Asian Cardiovasc Thorac Ann 2006;14:250-251
© 2006 Asia Publishing EXchange Ltd
Combined Minimally Invasive Coronary Bypass Surgery and Left Pulmonary Lobectomy
Philippe-Primo Caimmi, MD,
Pietro Di Biasi, MD1
Department of Cardiac Surgery, Ospedale Maggiore della Carita, Novara, Italy
1 Division of Thoracic and Cardiovascular Surgery, Policlinico Multimedica, Milan, Italy
For reprint information contact: Philippe-Primo Caimmi, MD Tel: 39 347 913 5414 Fax: 39 321 373 3526 Email: philippeprimo.caimmi{at}tin.it, Baluardo Massimo D’ Azeglio n. 5, Novara 28100, Italy.
 |
ABSTRACT
|
|---|
Two patients underwent combined heart and lung surgery performed through a limited left anterior thoracotomy. Good exposure of the left pulmonary hilum and the left anterior descending artery was obtained, allowing left upper lobectomy combined with off-pump coronary bypass grafting. This approach avoids potential complications due to sternotomy, staged operations, and cardiopulmonary bypass. These cases show that a limited thoracotomy allows safe and effective combined lung and cardiac surgery in carefully selected patients.
|
INTRODUCTION
|
|---|
Minimally invasive direct coronary artery bypass grafting (MIDCAB) performed on the beating heart avoids sternotomy and eliminates complications associated with cardiopulmonary bypass (CPB). Limited left anterior thoracotomy is a widely accepted approach in thoracic surgery that is becoming increasingly used in cardiac surgery.1 In this report, we describe the use of this approach with a slight modification in 2 patients who underwent combined heart and left-lung surgery. To the best of our knowledge, combined left upper lobectomy and myocardial revascularization without CPB performed through a limited thoracotomy has not been reported in the literature.
|
CASE REPORTS
|
|---|
CASE 1
A 54-year-old man with T2N0M0 left upper lobe adenocarcinoma and symptomatic critical stenosis in the left anterior descending coronary artery (LAD) unsuitable for percutaneous transluminal coronary angioplasty (PTCA) was referred to us. In light of the concomitant diseases, we decided to perform lung and cardiac procedures simultaneously through the same incision. Under general anesthesia and double-lumen endotracheal intubation to provide optimal selective ventilation, the patient was placed in the supine position with the bed flexed to increase the intercostal spaces. A limited left anterior thoracotomy of 15 cm was made through the fifth intercostal space without resecting or dissecting any part of the ribs. Through this approach, a good exposure of the left pulmonary hilum and the left upper lobe was obtained. Left upper lobectomy and hilar and mediastinal lymphadenectomy were performed using conventional techniques. Following that, the left internal mammary artery (LIMA) was harvested from above the first rib to the fifth intercostal space with the support of a LIMA-Lift (Cardiothoracic System, Cupertino, CA, USA). The patient was heparinized (1 mg·kg–1), and the LIMA was divided after ligation of the distal stump. After minimal lateral pericardiotomy on the beating heart, the LIMA was anastomosed to the middle portion of the LAD with the aid of a coronary stabilizer (Octopus II Plus; Medtronic, Inc., Minneapolis, MN, USA). Left upper lobectomy increased exposure of the heart and allowed LAD revascularization without ventilatory exclusion of the remaining portion of the left lung. In order to construct accurate distal anastomoses, stay sutures of 3/0 polypropylene with teflon pledgets were placed proximal and distal to the coronary arteriotomy to provide a stable bloodless field. Two intercostal tubes were inserted for drainage and the incision was closed. The patient was extubated 1 hour later. The postoperative period was uneventful, and the patient was discharged 4 days after surgery. After 6 months of follow-up, he remained free from angina and the tumor had not recurred.
CASE 2
A 78-year-old man presented with T3N0M0 left upper lobe squamous cell carcinoma, severe bilateral carotid artery stenosis, and disabling angina due to critical proximal stenosis of the LAD that was unsuitable for PTCA. The left subclavian artery was also stenosed, making the LIMA unsuitable as a graft. Through a limited left anterior thoracotomy of 15 cm, as described above, left upper lobectomy was performed. Following minimal pericardiotomy on the beating heart, a saphenous vein graft was anastomosed to the proximal descending aorta and the middle portion of the LAD with the aid of a coronary stabilizer. The graft lay anteriorly to the hilum in a gentle loop with a smooth course and little possibility of kinking even when the lung was well inflated. The patient was extubated 4 hours later. The postoperative period was free from complications, and the patient was discharged on postoperative day 5. After 6 months of follow-up, he was asymptomatic for angina and showed no sign of tumor recurrence.
