Ann Thorac Surg 1997;63:1790-1792
© 1997 The Society of Thoracic Surgeons
Case Report
Coronary Artery Bypass Grafting After a Bilateral Lung Volume Reduction Operation
Panayota Liopyris, MD,
Anastasios N. Triantafillou, MD,
Thoralf M. Sundt, III, MD,
Mark I. Block, MD,
Joel D. Cooper, MD
Divisions of Cardiothoracic Anesthesia and Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
Accepted for publication January 30, 1997.
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Abstract
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A 67-year-old man underwent coronary artery bypass grafting 3
months after a bilateral lung volume reduction operation for end-stage pulmonary emphysema. The principles of anesthetic management we have developed for use during volume reduction operations were applied with success in this individual and are described in detail. With the increasing application of this intervention as an alternative to lung transplantation, we anticipate further experience in the operative management of associated conditions after lung volume reduction operations.
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Introduction
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Lung volume reduction surgery has been proposed as a surgical palliation of chronic end-stage obstructive lung disease [1]. Initial experience with this procedure has been gratifying, with improvement of the patients' pulmonary and physical status. Although many of the patients undergoing this procedure are at risk for associated diseases, such as coronary artery disease, their ability to withstand further surgical procedures including open heart operations is, as yet, unknown. We describe a patient undergoing coronary artery bypass grafting after a bilateral lung volume reduction operation and the principles of the perioperative management we thought were critical to patient's outcome.
In April 1995, a 67-year-old man with severe, oxygen-dependent COPD underwent a successful lung volume reduction operation via a median sternotomy, with resection of 50% of the right lung and 40% of the left lung. Medical history was significant for hypertension, hypothyroidism, and previous heavy tobacco use. At discharge, his pulmonary function had improved as follows: the forced vital capacity was 3.58 L (84%, increased by 64%), the forced expiratory volume in 1 second was 1.54 L/min (46%, increased by 61%), and he required oxygen only with strenuous exercise. However, 3 months after the operation the patient suffered an inferior myocardial infarction. Cardiac catheterization demonstrated severe triple-vessel disease, including a high-grade lesion in the proximal left anterior descending coronary artery, and well-preserved left ventricular function. Physical examination was notable for diminished breath sounds bilaterally and mild expiratory wheezing. His electrocardiogram demonstrated T-wave inversion inferiorly. Chest radiography showed generalized emphysematous changes and a large retrosternal air space (Fig 1
). Room air arterial blood gases demonstrated a pH of 7.44, carbon dioxide tension of 36 mm Hg, and oxygen tension of 85 mm Hg. His medical regimen included daily thyroid replacement, steroids, and inhaled albuterol.
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Fig 1. . Preoperative posteroanterior and lateral chest radiographs. Note the amount of residual disease and the retrosternal air space.
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Surgical management of his coronary artery disease was planned. Our strategy for management of this patient included (1) thoracic epidural perioperative analgesia, (2) limited use of opioids, (3) use of vein grafts only, (4) aprotinin administration, (5) volatile anesthetic for intraoperative amnesia, (6) early extubation, and (7) early physical therapy.
The patient was premedicated with 9 mg of morphine. Standard monitoring was carried out, including radial and pulmonary artery catheters. A thoracic epidural catheter was inserted at the T3-T4 level under fluoroscopy. A test dose of 3 mL of 1.5% lidocaine with 1:200,000 epinephrine demonstrated sensory loss in the T4-T7 dermatomes. Anesthesia was induced with 250 mg sodium thiopental and 150 µg fentanyl, and maintained with isoflurane. Vecuronium was used for paralysis. Before skin incision, 8 mL of 0.5% bupivacaine with 1:200,000 epinephrine were administered in the epidural space. High-dose aprotinin, according to the Hammersmith regimen, was infused to minimize pulmonary injury due to cardiopulmonary bypass and reduce perioperative bleeding. A standard cardiopulmonary bypass circuit with a membrane oxygenator was used, with systemic hypothermia to 28°C. Cold crystalloid cardioplegia was employed for myocardial protection. Because of the patient's fused pleural spaces and concern over the creation of air leaks, the internal thoracic artery was not used. Three saphenous vein grafts were constructed during a 44-minute aortic cross-clamp time. Special care was taken to fully rewarm the patient to further facilitate early extubation and avoid mechanical ventilation-and thus minimize air leaks-postoperatively. The total cardiopulmonary bypass time was 99 minutes. No inotropic support was required to wean the patient from cardiopulmonary bypass. After bypass an additional dose of bupivacaine was administered, and a phenylephrine infusion was used to maintain systemic arterial pressure.
