HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alsir A.M. Ahmed Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ahmed, A. A.M. Articles by Sarsam, M. A.I. Search for Related Content PubMed PubMed Citation Articles by Ahmed, A. A.M. Articles by Sarsam, M. A.I. Related Collections Lung - cancer Coronary disease Minimally invasive surgery

Ann Thorac Surg 2001;71:2016-2018
© 2001 The Society of Thoracic Surgeons

---

Case report

Off-pump combined coronary artery bypass grafting and left upper lobectomy through left posterolateral thoracotomy

^a Department of Cardiac Surgery, The Royal Victoria Hospital, Belfast, Northern Ireland, United Kingdom

Accepted for publication May 6, 2000.

Address reprint requests to Dr Ahmed, Cardiac Surgical Unit, The Royal Victoria Hospital, Grosvenor Rd, Belfast BT12 6BA, Northern Ireland, UK
e-mail: alsir{at}hotmail.com

	Abstract

Top Abstract Introduction Comment References

 
A 61-year-old man with angina had a lesion in the left upper lobe of his lung on chest roentgenogram. Coronary angiography revealed a dominant circumflex lesion. Combined coronary artery bypass grafting (CABG) and left upper lobectomy was performed through left posterolateral thoracotomy without the use of cardiopulmonary bypass. Off-pump CABG abolishes the complications of cardiopulmonary bypass, while posterolateral thoracotomy provides a direct access to the circumflex vessels and is ideal for lung resection.

	Introduction

Top Abstract Introduction Comment References

 
Concomitant coronary artery bypass grafting (CABG) and lung resection has been performed in attempts to save patients the need for a second operation and also to reduce the cost. The major concern has been the impact of the cardiopulmonary bypass on the lung, notably the reduced long-term survival of patients with malignant tumors of the lung and other complications such as intrapulmonary hemorrhage. We performed a combined CABG and left upper lobectomy through a left posterolateral thoracotomy without the use of cardiopulmonary bypass.

A 61-year-old man was referred to our institution with a diagnosis of coronary artery disease and carcinoma of the left upper lobe of the lung. He had an anteroseptal myocardial infarct in 1995 and an inferior infarct in 1996. His symptoms were those of angina, stable on medical treatment. Medical history included hypertension and acute renal failure necessitating heomdialysis with complete recovery. He was a chronic heavy cigarette smoker until 2 months before surgery. There was no family history of coronary artery disease. His chest radiograph coincidentally showed a left upper lobe shadow (Fig 1). He subsequently underwent bronchoscopy, which was normal, but bronchial washings from the left upper lobe revealed metaplastic and atypical squamous cells. The computed tomography (CT) scan (Fig 2) confirmed the lesion to be in the left upper lobe. He underwent cardiopulmonary exercise testing during which he managed only 4.5 minutes before the test was discontinued because of chest pain and ST-segment depression in the lateral leads. Forced expiratory volume in 1 second (FEV₁) was 65% of predicted, forced vital capacity (FVC) was 74% of predicted. Clinical examination was unremarkable and a 12-lead electrocardiogram (ECG) showed evidence of inferior infarct with anterolateral ST-T wave changes. Cardiac catheterization showed anterior and apical hypokinesia with inferior dyskinesis. Ejection fraction was 30% to 35%. The left anterior descending coronary artery had no obstructive lesion.The first obtuse marginal branch of the circumflex artery had a long 90% stenosis proximally and the atrioventricular circumflex was occluded distally.

View larger version (156K): [in this window] [in a new window]   Fig 1. Chest radiograph showing a coin lesion in the left upper lobe (arrow).

View larger version (103K): [in this window] [in a new window]   Fig 2. Computed tomographic scan of the chest showing the lesion in the left upper lobe of the lung (arrow).

The first marginal circumflex was identified and proximal and distal stay sutures were placed around it. Using the CTS heart stabilizer (CTS Ultima system 2000 S; Cardiothoracic Systems, Cupertino, CA), the coronary artery was opened and a reversed saphenous vein graft was anastomosed to it with a 7/0 continuous proliene suture interrupted once. The ascending aorta was taped and the tape was used to pull it down into the wound to enable us to place the proximal end, which was performed with 6/0 proleine continuous suture. Throughout the procedure the patient’s hemodynamics were stable and his saturations were satisfactory. At the end of the procedure, the chest was drained with two left pleural drains, one apical and one basal.

The patient was extubated the next day, maintaining good arterial blood gases and stable hemodynamics after extubation.The overall postoperative course was smooth and the patient was discharged from the hospital in a good general condition on the 13th postoperative day. Histology showed adenocarcinoma with little glandular differentiation.

