Ann Thorac Surg 2009;88:661-663. doi:10.1016/j.athoracsur.2009.01.072
© 2009 The Society of Thoracic Surgeons
Case Reports
Combined Off-pump Coronary Artery Bypass Grafting and Thyroidectomy
A.P. Mehra, MCh*,
K.S. Shah, DNB,
P.C. Jain, MBBS,
S.K. Bhansali, MS,
J.D. Sunawala, MD,
B.V. Gandhi, MD,
A. Oswal, MBBS,
R.A. Karatela, PhD
Breach Candy Hospital and Research Centre, Mumbai, India
Accepted for publication January 27, 2009.
* Address correspondence to Dr Mehra, Department of Cardiothoracic Surgery, Breach Candy Hospital and Research Centre, Mumbai, India (Email: drarunmehra{at}hotmail.com).
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Abstract
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A 70-year-old Indian woman presented with an acute anterior wall myocardial infarction and a large multinodular goiter causing tracheal compression and dyspnea. Coronary artery angiography revealed severe triple-vessel disease, with an 80% occlusion of the left main stem, necessitating early coronary artery bypass grafting combined with total thyroidectomy. The procedure was performed successfully. At the 1-year follow-up, the patient remains euthyroid and in New York Heart Association functional class I. This case provides further evidence that combined coronary artery bypass grafting and total thyroidectomy is both feasible and safe.
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Introduction
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Thyroid dysfunction in patients with coronary disease is not an uncommon finding, particularly because abnormalities of thyroid function cause significant cardiac disease. Simultaneous cardiac and thyroid procedures have been reported, but there is no clear consensus regarding the optimal surgical management of patients with combined thyroid and cardiac disease. We present a case of combined coronary bypass grafting (CABG) and total thyroidectomy, and show that this may be the management of choice in patients with a severely ischemic myocardium and tracheal compression.
A 70-year-old Indian woman presented with an acute anterior wall myocardial infarction and a large multinodular goiter causing tracheal compression. On examination she was frail and weighed 35 kg. Her pulse was regular at 86 beats/min, and her blood pressure was 180/80 mm Hg. Her respiratory rate was 25 breaths/min. A large thyroid swelling was present in her neck, extending retrosternally and causing considerable dyspnea (Fig 1).
Venous biochemistry revealed that she was euthyroid (T3, 3.36 pmol/L; T4, 17.35 pmol/L; thyroid-stimulating hormone, 0.075 µIU/mL), and she also markedly anemic (hemoglobin, 8.9 g/dL). Arterial blood analysis suggested severe acidosis, which subsequently responded to treatment with oral sodium bicarbonate.
Her electrocardiogram (ECG) showed evidence of the recent myocardial infarction, and an echocardiograph revealed an impaired left ventricular ejection fraction of 0.40 and diastolic dysfunction. Coronary angiography demonstrated an 80% occlusion of the left main stem and a 70% proximal stenosis of the left anterior descending artery. Ostial narrowing (30% to 40%) of the circumflex artery and an 80% occlusive lesion of the right coronary artery were also found (Fig 2). A computed tomography (CT) scan of the chest demonstrated a large multinodular goiter, with retrosternal extension causing significant compression and distortion of the trachea (Fig 3).
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Fig 2. Coronary angiography demonstrates (A) an 80% occlusion of the left main stem, a near total occlusion of proximal left anterior descending artery, a 70% occlusion of circumflex coronary artery, and (B) an 80% occlusive lesion of the right coronary artery.
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Fig 3. A computed tomography image shows the patient's large retrosternal goiter with considerable compression and distortion of trachea.
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The patient was subsequently consented for a single procedure combining CABG and a total thyroidectomy.
Monitoring during anesthesia included ECG, radial artery cannulation, and a Swan-Ganz pulmonary artery catheter inserted from the right internal jugular vein. Pulse oximetry, rectal temperature, urine output, end-tidal carbon dioxide, and anesthesia gas concentration were also monitored. All monitoring catheters were inserted under local analgesia. After preoxygenation, flexible fiberoptic bronchoscopy was used to guide a well-lubricated 5.5-mm cuffed endotracheal tube (Portex, Smiths World, Watford, United Kingdom). With the airway secured, general anesthesia was facilitated.
The chest was opened through a midsternotomy incision. The left internal mammary artery and the left long saphenous vein were harvested. The left internal mammary artery was anastomosed to the left anterior descending coronary artery, and reversed long saphenous vein grafts were anastomosed to the obtuse marginal, and posterior descending coronary arteries. The heart was stabilized using an Octopus stabilizer (Medtronics Inc, Minneapolis, MN).
After the CABG, protamine sulphate was administered to reverse heparinization, and the thyroid gland was exposed with a collar incision in the neck, with a vertical T-shaped midline extension joining the collar incision to the chest incision. Total thyroidectomy was performed. The recurrent laryngeal nerves and the parathyroid glands were identified and preserved.
Figure 4
shows the excised thyroidal mass of dimensions 12.5 x 11 x 3 cm. Subsequent histologic analysis confirmed this to be a multinodular colloid goiter, with no evidence of malignancy.
