Ann Thorac Surg 1998;65:1130-1132
© 1998 The Society of Thoracic Surgeons
Case Reports
Combined Coronary Bypass and Liver Transplantation: Technical Considerations
Malek G. Massad, MDaa,
Enrico Benedetti, MDaa,
Raymond Pollak, MBaa,
Youssef G. Chami, MDbb,
Bradley S. Allen, MDaa,
Maria A. DeCastro, MDdd,
Thelma Wiley, MDcc,
Thomas J. Layden, MDcc
a Division of Cardiothoracic and Transplantation Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
b Division of Cardiology, University of Illinois at Chicago, Chicago, Illinois, USA
c Division of Digestive and Liver Diseases, University of Illinois at Chicago, Chicago, Illinois, USA
d Department of Anesthesiology, University of Illinois at Chicago, Chicago, Illinois, USA
Accepted for publication October 29, 1997.
Address reprint requests to Dr Massad, Division of Cardiothoracic Surgery (M/C 958), University of Illinois at Chicago, 840 S Wood St, CSB Suite 417, Chicago, IL 60612
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Abstract
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Combined coronary artery bypass grafting and orthotopic liver transplantation was carried out successfully in a 58-year-old man with angina pectoris and end-stage liver disease. To date, only 2 similar cases have been documented worldwide whereby the transplantation was performed either during cardiopulmonary bypass or with femoral-to-axillary venovenous bypass initiated at the termination of cardiopulmonary bypass. In this report we describe our experience with a simplified one-exposure approach for the combined operation using cardiopulmonary bypass in tandem with percutaneous femoral-to-right atrial venovenous bypass.
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Introduction
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Combined sequential coronary artery bypass grafting and orthotopic liver transplantation was carried out in a 58-year-old man with end-stage hepatic failure due to liver cirrhosis. The patient presented with portal hypertension, massive ascites, and esophageal varices. His cardiac symptoms consisted of angina pectoris occurring on mild exertion that had been increasing in frequency over the 6 to 8 weeks before his presentation. Pretransplantation evaluation included a dobutamine echocardiogram that showed a relatively preserved left ventricular function (ejection fraction of 0.50) with hypokinesia of the anterior wall. A coronary angiogram demonstrated critical stenosis in the proximal left anterior descending, intermediate, and circumflex coronary arteries with ostial involvement of the first obtuse marginal branch, and an occluded nondominant right coronary artery. The patient satisfied the liver transplant evaluation criteria and was listed for liver transplantation. He successfully underwent a combined quadruple coronary artery bypass in tandem with orthotopic liver transplantation.
After on-site evaluation of the donor liver by the procuring transplant team, the patient was brought to the operating theater. A standard median sternotomy incision was used. Fresh frozen plasma was used as a priming solution for cardiopulmonary bypass (preoperative prothrombin time was 16.4 seconds and partial thromboplastin time, 42 seconds). Aprotinin was administered as an intravenous loading dose of 2 million KIU (280 mg) followed by an infusion of 500,000 KIU/h (70 mg/h). Two million KIU (280 mg) of aprotonin was also added to the oxygenator priming solution. Heparinization was monitored with the celite activated clotting time to maintain an activated clotting time greater than 800 seconds. Cardiopulmonary bypass was conducted using a membrane oxygenator, hemofiltration, and mild hypothermia (30°C). The technique of integrated blood cardioplegia was used for myocardial protection as described previously [1]. Quadruple coronary artery bypass grafting was performed using two reversed saphenous vein conduits to sequentially bypass the left anterior descending and intermediate branches, and the first two obtuse marginal branches of the circumflex coronary artery. Upon termination of cardiopulmonary bypass, protamine was administered, the aortic and right atrial cannulas were removed, and the atrial cannulation purstring site was kept snared to access as the outflow limb of the venovenous bypass circuit during liver transplantation.
