Asian Cardiovasc Thorac Ann 2004;12:260-262
© 2004 Asia Publishing EXchange Ltd
Combined Coronary Artery Bypass Grafting and Lung Surgery
Suat N Ömero
lu, MD,
Hasan B Erdoan, MD,
Kaan Kirali, MD,
Atilla Ömerolu, MD1,
Mehmet E Toker, MD,
Nihan Kayalar, MD,
Gökhan 
pek, MD,
Cevat Yakut, MD
Department of Cardiovascular Surgery, Ko
uyolu Heart and Research Hospital
1 Department of Pathology, GATA Haydarpasa Training Hospital, Istanbul, Turkey
For reprint information contact: Suat N Ömerolu, MD Tel: 90 532 677 7646 Fax: 90 216 339 0441 Email: suatnail{at}yahoo.com Orman sokak no. 5/6, Florya, Bakirköy, Istanbul 34810, Turkey.
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ABSTRACT
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Combined coronary bypass and lung surgery was performed in 3 patients. Through a median sternotomy or a left thoracotomy, bypass grafting was performed on beating heart or under cardiopulmonary bypass, followed by the lung operation. The lung lesion was diagnosed as carcinoma in 2 patients and hydatid cyst in 1 patient. With few exceptions, beating heart coronary bypass through a median sternotomy can be performed in a combined operation.
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INTRODUCTION
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Concomitant diseases of the heart and lung are uncommon. In such patients, if angioplasty is not feasible, the coronary artery lesions can be treated in a staged or a combined operation. Combined coronary artery bypass grafting (CABG) and lung surgery can be performed through a median sternotomy or a right or left thoracotomy. We present 3 cases of combined heart and lung surgery, a surgical approach that is still rarely performed.
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CASE 1
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A 75-year-old male was treated for coronary artery disease (CAD) and lung carcinoma. Preoperative coronary angiography showed severe stenosis in the proximal left anterior descending artery (LAD) and the proximal right coronary artery (RCA). The peripheral angiogram revealed severe lesions in both superficial femoral arteries. On routine chest radiography, a lesion with smooth contours was detected in the upper right lung region. Thoracic computed tomography (CT) confirmed the presence of a solid lesion measuring 3 x 2 cm situated adjacent to the pleura in the posterior segment of the right upper lobe. A CT-guided fine-needle aspiration biopsy revealed the lesion as non-small cell carcinoma.
Through a standard median sternotomy, RCA and LAD anastomoses were performed on beating heart using saphenous vein grafts. The left internal mammary artery (LIMA) was not used because of severe peripheral arterial disease. The right pleura was then opened. Left lung ventilation was instituted through a Carlens tube, while the right lung was deflated. A tumor measuring 4 cm along the greatest dimension was detected in the posterior segment of the right upper lobe. Grossly, the pleura was free of tumor, but the mid-lobe lymph nodes appeared involved. The upper and middle lobes of the right lung were fused, obscuring the fissure. These lobes were resected. The postoperative period was uneventful. The pathologic diagnosis was moderately differentiated squamous cell carcinoma. The patient was doing well 11 months after the operation.
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CASE 2
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A 58-year-old male was treated for CAD and hydatid cyst of the lung. The coronary angiogram revealed severe stenosis in the LAD and the circumflex artery (CX) as well as total occlusion of the RCA. A coin-sized lesion detected on the chest radiograph (Figure 1
) was further investigated using spiral thoracic CT. The scan showed a cyst located in the anterior basal segment of the right lower lobe. Serology confirmed the diagnosis.
Through a median sternotomy and under cardiopulmonary bypass (CPB), the LAD was bypassed with the LIMA, and a high lateral branch of the CX and the right posterior descending artery with saphenous vein grafts. After weaning from CPB, heparin was neutralized. One-lung ventilation was instituted with the right lung deflated. The right pleura was opened, exposing a cyst measuring 5.5 x 5 x 4 cm in the lower lobe. Cystectomy and capitonnage were performed. Pathology confirmed the diagnosis of hydatid cyst. The patient was discharged on the 9th postoperative day on albendazole. He was asymptomatic 8 months postoperatively.
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CASE 3
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A 53-year-old male with a large nonoperable lung tumor underwent surgery for treating CAD and for open lung biopsy. The coronary angiogram revealed triple-vessel disease, with the RCA totally occluded and diminutive. Although the lung disease was clinically nonoperable, the patient had unstable angina pectoris and so CABG was performed to improve his quality of life.
Through a left thoracotomy and on beating heart, the LIMA was anastomosed to the LAD and a saphenous vein graft to the second obtuse marginal branch of the CX. Exploration of the lung revealed a deeply invasive tumor involving the descending aorta and extending into the chest wall and the costae. Adhesions were seen on the pericardium. A biopsy revealed high-grade neuroendocrine carcinoma with small and large cell features. Chemotherapy was administered, accompanied by radiotherapy. The patient was asymptomatic and free of chest pain 11 months after surgery.
The lesions and the surgical procedures performed in these 3 patients are summarized in Table 1.