The patient's postoperative course was uneventful. Both vocal cords functioned normally, and there was no change in voice. There was considerable relief of dysphagia and respiratory difficulty. The patient mobilized well and was discharged home on postoperative day 10, fully ambulant and angina free.
At follow-up 1 year later, she is euthyroid, and in New York Heart Association functional class I. Her left ventricular ejection fraction is 0.45, and there is no evidence of diastolic dysfunction. Her weight has improved modestly to 36.3 Kg.
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Comment
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Here we present a patient with two major problems: (1) extensive coronary artery disease with left main stem involvement, and (2) severe upper airway obstruction due to tracheal compression by a retrosternal goiter. Performing a CABG without the thyroidectomy would not have addressed her respiratory distress and might have led to difficulty at the time of attempted weaning from ventilation and extubation. Similarly, a thyroidectomy alone without concomitant revascularization could have been dangerous given the severity of her left main stem disease. Combined CABG and thyroidectomy addressed both her problems.
Indications for using an off-pump rather than on-pump approach in our patient include her age and impaired ejection fraction [1, 2]. Another advantage of off-pump procedures in cases such as ours lies in the greater flexibility of anticoagulation dose regimens [3]. Using lower heparin doses reduces the risk of bleeding from the vascular thyroid and also provides improved flexibility in the planning of the two-step procedure. Previous groups performing the same procedure using an on-pump technique have been limited in having to perform the thyroid intervention before initiating bypass and performing the CABG in order to minimize the risk of bleeding from full-dose heparinization [4]. Such a strategy might have proved hazardous for the present patient in view of the severe left main stem disease.
Cases of successful combined cardiac procedures and thyroidectomy have been reported [1, 4–9] and appear to be safe and surgically feasible given the anatomic vicinity of the two sites. Furthermore, one combined procedure may reduce the operative risk of two separate interventions and may provide the added advantage of reduced costs and reduced duration of in-patient stay.
In 50% to 75% of patients with normal preoperative thyroid function, a sick euthyroid state may develop for 1 to 4 days after cardiac operations [10] that results in a lowered cardiac output, elevated systemic vascular resistance, and the potential for hemodynamic instability. This derangement of thyroid function occurs acutely, may pose an intraoperative risk, and is one of the reasons for careful perioperative monitoring and correction of thyroid hormone levels [11].
In conclusion, combined CABG and total thyroidectomy can be done safely when indicated.
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References
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- Mehta YPS, Juneja R, Singh H, Sachdeva S, Trehan N. OPCAB and thyroidectomy in a patient with a severely compromised airway J Cardiothorac Vasc Anesth 2005;19:79-82.[Medline]
- Sharoni E, Song HK, Peterson RJ, Guyton RA, Puskas JD. Off pump coronary artery bypass surgery for significant left ventricular dysfunction: safety, feasibility, and trends in methodology over time--an early experience Heart 2006;92:499-502.[Abstract/Free Full Text]
- Englberger L, Streich M, Tevaearai H, Carrel TP. Different anticoagulation strategies in off-pump coronary artery bypass operations: a European survey Interact Cardiovasc Thorac Surg 2008;7:378-382.[Abstract/Free Full Text]
- Abboud B, Sleilaty G, Asmar B, Jebara V. Interventions in heart and thyroid surgery: can they be safely combined? Eur J Cardiothorac Surg 2003;24:712-715.[Abstract/Free Full Text]
- Wolfhard U, Krause U, Walz MK, Lederbogen S. Combined interventions in heart and thyroid surgery Chirurg 1994;65:1107-1110.[Medline]
- Matsuyama K, Ueda Y, Ogino H, et al. Combined cardiac surgery and total thyroidectomy: a case report Jpn Circ J 1999;63:1004-1006.[Medline]
- Litmathe J, Kurt M, Grabitz K, Knoefel WT, Gams E. Simultaneous coronary artery bypass grafting, replacement of the innominate artery and subtotal thyroidectomy in a 61 year-old patient: a case-report Chin Med J (Engl) 2005;118:699-701.[Medline]
- Koçak H, Becit N, Erkut B, Kaygin M. Combined coronary arterial bypass graft and thyroidectomy in a patient with giant goiter: how reliable is it? Thorac Cardiovasc Surg 2007;55:56-58.[Medline]
- Tang GH, Feindel CM, Gullane PJ, Butany J. Combined cardiac surgery and excision of a retrosternal thyroid mass: a case report J Card Surg 2006;21:281-283.[Medline]
- Holland FW, Brown PS, Weintraub BD, Clark RE. Cardiopulmonary bypass and thyroid function: a ‘euthyroid sick syndrome.‘ Ann Thorac Surg 1991;52:46-50.[Abstract/Free Full Text]
- Klemperer JD, Klein I, Gomez M, et al. Thyroid hormone treatments after coronary artery bypass surgery N Engl J Med 1995;333:1522-1527.[Medline]
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Abstract
Introduction