	Comment

Top Abstract Introduction Comment References

 
Combined CABG and lung resection surgery has been performed in selected patients under cardiopulmonary bypass either through median sternotomy or through posterolateral thoracotomy [1–3], or without the use of cardiopulmonary bypass through median sternotomy [4], or through both median sternotomy and posterolateral thoracotomy [4, 5]. We felt after viewing the angiogram, that the culprit lesion was the circumflex, and that the right coronary artery was a small vessel to graft.

Miller and colleagues [1] demonstrated that patients who underwent concomitant cardiac and pulmonary resection for lung cancer under cardiopulmonary bypass had compromised long-term survival compared with those who had staged procedures. Other complications such as intrapulmonary hemorrhage [2], and adverse immunologic reactions resulting in prolonged use of immunosuppressive drugs that may be detrimental to the long-term prognosis of patients with malignancies, have also been reported [3]. Off-pump CABG abolishes the cardiopulmonary bypass-induced pulmonary complications associated with lung resection. Mediastinal bleeding is also reduced with resultant reduction in the requirement for blood transfusion that is associated with increased risk of recurrence in patients with malignancies [3].

We believe that left posterolateral thoracotomy is the ideal approach for lung resection, and at the same time it provides direct access to the circumflex and the left anterior descending coronary artery territories. The slightly prolonged hospital stay in our case was due to a persistent air leak, which resolved spontaneously. Combined off-pump CABG and lung resection minimizes the cost and saves the patient another general anesthetic, another incision, the detrimental effects of cardiopulmonary bypass, and an overall longer hospital stay.

	References

Top Abstract Introduction Comment References

 

1. Miller D.L., Orszulak T.A., Pairolero P.C., Trastek V.F., Schaff H.F. Combined operation for lung cancer and cardiac disease. Ann Thorac Surg 1994;58:989-995.[Abstract]
2. Ulciny K.S., Schmelzer V., Flege J.B., et al. Concomitant cardiac and pulmonary operation: the role of cardiopulmonary bypass. Ann Thorac Surg 1992;54:289-295.[Abstract]
3. Rao V., Todd T.R.J., Weisel R.D., et al. Results of combined pulmonary resection and cardiac operation. Ann Thorac Surg 1996;62:342-347.[Abstract/Free Full Text]
4. 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]
5. Hensen A.G., Zeebregts C.J., Liem T.H., Gehlmann H., Lacquet L.K. Concomitant coronary artery revascularization and right pneumonectomy without cardiopulmonary bypass. J Cardiovasc Surg (Torino) 1999;40:161-163.[Medline]

This article has been cited by other articles:

				P.-P. Caimmi and P. Di Biasi Combined Minimally Invasive Coronary Bypass Surgery and Left Pulmonary Lobectomy Asian Cardiovasc Thorac Ann, June 1, 2006; 14(3): 250 - 251. [Abstract] [Full Text] [PDF]

				S. N Omeroglu, H. B Erdogan, K. Kirali, A. Omeroglu, M. E Toker, N. Kayalar, G. Ipek, and C. Yakut Combined Coronary Artery Bypass Grafting and Lung Surgery Asian Cardiovasc Thorac Ann, September 1, 2004; 12(3): 260 - 262. [Abstract] [Full Text] [PDF]

				P. Saxena and R. K. W. Tam Combined off-pump coronary artery bypass surgery and pulmonary resection Ann. Thorac. Surg., August 1, 2004; 78(2): 498 - 501. [Abstract] [Full Text] [PDF]

				W. Dyszkiewicz, M. M. Jemielity, C. T. Piwkowski, B. Perek, and M. Kasprzyk Simultaneous lung resection for cancer and myocardial revascularization without cardiopulmonary bypass (off-pump coronary artery bypass grafting) Ann. Thorac. Surg., March 1, 2004; 77(3): 1023 - 1027. [Abstract] [Full Text] [PDF]

				R.-K. Li, R. D. Weisel, P. W.M. Fedak, and D. A.G. Mickle Reply Ann. Thorac. Surg., July 1, 2002; 74(1): 299 - 299. [Full Text] [PDF]

				A. A.M. Ahmed and M. A.I. Sarsam Reply Ann. Thorac. Surg., July 1, 2002; 74(1): 300 - 300. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alsir A.M. Ahmed Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ahmed, A. A.M. Articles by Sarsam, M. A.I. Search for Related Content PubMed PubMed Citation Articles by Ahmed, A. A.M. Articles by Sarsam, M. A.I. Related Collections Lung - cancer Coronary disease Minimally invasive surgery