Asian Cardiovasc Thorac Ann 2003;11:277-278
© 2003 Asia Publishing EXchange Ltd
Malaria and Open Heart Surgery
Manoj Purohit, MD, Specialist Registrar
1 Department of Cardiac Surgery, Alder Hey Hospital, Eaton Road, Liverpool, L12 2AP, UK
We read the article by Balkanay M et al1 on Coronary Bypass Surgery in Patient With Malaria with great interest. This subject carries a great importance in endemic areas of malaria. The emergence of chloroquine resistant further complicates the situation. With the increasing world travel the boundaries of health problems are getting less defined as happened with authors.1
Authors were able to deal with the situation in the best possible way but it may not be feasible to apply the same principals in all the situations, the heterogeneity of malaria complicates the matter further. There are few question need to be resolved on this subject.
- Is malaria a valid indication of avoiding cardiopulmonary bypass; is it a new indication of off pump surgery? Is there evidence that there is increased hemolysis by cardiopulmonary bypass after previous malaria? Can cardiopulmonary bypass induce relapse of malaria?
- The malaria is one of the differential diagnosis of any undiagnosed postoperative fever,2 mainly because of possibility that patient was in incubation period and has developed diseases after the surgery or has relapsed from dormancy. Another reason is transmission of infection via blood transfusion (Post transfusion malaria), where the incubation period is very short.2,3
- It may not be possible to do off pump surgery in all cases and what should be the guidelines followed in them, specially in cases of unstable angina.
- Should cardiopulmonary bypass be avoided even after 2 weeks of radical Primaquine therapy (To eradicate hypnozoites form of P.vivax & P. ovale) after which the chances of relapse are negligible? Primaquine therapy itself can cause hemolysis in patients with G6PD deficiency.3
- Does the type of malaria matters, what about the malignant type, P. falciparum malaria, which causes complicated diseases, is developing chloroquine resistance in many parts of the world, doesn’t need radical therapy (no hypnozoites form) and is associated with worst hemolysis and complications.3 How long one should wait after successfully treated P. falciparum malaria to embark on surgery. The falciparum distorts the RBC’s and makes them ‘‘Cytoadherent’’ and can cause severe hemolysis.3 It will take 125 days to get the all existing erythrocytes replaced with the new ones.
- What if patient is a hepatic carrier, has not received radical therapy after last attack of malaria? If these are the findings in the history of patient, what should be the course of management in elective as well as in emergency situations?
- If there is an increased hemolysis after cardiopulmonary bypass, should patient be investigated for malaria?
We agree with the authors that further studies are needed but not only to compare off pump and on pump but to establish the safety of cardiopulmonary bypass also. A published report of conduction of cardiopulmonary bypass in active malaria has documented increased hemolysis but without any adverse outcome.4 Postoperative malaria is a separate subject of discussion but needs to be addressed, as all this is so interrelated. Most of the cases of malaria after the open-heart surgery has been attributed to blood transfusion but relapse have also being implicated.2 The possibility of induction of relapse of malaria by major surgery or blood transfusion because of its immunosuppressing action has been hypothesised,2 cardiopulmonary bypass has far greater effects than these so can be easily implicated for inducing relapse. The bottom line is, there are still grey areas remaining unnoticed in today’s advanced cardiac surgery, implications of which are not known and how the recent advances in cardiopulmonary bypass is going to effect all this needs to be evaluated.5
REFERENCES
- Balkanay M, Mansurog lu D, Kirali K, Suat NÖ, and Cevat Y. Coronary Bypass Surgery in Patient With Malaria. Asian Cardiovasc Thorac Ann 2002;10:160–1.[Abstract/Free Full Text]
- Gibney EJ. Surgical aspects of malaria. Br J Surg 1990 Sep;77(9):964–7.[Medline]
- White NJ, Breman JG. Malaria and Babesiosis: Diseases caused by red blood cell parasite. In: Braunwald E, Fauci AS, Kasper DL, editors. Harrison’s principles of internal medicine. 15th edition, New York: McGraw-Hill, 2001:782–81203–12.
- Gerdes A, Joubert-Hubner E, Sievers HH. Effect of cardiopulmonary bypass on a patient with endocarditis and malaria. J Extra Corpor Technol 2001 May;33(2):111–3.[Medline]
- Oddvar M, Erik Fe, Einar D, Vibeke B, Conny A, Kolbjørn H et al. Centrifugal Pump and Heparin Coating Improves Cardiopulmonary Bypass Biocompatibility Ann Thorac Surg 1996 62:1134–40.[Abstract/Free Full Text]
