. Although the operative mortality
rate has been low (0 to 6.5%),9
avoiding cardiopulmonary
bypass with complete intraoperative anticoagulation and postoperative
coagulopathy seems to be an advantage when another procedure in the
chest is contemplated. Fluid overload and activation of the
inflammatory response, which may result in pulmonary dysfunction, are
eliminated when CABG is performed without cardiopulmonary bypass. Our
patients were successfully extubated within 3 h after surgery.
Theoretically, the depression of cell-mediated immunity sustained
during cardiopulmonary bypass10
11
12
may enhance tumor
dissemination. It should be emphasized that both patients in our
experience had early cancers and that the follow-up was relatively
short. To demonstrate a survival advantage, a larger study with a
longer follow-up period is in order.
Our patient who underwent replacement of a partially occluded graft
between the left subclavian artery and the descending aorta was stable
throughout the duration of aortic and subclavian cross-clamping.
However, ventricular fibrillation occurred as a result of acute
hypovolemia on the removal of a temporary shunt. The LAD coronary
artery territory, already supplied by the LITA graft, might have been
ischemic while the left subclavian artery was clamped for removal and
replacement of the old graft, making it more vulnerable to hypotension.
A reversed order of actions should have been considered, but initial
graft replacement could have exposed the unprepared left ventricle to
increased afterload and oxygen requirements. This afterload may have
been tolerated. In addition, the new graft can serve as the origin of a
vein graft when the LITA is calcified, as may frequently occur in
patients with coarctation after the fourth decade.13
An
alternative approach, suggested recently by Izhar et al,14
is to perform both procedures through midline sternotomy incisions
using cardiopulmonary bypass.
Our limited experience and that reported in the literature support the
conclusion that simultaneous thoracic surgical procedure and coronary
artery bypass surgery can be performed successfully, provided that the
surgical team has the technical flexibility and the cooperation of
their cardiology counterparts.
|
Footnotes
|
|---|
Abbreviations: CABG = coronary artery bypass
grafting; LAD = left anterior descending; LITA = left internal
thoracic artery
Received for publication October 10, 2000.
Accepted for publication January 23, 2001.
|
References
|
|---|
-
Subramanian, VA, McCabe, JC, Geller, CM (1997) Minimally invasive direct coronary artery bypass grafting: two-year clinical experience. Ann Thorac Surg 64,1648-1655[Abstract/Free Full Text]
-
Diegeler, A, Falk, V, Walther, T, et al (1997) Minimally invasive coronary-artery bypass surgery without extracorporeal circulation [letter]. N Engl J Med 336,1454[Free Full Text]
-
. EPIC Investigators. (1994) Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty. N Engl J Med 330,956-961[Abstract/Free Full Text]
-
Gregorini, L, Marco, J, Fajadet, J, et al (1995) Ticlopidine alternates post-angioplasty thrombin generation [abstract]. Circulation 92(suppl),I-608
-
Brutel de la Riviere, A, Knaepen, P, Van Swieten, H, et al (1995) Concomitant open heart surgery and pulmonary resection for lung cancer. Eur J Cardiothorac Surg 9,310-314[Abstract]
-
Rao, V, Todd, TR, Weisel, RD, et al (1996) Results of combined pulmonary resection and cardiac operation. Ann Thorac Surg 62,342-347[Abstract/Free Full Text]
-
Yellin, A, Moshkovitz, Y, Simanski, DA, et al (1994) Coronary revascularization and pulmonary lobectomy without cardiopulmonary bypass. Thorac Cardiovasc Surg 108,797-799
-
Friedrich, GJ, Bonatti, J, Dapunt, OE (1997) Preliminary experience with minimally invasive coronary-artery bypass surgery combined with coronary angioplasty. N Engl J Med 336,1454-1455
-
Danton, MHD, Anikin, VA, McManus, KG, et al (1998) Simultaneous cardiac surgery with pulmonary resection: presentation of series and review of literature. Eur J Cardiothorac Surg 13,667-672[Abstract/Free Full Text]
-
Knudsen, F, Andersen, LW (1990) Immunological aspects of cardiopulmonary bypass. J Cardiothorac Vasc Anesth 4,245-258
-
Jensen, RH, Storgaard, M, Vedelsdal, R, et al (1995) Impaired neutrophil chemotaxis after cardiac surgery. Scand J Cardiothorac Surg 29,115-118
-
Markewitz, A, Faist, E, Lang, S, et al (1996) An imbalance in T-helper cell subsets alters immune response after cardiac surgery. Eur J Cardiothorac Surg 10,61-67[Abstract]
-
Rozanski, J, Juraszynski, Z, Kusmierczyk, M, et al (1999) Repair of coarctation of the aorta with simultaneous coronary artery bypass grafting without cardiopulmonary bypass. Eur J Cardiothorac Surg 15,536-538[Abstract/Free Full Text]
-
Izhar, U, Schaff, HV, Mullany, CJ, et al (2000) Posterior pericardial approach for ascending aorta-to-descending aorta bypass through a median sternotomy. Ann Thorac Surg 70,31-37[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
J. Litmathe, N. Atmaca, D. Menghesha, and A. Krian
Combined procedures using the extracorporeal circulation and urologic tumor operation - experiences in six cases
Interactive CardioVascular and Thoracic Surgery,
March 1, 2004;
3(1):
132 - 135.
[Abstract]
[Full Text]
[PDF]
|
|
|
TOP
Abstract
Introduction
