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Ann Thorac Surg 2001;71:1343-1344
© 2001 The Society of Thoracic Surgeons

Case report

Combined off-pump coronary surgery and right lung resections through midline sternotomy

Massimo A. Mariani, MD, PhDa, Wim J. van Boven, MDa, Vincent A.M. Duurkens, MDc, Sjef M. Ernst, MD, PhDb, Henry A. van Swieten, MD, PhDa

a Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
b Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
c Department of Respiratory Diseases, St. Antonius Hospital, Nieuwegein, The Netherlands

Accepted for publication May 6, 2000.

Address reprint requests to Dr van Boven, Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
e-mail: vboven{at}worldonline.nl


   Abstract
Top
 Abstract
Introduction
 Case reports
 Comment
 References
 
Concomitant severe coronary artery disease and lung malignancies are uncommon. Combining conventional coronary surgery with cardiopulmonary bypass with lung resection is still a controversial issue. Conversely, combining off-pump coronary surgery with right lung resections through a midline sternotomy can be an attractive approach. Off-pump coronary surgery avoids the risks of cardiopulmonary bypass, reduces systemic inflammatory response and does not affect the immune system. We report a series of three patients successfully operated using this approach.


   Introduction
Top
 Abstract
 Introduction
Case reports
 Comment
 References
 
Concomitant severe coronary artery disease requiring coronary surgery and lung malignancies occur rarely and are reported in about 0.4% of patients undergoing coronary surgery [1–2]. There is currently no definite agreement whether a combined surgical approach should be preferred to a staged one [1, 3].

A combined approach avoids the need of a second major procedure and may improve both early surgical results and late follow-up [2, 4]. Combining conventional coronary surgery with cardiopulmonary bypass (CPB) and lung resection has given satisfactory results [4]. However, the adverse effects of CPB and systemic heparinization are still a matter of concern in combined procedures [1, 3]. Off-pump coronary surgery may reduce the risk of perioperative complications related to CPB and systemic heparinization [5–6].

We report here a series of three patients with concomitant coronary artery disease and lung malignancy who were treated by combining off-pump coronary surgery and right lung resections through a midline sternotomy. At operation, all three patients were positioned supine and a double lumen endotracheal tube was positioned. A standard midline sternotomy was performed. Off-pump coronary surgery was performed first.


   Case reports
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 Abstract
 Introduction
 Case reports
Comment
 References
 
Case 1
A 74-year-old man was admitted with a diagnosis of squamous cell carcinoma of the right upper lobe and angina pectoris. Coronary angiography showed a three-vessel disease. The left internal mammary artery was anastomosed to the left anterior descending artery and a segment of saphenous vein was anastomosed to the right posterior descending artery on the beating heart, with the use of the Octopus Tissue Stabilizer (Medtronic, Minneapois, MN) [7]. The obtuse marginal branch was not graftable due to its poor quality. Therefore transmyocardial laser revascularization [8] was performed on the lateral wall with a Spectranetics CVX 3000 Excimerlaser (Spectranetics, Colorado Springs, CO). Through the same surgical access, a right pneumonectomy was performed.

Case 2
A 50-year-old man was admitted with a diagnosis of differentiated adenocarcinoma of the right upper lobe, atrial fibrillation, and angina pectoris. Coronary angiography showed a two-vessel disease. The left internal mammary artery was anastomosed to the left anterior descending artery and a segment of saphenous vein was anastomosed to the right posterior descending artery on the beating heart [9]. Through the same surgical access, a right upper lobectomy was performed.

Case 3
A 68-year-old man was admitted with a diagnosis of adenocarcinoma of the right upper lobe and angina pectoris. Coronary angiography showed a two-vessel disease. The left internal mammary artery was anastomosed to the left anterior descending artery and a segment of saphenous vein was anastomosed to the right coronary artery on the beating heart [9]. Through the same surgical access, a right upper lobectomy was performed.

In all patients, bronchus closure was performed by stapling. Extensive mediastinal and hilar lymph node sampling did not show metastases in any patient. All patients had an uneventful postoperative course and are disease-free at follow-up (see Table 1).


