Ann Thorac Surg 2008;86:1674-1676. doi:10.1016/j.athoracsur.2008.04.093
© 2008 The Society of Thoracic Surgeons
Case Reports
Off-Pump Coronary Artery Bypass Grafting in Patient with Sheehan's Syndrome
Qiang Fu, MD, PhDa,
Hao Zhang, MDa,
Min Peng, MDa,
Hua Gao, MDb,
Liqun Jia, MDa,
Minxin Wei, MD, PhDa,*
a Department of Cardiovascular Surgery, Tianjin Medical University General Hospital, Tianjin, P.R. China
b Department of Endocrinology, Tianjin Medical University General Hospital, Tianjin, P.R. China
Accepted for publication April 25, 2008.
* Address correspondence to Dr Wei, Department of Cardiovascular Surgery, Tianjin Medical University General Hospital, #154 Anshan Dao, Heping District, Tianjin, 300052, P.R. China (Email: minxinw{at}126.com).
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Abstract
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A patient with angina pectoris and Sheehan's syndrome underwent off-pump coronary bypass grafting. Perioperative hydrocortisone and oral thyroxin replacement were used, and no relative complication was found postoperatively. Careful perioperative hormonal management is necessary and safe for patients with hypopituitarism to receive off-pump coronary artery bypass grafting.
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Introduction
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Hormone replacement therapy has been used in treatment of primary and secondary hypopituitarism. Glucocorticoid and thyroid hormone are necessary for patients with these disorders to prevent adrenal insufficiency and hypothyroidism perioperatively. Perioperative thyroid hormone replacement in patients with angina pectoris should be done cautiously because it may aggravate myocardial ischemia and cause acute myocardial infarction and affect the sensitivity of vascular smooth muscle for catecholamine. We report one case of a patient with Sheehan's syndrome and symptomatic multi-vessel coronary artery disease who underwent off-pump coronary artery bypass grafting with careful perioperative hormonal management.
A 60-year-old woman who had been diagnosed with Sheehan's syndrome was admitted to Tianjin Medical University General Hospital because of effort angina. Echocardiogram showed globally depressed left ventricular contractility with an ejection fraction of 45%. Coronary angiography revealed severe stenosis of the left main coronary artery (60%), the anterior descending branch (80%), the left circumflex coronary artery (95%), and the posterior descending branch (70%).
At the time of admission, she received 50 µg of thyroxine and 5 mg of prednisone daily. The endocrinological data at admission were as follows: cortisol (< 1 µg/dL [normal range, 5 
25 µg/dL]; adrenocorticotropic hormone, 1.5 pg/mL [normal range, 0 46 pg/mL]; free triiodothyronine (T3), 2.11 pmol/L [normal range, 3.5 6.5 pmol/L]; free thyroxine (T4), 7.97 pmol/L [normal range, 11.5 23.5 pmol/L]). Prednisone dose was increased to 10 mg daily, and 100 mg of hydrocortisone was given intravenously the day before the operation. Routine off-pump coronary artery bypass grafting was carried out using left internal mammary artery graft to anterior descending branch and saphenous vein grafts to posterior descending branch, first diagonal branch, and first obtuse marginal vessel. On the day of the operation, an intravenous dose of 100 mg of hydrocortisone was given before anesthesia and after the operation, respectively. Hydrocortisone at 100 mg intravenously every 6 hours was used within 48 hours after the operation. Serum concentrations of cortisol remained within normal physiological range during the operation, and remained more than twice as much as baseline level with 100 mg to 400 mg of hydrocortisone replacement daily. On postoperative days 8 and 9 after the operation, hydrocortisone dose was decreased from 100 mg to 0 mg daily. The patient suffered from vomiting and chest distress. Serum concentration of cortisol was 2.5 µg/dL. Therefore, the dose of hydrocortisone was increased to 50 mg daily, and the symptoms disappeared. Cortisol dose was tapered off to 15 mg of prednisone orally for 14 days after the operation.
Thyroxin (50 µg daily) was given by nasogastric tube when the patient was still ventilated and the same dose was given after the operation. Concentrations of free T3 and free T4 remained below the lower limit of normal range perioperatively. No severe perioperative complications occurred. The patient was discharged 3 weeks after the operation, and she received 15 mg of prednisone and 50 µg of thyroxine daily. The patient remains asymptomatic on follow-up after 5 months.
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Comment
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Coronary artery disease in patients with hypopituitarism is not rare [1], but there have been few reported cases of coronary artery bypass grafting in patients with hypopituitarism [2, 3]. Patients with hypopituitarism should receive appropriate hormone replacement therapy as soon as the diagnosis is confirmed. Hormones that may influence the perioperative course include glucocorticoids and thyroid hormones. Postoperative adrenal insufficiency manifested as hypotension, sepsis, fever, vomiting, toxic psychosis, and surgical stress played a strategic role in lack of response to therapy in some patients with adrenal insufficiency [4]. Previous studies suggest that thyroid hormone deficiency might cause derangement of cardiovascular, pulmonary, renal, and central nervous system functions, and alter drug metabolism in ways that could predispose to surgical complications [5].
