Asian Cardiovasc Thorac Ann 2002;10:160-161
© 2002 Asia Publishing EXchange Pte Ltd
Coronary Bypass Surgery in Patient With Malaria
Mehmet Balkanay, MD,
Denyan Mansuro
lu, MD,
Kaan Kirali, MD,
Suat Nail Ömerolu, MD,
Cevat Yakut, MD
Department of Cardiovascular Surgery Ko uyolu Heart and Research Hospital Istanbul, Turkey
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Denyan Mansurog lu, MD Tel: 90 216 325 5457 Fax: 90 216 339 0441 email: drdenyan{at}yahoo.com Department of Cardiovascular Surgery, Kouyolu Heart and Research Hospital, Kadiköy, Istanbul 81020, Turkey.
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ABSTRACT
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A 65-year-old man with unstable angina pectoris developed malaria prior to coronary artery bypass grafting. After 3 weeks on antimalarial therapy, left internal mammary artery-toleft anterior descending artery anastomosis was performed on the beating heart to avoid the effects of cardiopulmonary bypass. There was no complication in the early postoperative period.
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INTRODUCTION
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Malaria is a protozoan infection transmitted to humans by the female Anopheles mosquito.1 The life-cycle in humans begins with the introduction of sporozoites into the blood from the saliva of the biting mosquito.2 Transmission across the placenta, via blood transfusions, and through intravenous drug abuse can also occur. Positive thick and thin Giemsa-stained blood smears must be performed to diagnose malaria and identify the species. Fever with shaking chills are the first symptoms in most patients. Antimalarial therapy should be continued for a minimum of 3 weeks before any surgical intervention.3 An extensive literature search concerning the effects of off-pump coronary artery bypass grafting (CABG) on patients with active malaria found no previous report.
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CASE REPORT
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A 65-year-old man who was visiting Turkey, presented with unstable angina pectoris of 2 weeks': duration. His physical examination was normal. Electrocardiography demonstrated negative T waves in the anterior precordial leads, but there was no evidence of previous myocardial infarction. After the detection of anterolateral and apical ischemia on thallium-201 myocardial scintigraphy, coronary angiography was performed. A long segment of severe stenosis (90%) was observed in the proximal left anterior descending artery; the other coronary arteries were normal. Left ventricular function and valvular motions were normal on echocardiography. Because the lesion was located proximally and constituted a long-segment stenosis, coronary angioplasty and stent application were not possible; thus it was decided to perform CABG. One day prior to surgery, the patient developed a high fever (40°C) with shaking chills in a cycle typical of malaria. He admitted that he had contracted malaria 6 months previously and had been using primaquine, but he had stopped his therapy without consulting his doctor. Routine preoperative laboratory studies were within normal limits. Positive thick and thin Giemsa-stained blood smears confirmed the diagnosis of malaria and identified Plasmodium vivax as the responsible species. Primaquine 15 mg daily was started and continued for 3 weeks before surgery. With the patient fever-free, off-pump CABG was planned to avoid the potential adverse effects of cardiopulmonary bypass (CPB) on red blood cells. Left internal mammary artery-to-left anterior descending artery anastomosis was performed on the beating heart. There were no ischemic or hemodynamic changes during anastomosis (7 minutes). The patient was extubated 3 hours postoperatively, and primaquine therapy was resumed immediately. Blood products were not used. He had no fever during the postoperative period, and laboratory results were within normal limits. He was discharged on the 5th postoperative day, on continuing antimalarial therapy.
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DISCUSSION
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There are four species of Plasmodium parasite that infect humans: Plasmodium vivax, Plasmodium ovale, Plasmodium malaria, and Plasmodium falciparum. The main symptom of malaria is fever which coincides with the maturing of the parasites and the resultant destruction of red blood cells. This occurs every 40 to 50 hours in vivax and ovale infections, and at 72-hour intervals during Plasmodium malaria infection.4 The fever rises rapidly to 41°C with shaking chills, and is frequently accompanied by nausea and vomiting. Splenomegaly and hepatomegaly occur in most patients. The species attack reticulocytes and erythrocytes of all ages, and cause severe hemolysis resulting in hemolytic anemia and hemoglobinuria. The permeability of the erythrocyte cell membrane can be changed by the parasite, and red blood cells are predisposed to invade vessel walls. The affected red blood cells become agglutinated, plugging capillaries with resultant thrombosis and local hypoxia. When cerebral malaria occurs, it can often be fatal. Falciparum malaria is the most serious type with up to 10% mortality. The other 3 types are much less severe, and they infect only the reticulocytes or older erythrocytes, resulting in destruction of less than 2% of the red blood cells. Symptoms can recur or the malaria can become milder a long time after the first period because of a latent extraerythrocytic cycle.
Coronary bypass surgery is performed routinely under CPB. However, the traumatic effect of CPB on blood cells can cause adverse effects during the postoperative period.5 We have previously reported that off-pump CABG decreases postoperative morbidity and mortality in high-risk patients.6 Thus, off-pump surgery was chosen in this patient to avoid the adverse effects of CPB and hemolysis. However, there is one report of a patient with malaria undergoing CPB for aortic valve replacement; no hemolysis was observed postoperatively, and it was suggested that CPB could be safely used in patients with malaria.7 There are a limited number of patients with malaria who require cardiac surgery, and there have been no comparative studies of on-pump and off-pump procedures in such cases. Nevertheless, it would seem prudent to avoid CPB except in situations where the use of extracorporeal circulation is essential.
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REFERENCES
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ABSTRACT
INTRODUCTION