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DISCUSSION
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Concomitant cardiac and lung surgery, although still rare, is performed more frequently in recent years.1 Coronary angioplasty, if feasible, should be the first choice of therapy for patients with concomitant CAD and lung disease.2 Those with coronary lesions that are not suitable for angioplasty can be treated by combined or staged surgical procedures. Some studies suggest that staged operations are preferable because of shorter operation time and less technical complexity; accordingly, only patients who cannot tolerate a second operation should undergo a combined procedure.1 However, the time delay in staged operations may result in progression of the lung tumor to a later stage in patients who are treated for CAD first. On the other hand, if the lung operation is carried out first, it may result in worsening ischemia. Additionally, the need for a second operation means, overall, longer hospital stay and higher costs.3 For these reasons, combined surgery that includes off-pump CABG is becoming more common.
In a combined operation, CABG should precede lung surgery in order to minimize ischemic complications related to severe coronary artery lesions. It has been reported that sequencing the procedures this way reduces postoperative morbidity and mortality.4
These operations can be performed under CPB or on beating heart.1,5 The drawbacks of CPB include an increased risk of hemorrhage due to heparinization and blood coming into contact with the cannulas, an additional potential risk of tumor dissemination and growth owing to the immunosuppressive and inflammatory attributes of CPB, and longer operation time.2,5 Nevertheless, CPB is sometimes inevitable. When the CAD is amenable to beating heart surgery, the side effects of CPB and crossclamping can be avoided, besides reducing operation time and costs.
A left or right thoracotomy is adequate when the lung and cardiac lesions are on the same side.2,3 However, when both the left and right coronary systems are involved or when the lung lesion is on the contralateral side, median sternotomy is preferred.5 An advantage of median sternotomy over thoracotomy is that it has fewer deleterious effects on respiratory function tests.5
In patients with a lung lesion who have had a prior bypass operation, thoracotomy is preferred over median sternotomy, but care should be taken not to damage the grafted LIMA. It is important to note that in cases where the lung lesion is located in the left lower lobe a combined procedure through a median sternotomy is technically difficult and should be avoided.1,6
For adequate tumor staging, the paratracheal, subcarinal, and inferior pulmonary ligament lymph nodes should be sampled thoroughly. Since access to the subcarinal nodes may be difficult in some cases, an alternative approach through the posterior pericardium has been proposed. This can be accomplished by retracting the aorta medially and the superior vena cava laterally.
In combined surgery that requires a valve operation instead of CABG, the cardiac procedure has to be performed on CPB. A median sternotomy can be successfully employed for all valve operations. With mitral valve disease and right-sided lung lesions, a right thoracotomy can be an alternative approach.
Patients who require complex cardiac procedures, such as concomitant CABG and valve surgery, or who require left lower lobectomy or left pneumonectomy, may not tolerate a combined operation and will probably benefit more from staged procedures. This is especially so when pulmonary functions are compromised. In these patients, in order to reduce operation time and to avoid CPB (so as to minimize adverse effects on pulmonary functions), a hybrid myocardial revascularization procedure on beating heart may be employed to make a combined operation feasible. Where CPB is inevitable, as in patients with concomitant lung lesions and valve disease, fluid retention by hemoconcentration7 and leukocyte filtration8 are therapeutic options for minimizing CPB-related lung injury.
In conclusion, we believe that median sternotomy can be used in all patients with concomitant severe CAD and lung pathology undergoing combined surgery, except where the lung lesion is located in the left lower lobe. Myocardial revascularization on beating heart, when feasible, is preferred over the use of CPB in combined surgery in order to avoid the side effects of CPB, especially hemorrhage, and thus to make the ensuing lung surgery safer.
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REFERENCES
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- Miller DL, Orszulak TA, Pairolero PC, Trastek VF, Schaff HV. Combined operation for lung cancer and cardiac disease. Ann Thorac Surg
1994;58:989–93.[Abstract]
- Al-Attar N, Salvi S, Sebbag U, Nataf P. Combined left pneumonectomy and off-pump coronary artery bypass through left thoracotomy. Eur J Cardiothorac Surg
2001;19:226–8.[Abstract/Free Full Text]
- Ahmed AA, Sarsam MA. Off-pump combined coronary artery bypass grafting and left upper lobectomy through left posterolateral thoracotomy. Ann Thorac Surg
2001;71:2016–8.[Abstract/Free Full Text]
- Thomas P, Giudicelli R, Guillen JC, Fuentes P. Is lung cancer surgery justified in patients with coronary artery disease? Eur J Cardiothorac Surg
1994;8:287–91.[Abstract]
- Ulicny KS, Schmelzer V, Flege JB Jr, Todd JC, Mitts DL, Melvin DB, et al. Concomitant cardiac and pulmonary operation: the role of cardiopulmonary bypass. Ann Thorac Surg
1992;54:289–95.[Abstract]
- Mariani MA, van Boven WJ, Duurkens VA, Ernst SM, van Swieten HA. Combined off-pump coronary surgery and right lung resections through midline sternotomy. Ann Thorac Surg
2001;71:1343–4.[Abstract/Free Full Text]
- Habib RH, Zacharias A, Engoren M. Determinants of prolonged mechanical ventilation after coronary artery bypass grafting. Ann Thorac Surg
1996;62:1164–71.[Abstract/Free Full Text]
- Gu YJ, de Vries AJ, Boonstra PW, van Oeveren W. Leukocyte depletion results in improved lung function and reduced inflammatory response after cardiac surgery. J Thorac Cardiovasc Surg
1996;112:494–500.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