Yasuda and colleagues [2] reported that 3 patients received coronary artery bypass grafting with cardopulmonary bypass, and they administrated an intravenous dose of 200 or 300 mg of cortisol in addition to 1,000 mg of cortisol in priming volume of cardopulmonary bypass, which gradually decreased to maintain cortisol concentrations within a normal range for 14 days [2]. Syed and associates [3] reported that 4 patients received coronary artery bypass grafting with cardopulmonary bypass. They managed all patients perioperatively with hydrocortisone (100 mg intravenously every 6 hours) and the doses were switched back to their regular hormonal replacement according to the preoperative regimen of doses and route of administration within 48 hours [3]. It was found that a marked increase in serum cortisol to twice the baseline level in response to the stress of general surgery [6]. The present case received off-pump coronary artery bypass grafting. Intravenous hydrocortisone (100 mg intravenously every 6 hours) and prednisone orally (10 mg daily) were administered to maintain serum concentration of cortisol twice of the baseline level within 48 hours after the operation. This regimen provides glucocorticoids equivalent to the maximal daily production in a normal person during periods of "stress" [7]. The dose was gradually decreased to maintain cortisol concentrations within the normal range for 14 days. We found that the patient manifested some adrenal insufficiency symptoms such as vomiting and chest distress when hydrocortisone dose was decreased from 100 mg to 0 mg daily, and serum concentration of cortisol was below normal level. Large dose of cortisol replacement may induce hypopotassemia, atrial fibrilation with quick ventricular rate, fluid retention, so we should pay attention to potassium supply and diuresis. In this patient, intravenous amiodarone was used for atrial fibrillation prophylaxis and the dose of diuretic was doubled to relieve fluid retention.
Therapeutic thyroxine dosage increases heart rate, myocardial contractility and myocardial oxygen consumption, and might result in worsening angina pectoris, myocardial infarction, or sudden death [8]. In constant with previous reports [2, 3], low-dose thyroxine was used perioperatively in the present case. Perioperative blood concentrations of free T3 and free T4 remained below the lower limit of normal range. No relative complication was found postoperatively. Based on the previously mentioned case analysis, we can conclude that perioperative suboptimal thyroxin replacement and remaining blood concentrations of free T3 and free T4 below the lower limit of normal range are a safe and appropriate thyroxin replacement that could be used after the operation.
In our experience, off-pump coronary artery bypass grafting, when indicated, can be safely performed in patients with Sheehan's syndrome. "Stress doses" of intravenous hydrocortisone and routine oral thyroxin provide adequate hormonal cover in the perioperative period.
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References
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- Rosen T, Bengtsson BA. Premature mortality due to cardiovascular disease in hypopituitarism Lancet 1990;336:285-288.[Medline]
- Yasuda T, Kawasuji M, Ishida Y, Sakakibara N, Fujii S, Nishida S, Watanabe Y. Coronary artery bypasss grafting in patients with hypopituitarism Jpn Circ J 2000;64:207-208.[Medline]
- Syed AU, Al Fagih MR, Fouda M. Coronary bypass surgery in patients with Sheehan's syndrome Eur J Cardiothorac Surg 2001;20:1264-1266.[Abstract/Free Full Text]
- Hubay CA, Weckesser EC, Levy RP. Occult adrenal insufficiency in surgical patients Ann Surg 1975;181:325-332.[Medline]
- Ladenson PW, Levin AA, Ridgway EC, Daniels GH. Complications of surgery in hypothyroid patients Am J Med 1984;77:261-266.[Medline]
- Ishihara H, Ishida K, Matsui A, Kudo T, Oyama T. Adrenocortical response to general anesthesia and surgery Can Anaesth Soc J 1979;26:186-191.[Medline]
- Haynes Jr RC. Adrenocorticotrophic hormones: adrenocortical steroids and their synthetic analogs; inhibitors of the synthesis and actions of adrenocortical hormonesIn: Goodman GA, Rall TW, Nies AS, Taylor P, editors. Goodman and Gilman's: the pharmacological basis of therapeutics. 8th ed.. New York, NY: Pergamon Press; 1990. pp. 1453-1454.
- Syed AU, El Watidy AF, Akhlaque NB, et al. Coronary bypass surgery in patients on thyroxin replacement therapy Asian Cardiovasc Thorac Ann 2002;10:107-110.[Abstract/Free Full Text]
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Abstract
Introduction