The transplantation was performed through a bilateral subcostal incision with a midline extension to the open sternotomy wound providing adequate traction-free exposure (Fig 1). After standard dissection for the recipient hepatectomy, the right common femoral vein was accessed percutaneously with a 16F Duraflo II heparin-treated cannula (Research Medical Inc, Midvale, UT) to serve as the inflow limb of a venovenous bypass circuit. An 18F Research Medical cannula inserted through the purstring suture in the right atrial appendage served as the outflow limb. The bypass circuit consisted of a centrifugal pump with Carmeda bioactive surface (Medtronic, Anaheim, CA) and Duraflo II heparin-treated membrane oxygenator and tubings (Baxter-Bentley Laboratories, Irvine, CA). The suprahepatic and infrahepatic venae cavae were then clamped and venovenous bypass was initiated at a rate of 1,500 mL/min while the recipient hepatectomy and the allograft caval and portal vein anastomoses were completed. The hepatic arterial and biliary anastomoses were then completed, and the chest and abdominal wall were closed in the standard fashion. The total venovenous bypass time was 79 minutes. The hepatic cold ischemia time was 6 hours. Total operating room time was 7
hours. The patient had an uneventful recovery and was discharged home 19 days after his operation. He continues to do well at 6 weeks of follow-up.
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Fig 1. Technique of femoral venous-to-right atrial bypass initiated after completion of coronary bypass grafting. (1 = membrane oxygenator and heat exchanger; 2 = centrifugal pump; 3 = cardiotomy reservoir and filter; inset A = surgical incision; inset B = coronary bypass grafts [hollow circles].)
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Comment
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Combined coronary artery bypass grafting and orthotopic liver transplantation has been performed previously on two separate occasions using two different techniques (Table 1) [2, 3]. In 1995, Morris and associates [2] first reported on the combined approach. After coronary grafting was completed on cardiopulmonary bypass, the chest was temporarily closed and reopened later to facilitate exposure from above the diaphragm [2]. The transplantation was performed on venovenous bypass draining the left femoral and portal veins and infusing the left axillary vein. In 1996, Manas and colleagues [3] from the United Kingdom reported on another patient who underwent a combined sequential approach. In their case, continued need for vasoconstrictors necessitated the continuation of cardiopulmonary bypass for 8 hours, during which the patient was rewarmed to 37°C and the hepatic allograft was transplanted.
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Table 1. Combined Coronary Artery Bypass and Orthotopic Liver Transplantation: World Experience on Record Between 1966 and 1998
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In the present case, the bilateral subcostal extension of the sternotomy incision provided a hands-free exposure of the upper abdomen. Temporary closure of the sternotomy at the conclusion of coronary bypass grafting as in the case of Morris and associates was not attempted (1) to provide adequate exposure during the transplantation, (2) to provide access to the mediastinal structures in the event of an unexpected hemodynamic instability [2], and (3) to evaluate the mediastinal structures for any ongoing hemorrhage caused by the severe coagulopathy often seen in liver transplant recipients. Continued need for cardiopulmonary bypass during the transplantation as in the case of Manas and colleagues was not thought to be indicated with the patient’s hemodynamics optimized, and that allowed completion of the transplantation without the need for heparin. Furthermore, using the right atrial appendage as the outflow limb for the venovenous bypass simplified the technique and avoided the need to access the axillary vein as in the case reported by Morris and associates [2].
Simultaneous coronary artery bypass grafting and orthotopic liver transplantation may be considered for a select group of patients in whom optimization of the cardiac status with medical therapy or catheter-based intervention may not be adequate before transplantation. Although further experience with the approach we described is needed, we do recommend this simplified one-exposure technique for patients who require the combined procedure.
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References
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- Buckberg G.D., Beyersdorf F., Allen B.S., Robertson J.M. Integrated myocardial management: background and initial application. J Card Surg 1995;10:68-89.[Medline]
- Morris J.J., Hellman C.L., Gawey B.J., et al. Three patients requiring both coronary artery bypass surgery and orthotopic liver transplantation. J Cardiothorac Vasc Anesth 1995;9:322-332.[Medline]
- Manas D.M., Roberts D.R.D., Heaviside D.W., et al. Sequential coronary artery bypass grafting and orthotopic liver transplantation: a case report. Clin Transplant 1996;10:320-322.[Medline]
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Abstract
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