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  		Table 1. List of Cases and Follow-up

 

   Comment
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 Abstract
 Introduction
 Case reports
 Comment
References
 
When a combined procedure is planned for patients with concomitant coronary artery disease and lung malignancy, coronary surgery should ideally be performed off-pump [9]. Moreover, coronary surgery should be performed prior to lung resection in order to minimize the risks related to the increased myocardial oxygen consumption during and after lung resection. We believe that off-pump coronary surgery combined with lung resection through midline sternotomy should be taken into consideration in patients with symptomatic coronary artery disease and malignancies involving the right lung. This combined approach may improve the clinical results in these patients by reducing the risks of postoperative complications such as bleeding and lung dysfunction in the residual lung. Furthermore, healing of the bronchial closure may be improved by avoiding the edema of the peribronchial tissue associated with use of CPB. Avoiding CPB also reduces the negative impact on the immune system [6], therefore limiting the risk of tumor growth or dissemination. This fact may be of importance because life expectancy of these patients is determined by tumor stage [9]. However, this combined approach through midline sternotomy is mainly suited to cases of right lung resections, or occasionally in the case of left upper lung resection. Left lower lobectomy or left pneumonectomy are extremely cumbersome through a midline sternotomy, and a staged approach should be preferred [3]. In these cases, the left lung resection could be performed through a left thoracotomy shortly after off-pump coronary surgery or, alternatively, both procedures might be combined through a left posterolateral thoracotomy whenever the revascularization of the right coronary artery is not needed.

In conclusion, we believe that combining off-pump coronary surgery with right lung resection through a midline sternotomy can be an attractive approach for the complex problem of concomitant coronary artery disease and right lung malignancies.


   References
Top
 Abstract
 Introduction
 Case reports
 Comment
 References
 

  1. Johnson J.A., Landreneau R.J., Boley T.M., et al. Should pulmonary lesions be resected at the time of open heart surgery?. Am Surg 1996;62:300-303.[Medline]
  2. Rao V., Todd T.R., Weisel R.D., et al. Results of combined pulmonary resections and cardiac operations. Ann Thorac Surg 1996;62:342-346.[Abstract/Free Full Text]
  3. Voets A.J., Joesoef K.S., van Teeffelen M.E. Synchroneously occurring lung cancer (stage I–II) and coronary artery disease: concomitant versus staged surgical approach. Eur J Cardiothorac Surg 1997;12:713-717.[Abstract]
  4. Brutel de la Riviere A., Knaepen P., van Swieten H., et al. Concomitant open heart surgery and pulmonary resection for lung cancer. Eur J Cardiothorac Surg 1995;9:310-314.[Abstract]
  5. Gu Y.J., Mariani M.A., van Oeveren W., Grandjean J.G., Boonstra P.W. Reduction of the inflammatory response in patients undergoing minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1998;65:420-424.[Abstract/Free Full Text]
  6. Partrick D.A., Moore E.E., Fullerton D.A., Barnett C.C., Jr, Meldrum D.R., Silliman C.C. Cardiopulmonary bypass renders patients at risk for multiple organ failure via early neutrophil priming and late neutrophil disability. J Surg Res 1999;86:42-49.[Medline]
  7. Jansen E.W., Laphor J.R., Borst C., Grundeman P.F., Bredee J.J. Off-pump coronary bypass grafting: how to use the Octopus Tissue Stabilizer. Ann Thorac Surg 1998;66:576-579.[Abstract/Free Full Text]
  8. Hughes G.C., Abdel-Aleem S., Biswas S.S., Landolfo K.P., Lowe J.E. Transmyocardial laser revascularization: experimental and clinical results. Can J Cardiol 1999;15:797-806.[Medline]
  9. Danton M.H., Anikin V.A., McManus K.G., McGuigan J.A., Campalani G. Simultaneous cardiac surgery with pulmonary resection: presentation of series and review of literature. Eur J Cardiothorac Surg 1998;13:667-672.[Abstract/Free Full Text]



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