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J Thorac Cardiovasc Surg 1994;108:797-799
© 1994 Mosby, Inc.
LETTERS TO THE EDITOR |
Department of Thoracic Surgerya
Department of Cardiac Surgeryb
The Chaim Sheba Medical Center
Tel Hashomer 52621, Israel
To the Editor:
The management of lung nodules in patients requiring coronary revascularization is somewhat controversial. Although pulmonary resections for malignancy and coronary bypass operations have been done concomitantly,
1-5 some data suggest that immunosuppressive effects 6,7 and coagulopathy associated with the use of cardiopulmonary bypass may increase the operative morbidity and mortality and decrease the long-term survival.
In an attempt to circumvent these possible hazards on the one hand and to avoid the need for two separate procedures on the other, we decided to perform the operation through a bilateral submammary anterior thoracotomy while the coronary bypass was performed on the beating heart.
Case report
A 52-year-old man with a history of heavy smoking and three episodes of myocardial infarction had severe accelerating anginal syndrome. Coronary angiography showed 80% obstruction of the midportion of the left anterior descending coronary artery, 99% obstruction of the first and second marginal branches, and 100% obstruction of the midportion of the right coronary artery, which was filled by collaterals. Left ventricular function was normal except for akinesis of the diaphragmatic wall.
A chest x-ray film revealed a cavitating lesion of the upper lobe of the right lung, localized in the posterior segment by computed tomographic scan. No hilar or mediastinal lymphadenopathy was present. Skin tests for tuberculosis were negative, and bronchoscopic examination was noncontributory. The working diagnosis was that of bronchogenic carcinoma in lieu of the absence of the lesion on previous radio graphs in this heavy smoker and the rarity of fungal infections in Israel.
The patient was anesthetized in the usual manner with standard monitoring for coronary bypass. A regular (single-lumen) endotracheal tube was used. The skin incision was carried from one anterior axillary line to the contralateral line beneath the breast folds. The right pleural space was entered through the fourth intercostal space all the way to the sternum, the right internal mammary vessels being ligated and divided. The left pleural space was entered, reaching about 3 cm from the sternum. The sternum was cut transversely with a Gigli saw, with care taken to preserve the left mammary artery. The internal mammary artery was dissected caudally from the chest wall as far as possible and then divided. Thereafter, the artery was dissected easily all the way to its origin, with the aid of a second rib spreader. At this stage the lung lesion was inspected (macroscopically it resembled a primary carcinoma), a biopsy specimen was taken, and the lung and mediastinum were evaluated for resectability. When this was assured, we decided to continue with the cardiac procedure.
Heparin was given at a dose of 2 mg/kg. The course of the left anterior descending coronary artery was intramyocardial, and the artery was distally exposed very close to the apex of the left ventricle. Therefore a segment of vein was sutured to the left internal mammary artery, which was then anastomosed to the distal left anterior descending artery. Eight minutes of local ischemia was needed to complete the procedure. A saphenous vein graft was anastomosed to the obtuse marginal branch (13 minutes of ischemia). On receiving the frozen section report showing a squamous cell carcinoma, we performed a standard right upper lobectomy and hilar and mediastinal lymphadenectomy. The chest was closed with two steel wire sutures to the sternum and heavy Vicryl pericostal sutures (Ethicon, Inc., Somerville, N.J.).
The patient was extubated 12 hours after the operation, and the chest tubes were removed 24 hours later. The remainder of the postoperative course was uneventful except for ventricular arrhythmia, and the patient was discharged in good condition on the tenth postoperative day. The electrocardiogram was similar to the preoperative reading, and ventricular function (echocardiogram, multiple gated acquisition scan) was within normal limits.
The histologic report showed a 3.5 cm cavitated, well-differentiated squamous cell carcinoma. All lymph nodes were free of tumor.
Discussion
The concomitant occurrence of critical cardiac disease and resectable pulmonary lesion is not common, the prevalence ranging from 0.2% to 0.5%. 1,2,5 Invariably, the lung lesions are found on routine preoperative chest radiographs, they usually are peripheral, and their exact nature is uncommonly determined by sputum cytologic or bronchoscopic studies. Intensive diagnostic measures are usually considered unwarranted in these patients, who often require urgent cardiac operations. 1 An unusually high proportion of them will reach the operating room without a tissue diagnosis. We elected not to perform a percutaneous needle biopsy because of this patient's unstable condition.
The reluctance to combine the cardiac and pulmonary procedures stems from two main reasons: (1) technical problems associated with anticoagulation and coagulopathy on the one hand and limited exposure for the lung procedure through the median sternotomy on the other; (2) perioperative immunosuppression that might increase the short-term infectious complications and adversely affect long-term cancer-related survival. For these reasons most surgeons prefer to perform the procedures separately, the heart operation done first to minimize mortality. Using this strategy, Dernevik and Larsson 2 were able to resect five of six cancers. Three patients died in the follow-up period.
When the procedures are done concomitantly, most investigators 1,3,5 prefer to perform the combined operation through a median sternotomy. This is not necessarily an optimal approach. Left lower lobectomy is extremely difficult to perform, especially in the presence of an enlarged heart. Resection might be inadequate, because the posterior lung fields are not easily accessible. Even left upper lobectomy might prove problematic and necessitate a return to cardiopulmonary bypass. 4 Mediastinal lymphadenectomy might be incomplete. Although some of these procedures could be achieved with the patient receiving pump support, it would be a bad strategy with regard to tumor spread and blood loss and transfusion.
The pronounced immunologic changes associated with cardiopulmonary bypass 6,7 can affect the immediate result (infection), as well as long-term survival. Although this effect was not noticed in one series, 1 in which the 5-year survival was 88%, in a more recent publication 5 only four of 11 patients were alive and free of disease at a follow-up period of 1 to 18 months despite the fact that all had early stage cancer (stage I, nine patients; stage II, two patients). This immunosuppressive phenomenon could be circumvented if coronary revascularization was performed without cardiopulmonary bypass, as described recently 8 and practiced by us in 240 patients.
The bilateral transsternal anterior thoracotomy offers a superior exposure and allows (1) good visualization of the mediastinum for lymphadenectomy, (2) harvesting of the left internal mammary artery, and (3) comfortable performance of anastomoses to the left anterior descending and marginal arteries. If the patient requires cardiopulmonary bypass for hemodynamic considerations or complete revascularization, the right atrium and aorta are easily accessible.
Because of our experience and that of others with coronary revascularization without pump support, our familiarity with bilateral transsternal thoracotomy, and the results of concomitant cardiac and pulmonary procedures, and encouraged by the present case, we believe that this approach is suitable for patients who need combined heart-lung procedures and in whom revascularization can be performed without cardiopulmonary bypass.
References
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