|
DISCUSSION
|
|---|
Minimally invasive surgical procedures are attractive options, as they promise reduced morbidity and better cosmetic results. Concomitant lesions of the heart and lungs are uncommon; but when present, they may pose a surgical dilemma. Traditionally, the surgical procedures are staged with the cardiac surgery performed first followed by pulmonary resection. Having 2 operations coupled with the delay in lung resection allowing more time for tumor growth and dissemination, which is further boosted by the immunosuppressive effects of CPB, possibly contributes to increased morbidity and mortality. On the other hand, concerns exist about simultaneous pulmonary resection with cardiac surgery, including inadequate exposure for lung resection and for posterior mediastinal lymph node sampling through a median sternotomy as well as altered immune response and coagulopathy due to CPB.2–5 In view of these problems, we chose to perform a one-stage combined procedure through a limited thoracotomy without using CPB. A similar procedure, but with left lower lobectomy, has been described by Miura and associates.6
Through a slightly larger incision than that usually made in MIDCAB, we obtained a good exposure of the left pulmonary hilum and associated anatomic structures as well as the LAD. Access to the posterior mediastinum for lymph node sampling is also possible, avoiding the double incisions sometimes necessary in the sternotomy approach and thus reducing postoperative complications.7 We performed MIDCAB with the assistance of devices for LIMA harvesting and LAD stabilization. These aids enable safe and precise off-pump bypass grafting. Left lower lobe ventilation can continue during vessel harvesting and grafting without compromising exposure of the operative field. Omitting CPB avoids immunologic responses and their effects on long-term prognosis, as well as significantly reducing postoperative bleeding and blood requirement.1 It also avoids pulmonary dysfunction, which may adversely affect the outcome of simultaneous lung and cardiac surgery. Both our patients had single-vessel (LAD) disease, but in patients with double- or triple-vessel disease the addition of PTCA of the right coronary artery and the circumflex system (the "hybrid" procedure) or surgical revascularization limited to the culprit vessels may be effective therapeutic options.
In both our cases, a limited thoracotomy resulted in less postoperative pain and rapid recovery of pulmonary function. These benefits are particularly important in these patients, as they may need to undergo further treatment later, such as adjuvant chemotherapy and radiotherapy.8 In conclusion, a limited left anterior thoracotomy allows safe and effective combined lung and cardiac surgery in carefully selected patients.
|
REFERENCES
|
|---|
- Calafiore AM, Di Giammarco G, Teodori G, Bosco G, D’Annunzio E, Barsotti A, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658–63.[Abstract/Free Full Text]
- Rao V, Todd TR, Weisel RD, Komeda M, Cohen G, Ikonomidis JS, et al. Results of combined pulmonary resection and cardiac operation. Ann Thorac Surg 1996;62:342–7.[Abstract/Free Full Text]
- Danton MH, Anikin VA, McManus KG, McGuigan JA, Campalani G. Simultaneous cardiac surgery with pulmonary resection: presentation of series and review of literature. Eur J Cardiothorac Surg 1998;13:667–72.
- 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]
- Ibarra-Perez C. Combined coronary artery bypass grafting and lung cancer operation. Ann Thorac Surg 2002;74:299–300.[Free Full Text]
- Miura M, Nakame T, Itoh Y, Aikawa K, Isogami K, Ohkuda K. [A case of simultaneous off-pump CABG and left lower lobectomy via left anterolateral thoracotomy]. Kyobu Geka 2000;53:963–5. Japanese.[Medline]
- de la Riviere B, Knaeper P, Van Swieiten H, Vanderswchueren R, Ernest J, Van den Bosch J. Concomitant open heart surgery and pulmonary resection for lung cancer. Eur J Cardiothorac Surg 1995;9:310–4.[Abstract]
- Gaudino M, Santarelli P, Bruno P, Piancone FL, Possati G. Palliative coronary artery surgery in patients with severe noncardiac diseases. Am J Cardiol 1997;80:1351–2.[Medline]
This article has been cited by other articles:
|
|
|
|
 
P. Saxena and R. Tam
COMBINED OFF-PUMP CORONARY ARTERY SURGERY AND LUNG RESECTION THROUGH THORACOTOMY
Asian Cardiovasc Thorac Ann,
December 1, 2006;
14(6):
537 - 538.
[Full Text]
[PDF]
|
|
|
TOP
ABSTRACT
INTRODUCTION
