Asian Cardiovasc Thorac Ann 2007;15:e75-e76
© 2007 Asia Publishing EXchange Ltd
Combined Coronary Artery Re-operation and Pulmonary Resection for Hemoptysis
Tomonobu Abe, MD,
Makoto Kajiyama, MD,
Keiji Ohara, MD,
Mineo Asaoka, MD,
Masashi Toyama, MD,
Atsukata Kobayashi, MD
Department of Thoracic and Cardiovascular Surgery, Toyohashi Municipal Hospital, Aichi, Japan
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ABSTRACT
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We present a 59-year-old woman who underwent combined pulmonary resection for bronchiectasis with massive, recurrent hemoptysis and redo coronary artery bypass. She had previously been hospitalized four times for massive hemoptysis. She had also undergone coronary artery bypass and had symptomatic severe graft disease. We performed simultaneous right middle lobectomy and redo triple bypass. At surgery, lobectomy was performed before heparinization, then redo bypass was performed using on-pump cardiopulmonary bypass. The postoperative course was uneventful.
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INTRODUCTION
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The surgical management of patients with concomitant lung lesions and heart disease remains controversial.1,2 Co-existence of heart disease increases the operative mortality when patients undergo pulmonary resection.3 Traditionally, the surgical procedures have been staged, with cardiac surgery being performed first followed by pulmonary resection at a later date. Several surgeons prefer simultaneous surgery for its potential medical and economic benefits. Most published series regarding combined pulmonary resection and cardiac surgery described patients with a malignant pulmonary lesion,1,2 while most of the reported benign cases involved granulomata or emphysematous blebs.1 Bronchiectasis is a disease that requires surgery under certain conditions although it has become rare in industrialized countries.4 We report a patient who was treated with combined middle lobectomy for bronchiectasis with massive, recurrent hemoptysis and redo triple coronary artery bypass grafting (CABG).
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CASE REPORT
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A 59-year-old woman was referred to our department for pulmonary resection due to bronchiectasis involving both lungs. She was admitted for massive hemoptysis, resulting in her 4th hospitalization for hemoptysis. Bronchoscopy showed that the source of the blood was the right middle lobe. The patient underwent emergency angiography, followed by successful embolization of the responsible bronchial arteries. However, the physicians had concerns about the possibility of recurrence as the patient had previously undergone embolization which had been effective for only two months. The patient also had a long history of ischemic heart disease and had undergone double bypass 12 years before the current hospitalization.
In addition, the patient presented with Class 3 angina. Coronary angiography showed severe graft and native artery disease. The graft to the left descending artery (LAD) was totally blocked, while the other graft to the circumflex artery showed severe stenosis. All three native systems were also diseased. The patient was therefore scheduled for a combined middle lobectomy and redo CABG.
At surgery, a redo median sternotomy was performed and the right pleural space was opened. Middle lobectomy was performed prior to heparinization in order to prevent a massive hemorrhage during cardiopulmonary bypass (CPB) which could precipitate a catastrophic sequence. After the middle lobectomy was completed, the heart was dissected and CPB was established. Triple bypass was performed by saphenous vein graft to the distal LAD, left radial artery to a diagonal artery, and saphenous vein graft to the posterior descending artery. The obtuse marginal arteries were not graftable. The patient was weaned off CPB without incident and heparin was reversed. The right lung was checked to confirm the absence of active bleeding.
The patient was extubated 7 hours postoperatively. Air leak persisted for 8 days, but she did not have any other complications. She complained of vague angina-like symptoms after being discharged so a coronary angiogram was performed and all grafts were patent. On follow-up, the patient has not demonstrated any respiratory symptoms.
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DISCUSSION
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Concomitant lesions of the heart and lungs are a challenge for thoracic and cardiovascular surgeons. Co-existing cardiac disease significantly increases the operative mortality following lung resection in patients undergoing pneumonectomy,3 while lung disease is a risk factor for operative mortality in CABG patients.5 Simultaneous surgery may reduce morbidity and mortality throughout the treatment course for both lesions.2
The surgical indication for lung resection in our patient was a rare one; bronchiectasis with massive, recurrent hemoptysis. She also had significant ischemic heart disease, though the condition was stable. We naturally were concerned about the risk of massive hemorrhage during CPB if staged surgery involving CABG first, followed by lung resection, had been chosen. Massive hemoptysis during CPB has often been reported to be fatal.6 In addition, the risk of perioperative myocardial infarction can be associated with the opposite staged approach; pulmonary resection first followed by CABG on a later day.
However, the same dilemma persisted after deciding to perform simultaneous surgery. The timing of lung resection is an important issue in simultaneous surgery. Some surgeons prefer to perform pulmonary resection before CPB due to the risk of dissemination by CPB in patients with lung carcinoma, while others prefer to perform lung resection on-pump for better exposure provided by an empty heart. Still others prefer to resect the lung after reversal of anticoagulation for better hemostasis.2 There were no data available to estimate the degree of risk during CPB in our patient. The incidence of perioperative myocardial infarction is quite small in patients with stable angina.7 Therefore, primary lung resection followed by CABG was selected as the optimal surgical approach.
It could be argued that the patient could have been treated more safely by off-pump bypass. One of the scientifically proven benefits of off-pump bypass is that it decreases hemorrhage and blood product requirement.8 However, this patient was a redo case in which we initially planned to bypass to the distal circumflex artery as well. Furthermore, her target vessels, especially the distal descending artery, were very small. We thought that better revascularization could be achieved on-pump in this case.
We report successful treatment of bronchiectasis with massive, recurrent hemoptysis with combined surgery of redo CABG and middle lobectomy. To our knowledge, concomitant heart and lung surgery for this indication has not been reported previously.
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REFERENCES
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- 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.[Medline]
- Patel RL, Townsend ER, Fountain SW. Elective pneumonectomy: factors associated with morbidity and operative mortality. Ann Thorac Surg 1992;54:84–8.[Abstract]
- Agasthian T, Deschamps C, Trastek VF, Allen MS, Pairolero PC. Surgical management of bronchiectasis. Ann Thorac Surg 1996;62:976–8.[Abstract/Free Full Text]
- Shroyer AL, Coombs LP, Peterson ED, Eiken MC, DeLong ER, Chen A, et al. The Society of Thoracic Surgeons: 30-day operative mortality and morbidity risk models. Ann Thorac Surg 2003;75:1856–65.[Abstract/Free Full Text]
- Smythe WR, Gorman RC, DeCampli WM, Spray TL, Kaiser LR, Acker MA. Management of exsanguinating hemoptysis during cardiopulmonary bypass. Ann Thorac Surg 1999;67:1288–91.[Abstract/Free Full Text]
- Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery---executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 2002;105:1257–67.[Free Full Text]
- Cheng DC, Bainbridge D, Martin JE, Novick RJ. Does off-pump coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with conventional coronary artery bypass? A meta-analysis of randomized trials. Anesthesiology 2005;102:188–203.[Medline]
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ABSTRACT
INTRODUCTION
