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Concomitant cardiac and pulmonary operations
J
THORAC CARDIOVASC SURG
90:662-667, 1985
Concomitantcardiac and pulmonary operations From 1965 tlu'ough 1983,43 patients underwent concomitant cardiac and pulmonary proceduresat our imtitution. Most patients presented with cardiac symptoms and were incidentally found to have a roentgenographically indeterminate hmg nodule. The pulmoJUlry diagnosis of 38 patients was unknown preoperatively, and nine of these had a malignant lesion. All 43 cardiac procedures necessitated extracorporeal circulation. Thirty-one patients had benign pulmonary disease, 10 had bronchogenic carcinoma, and two had metastatic carcinoma. Concomitant pulmonary procedures were performed via median sternotomy and included single wedge resections in 32 patients, lobectomy in seven, multiple wedge resections in three, and pneumonectomy in one. Most resections were performed either before or after imtitution of bypass, without systemicanticoagulation. Of the two operativedeaths (4.6%), one was related to intraparenchymal pulmonary hemorrhage after multiple wedge resections during anticoagulation. Tbus, pulmonary resectionsperformed during anticoagulationmay be associated with increasedrisk and probably should be avoided. The second death was cardiac in origin and not related to pulmonary resection. The remaining patients recovered uneventfully. Defmitive correction of both cardiac and pulmonary disease can be performed at one operation via a single incisionwith safety and benefit to the carefully selected patient.
Jeffrey M. Piehler, M.D. Peter C. Pairolero, M.D., Hartzell V. Schaff, M.D. Francisco J. Puga, M.D.,
(by invitation), Victor F. Trastek, M.D. (by invitation), James R. Pluth, M.D., Gordon K. Danielson, M.D., (by invitation), Thomas A. Orszulak, M.D. (by invitation), and Rochester, Minn.
concomita~t
Rients with surgical diseases of the heart and lungs are a therapeutic challenge to the cardiothoracic surgeon. Generally, these patients present with surgically correctable cardiac disease and are found to have a pulmonary process, usually an asymptomatic nodule, for which operative management is also appropriate. Less frequently, these patients present with pulmonary disease and are found to have cardiac disease which, if untreated, would significantly increase the risk of the pulmonary operation. The cardiac and pulmonary lesions could be treated at one combined procedure or alternatively with two procedures in a staged fashion, with the sequence based on clinical priority. Historically, there has been generalized reluctance to perform a pulmonary operation at the time of a cardiac procedure that requires extracorporeal circulation, presumably From the Section of Thoracic and Cardiovascular Surgery, Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minn. Read at the Sixth-fifth Annual Meeting of The American Association for Thoracic Surgery, New Orleans, La., April 29-May I, 1985. Address for reprints: Jeffrey M. Piehler, M.D., Mayo Clinic, 200 First St., S.W., Rochester, Minn. 55905.
662
because of coagulation defects related to heparinization and limited pulmonary exposure gained through a median sternotomy. Nevertheless, prompt definitive correction of both disease entities without the need for a second procedure is clearly advantageous, especially if done through the same incision.
Patients The clinical records of all patients who underwent concomitant pulmonary and cardiac procedures that required extracorporeal circulation from January, 1965, through December, 1983, at our institution were reviewed. Excluded were patients who had (l) concomitant pulmonary resections required for iatrogenic intraoperative pulmonary complications, (2) pulmonary resections for congenital sequestration at the time of correction of anomalous pulmonary drainage, and (3) pulmonary procedures performed with extracorporeal circulation without a concomitant cardiac procedure. There were 43 patients (32 male and 11 female) with a mean age of 56.4 years (range 12 to 76). Forty patients (93%) presented with cardiac symptoms and had the pulmonary lesion incidentally discovered. For these patients, cardiac symptoms were predominantly related to coronary artery disease in 25 patients, valvular
Volume 90
Concomitant cardiac and pulmonary operations 6 6 3
Number 5 November. 1985
Table n. Pulmonary disease in 43 patients undergoing concomitant cardiac and pulmonary operations
Table I. Cardiac procedures performedin 43 patients undergoing concomitant cardiac and pulmonary operations Procedure
Patients
No. of patients
CABG Aortic valve replacement Mitral valve replacement Mitral valve repair CABG and left ventricular aneurysm repair Mitral valve repair, CABG, and tricuspid annuloplasty Aortic valve and mitral valve replacement Pulmonary atresia and ventricular septal defect repair Atrial septal defect closure Resection of right ventricular tumor Resection of right atrial tumor
26 4 4 2 I I
Total
43
Diagnosis
No.