At the end of the procedure the muscle relaxant was reversed. Shortly thereafter, the patient begun to regain consciousness and spontaneous respiration with increasing tidal volume. Measurement of arterial blood gases demonstrated a pH of 7.17, carbon dioxide tension of 79 mm Hg, and oxygen tension of 220 mm Hg. The patient was then extubated, and ventilation was assisted by face mask. When able to follow commands he was transported to the intensive care unit and a continuous epidural infusion of 0.2% bupivacaine initiated. Chest physical therapy was administered shortly after arrival in the intensive care unit and every 2 hours thereafter. A small air leak was present at the end of the operation, but it sealed spontaneously before discharge. There were no further complications, and he was discharged home on the fifth postoperative day. The epidural catheter was removed on the fourth day.
Despite the initially uneventful recovery, the patient's wound dehisced with complete disruption of the sternotomy closure 2 weeks postoperatively while he was coughing vigorously, a complication possibly related, to some extent, to chronic steroid intake. Uncomplicated reclosure was undertaken at his local hospital with the patient under light general anesthesia, with prompt extubation. Currently, 17 months after coronary artery bypass grafting, the patient continues to do well and is free of further cardiac symptoms. He continues to require oxygen only with extreme exertion.
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Comment
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Based on the work of Brantigan and associates [2], lung volume reduction operations are intended to reduce total thoracic volume and improve chest wall mechanics in patients with severe chronic obstructive pulmonary disease. Given the comorbidities present in the population undergoing lung volume reduction operations, as the number of patients who have undergone these procedures increases we can anticipate a demand in the future for a variety of surgical interventions including coronary artery bypass grafting. As yet experience with such procedures is limited. Successful outcomes will require an understanding of the pathophysiology of their underlying condition, the impact of lung volume reduction operations, and the principles of anesthetic management that have made lung volume reduction possible.
After a thoracic operation, patients-particularly those with preexisting lung disease-are prone to pulmonary complications [3, 4] caused by pain, discoordination of respiratory muscles, and inability to cough. After lung volume reduction operations and despite a functional improvement, patients are also at risk because by no means could they be considered as cured of emphysema. In addition, a previous sternotomy and the presence of a retrosternal air space, as in this patient, is of particular concern as it could present a significant risk for direct lung trauma during sternal split and spread and subsequent development of postoperative air leak.
Insertion of an epidural catheter before an operation requiring anticoagulation is controversial. However, clinical studies have failed to show significant morbidity [5], even in patients undergoing coronary artery bypass grafting [6]. It has been postulated that although puncture of epidural vessels during placement of epidural catheters occurs in 3% to 12% of cases [7], formation of a symptomatic epidural hematoma is a rare event [8].
We believe that epidural analgesia, along with all the other measures, contributed to our ability to extubate this patient, in the controlled environment of the operating room, in an alert and practically pain-free state with satisfactory respiratory mechanics.
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Footnotes
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Address reprint requests to Dr Triantafillou, Department of Anesthesiology, Washington University School of Medicine, 660 S Euclid Ave, St. Louis, MO 63110.
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References
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- Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109:106–19.[Abstract/Free Full Text]
- Brantigan OC, Mueller E, Kress MB. A surgical approach to pulmonary emphysema. Am Rev Respir Dis 1959;80:194–206.[Medline]
- Tarhan S, Moffitt E, Sessler A, Douglas W, Taylow W. Risk of anesthesia and surgery in patients with chronic bronchitis and chronic obstructive pulmonary disease. Surgery 1973;74:720–6.[Medline]
- Ali J, Weisel R, Layrig A, Kripke B, Hectman H. Consequences of postoperative alterations in respiratory mechanics. Am J Surg 1974;128:376–82.[Medline]
- Joachimson P, Nystrom S, Tyden H. Early extubation after coronary artery surgery in efficiently rewarmed patients: a postoperative comparison of opioid anesthesia versus inhalational anesthesia and thoracic epidural analgesia. J Cardiothorac Anesth 1989;3:499–504.
- Hoar PF, Hickey RF, Ullyot DJ. Systemic hypertension following myocardial revascularization. A method of treatment using epidural anaesthesia. J Thorac Cardiovasc Surg 1976;71:859–69.[Abstract]
- Leim TH, Booij LH, Hasenbos MA, Gieden MJ. Coronary artery bypass grafting using two different anesthetics techniques. Hemodynamic results. J Cardiothorac Vasc Anesth 1992;6:148–55.[Medline]
- Sage DJ. Epidurals, spinals and bleeding disorders in pregnancy: a review. Anaesth Intensive Care 1990;18:319–26.[Medline]
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Abstract
Introduction