Benign Granuloma Chronic inflammation Hamartoma Pulmonary infarct Bullae Malignant Bronchogenic carcinoma Metastatic carcinoma Total
Legend: CABG, Coronary artery bypass grafts.
heart disease in 12, cardiac tumor in two, and congenital heart disease in one. Forty-one of the cardiac procedures were performed electively, and two were performed on an urgent basis (Table I). There were no emergency procedures. Three patients presented with pulmonary signs and symptoms. Two of these patients presented with hemoptysis from bronchogenic carcinoma and developed unstable angina pectoris during their evaluation; the third presented with recurrent pneumothorax from apical pleural bullae and was found to have an asymptomatic atrial septal defect. The pulmonary lesion was identified on the preoperative chest roentgenogram in all patients and appeared as a solitary nodule in 33 patients, infiltrate in five, multiple nodules in three, and emphysematous bullae in two. At the time of operation, the pulmonary diagnosis had been established in two patients (4.6%), was highly suspected in three (7.0%), and was unknown in 38 (88.4%). The diagnosis had been established by preoperative bronchoscopic biopsy in two patients with bronchogenic carcinoma and was highly suspected by the roentgenographic appearance in two patients with emphysematous bullae and by a history of resected metastatic lesions in one patient with metastatic renal cell carcinoma. Thirty-one patients (72.1 %) had benign pulmonary disease, 10 (23.3%) had bronchogenic carcinoma, and two (4.6%) had metastatic carcinoma (Table II). Ofthe 38 patients with undiagnosed pulmonary lesions, nine (23.7%) proved to have malignant lesions. Ten patients (seven males and three females) were found to have bronchogenic carcinomas (Table III). Their mean age was 63.9 years (range 50 to 76). All 10
%
31
72.1 41.9 9.3 9.3 7.0 4.6
18 4 4 3 2
12
27.9 23.3 4.6
10 2 43
100.0
Table m. Cell type, TNM classification, tumor location, and procedure in 10 cases of bronchogenic carcinoma Cell type Squamous cell Adenocarcinoma
Bronchoalveolar
Large cell
TNM TI TI TI TI T2 T2 TI T2 T2 T2
NO MO NO MO NO MO NO MO NO MO NI MO NO MO NO MO NO MO NI MO
Tumor location
Procedure
R upper lobe L upper lobe Rr lower lobe L upper lobe R lower lobe R lower lobe L upper lobe L upper lobe L upper lobe R lower lobe
Lobectomy Lobectomy Wedge Lobectomy Lobectomy Pneumonectomy Wedge Lobectomy Lobectomy Wedge
patients underwent coronary artery bypass grafting, with two to five vessels being bypassed. All patients were in New York Heart Association Class III or IV at the time of operation. Mediastinal and hilar lymph node sampling was done in all patients, and nine patients had curative resections. Most of the patients required only simple wedge excision of the pulmonary lesions (Table IV); eight patients, however, required major resection. Forty-one pulmonary resections were performed via the median sternotomy. One patient who underwent a right upper lobectomy for bronchogenic carcinoma required lateral extension of the sternotomy into the right third intercostal space to facilitate exposure, and a second patient who had the mitral valve replaced via a right thoracotomy had a pulmonary wedge resection performed through the same incision. Standard pulmonary techniques were employed for all resections, the mechanical stapler being utilized for all bronchial closures and for 27 of the 35 wedge excisions.
The Journal of
6 6 4 Piehler et al,
Thoracic and Cardiovascular Surgery
Table IV. Type and location of pulmonary resections in 43 patients undergoing concomitant cardiac and pulmonary operations Resection Wedge
Location Right Upper lobe Middle lobe Lower lobe Lung Left Upper lobe Lower lobe Lung Total
8 4 6
I
Lobectomy
I
Multiple wedge
2 I 0
9 5
4 0
0
Pneumonectomy
0 7 (16.3%)
Most of the pulmonary procedures were performed either before or after bypass (Table V), during which time anticoagulation with heparin either had not been instituted or had been reversed with protamine sulfate. Pulmonary resection was appropriate for the pathological condition in 39 patients (90.7%), in that wedge resections were performed for benign lesions or pulmonary metastasis and formal lobectomies or pneumonectomies were performed for bronchogenic carcinoma. Two additional patients had appropriate wedge resections for bronchogenic carcinoma: One had extensive hilar nodal metastasis and pulmonary function that precluded the necessary pneumonectomy, and the other had a second primary bronchoalveolar cell carcinoma without nodal involvement. In two additional patients (4.6%), however, pulmonary resection could be judged inappropriate for the lesion: One had lobectomy for a granuloma of the right upper lobe, and the other had wedge resection alone for bronchogenic carcinoma.
Results There were two (4.6%) operative deaths (within 30 days or the same hospitalization), only one of which was related to the pulmonary procedure. This occurred in a young woman with a previously resected renal cell carcinoma who presented with multiple bilateral pulmonary metastases and an additional large metastasis to the anterior right ventricular free wall, causing severe right heart failure. A right lower lobectomy with multiple wedge resections in the remaining right lung had been performed previously via a right thoracotomy. At a subsequent procedure employing extracorporeal circulation, the patient had excision of the right ventricular tumor through a median sternotomy and, while still on bypass to facilitate lung mobilization, had seven nodules in the left lung removed by wedge excision. The procedure was complicated by intraparenchymal pulmo-
Total 10 4 7 2
0
0
32 (74.4%)
I
I (2.3%)
2
13 5 2
3 (7.0%)
43
nary hemorrhage, and the patient died of acute respiratory insufficiency the day after the operation. The second death was unrelated to the pulmonary procedure and occurred in a 71-year-old woman who had acute aorta-coronary graft occlusion and died of a myocardial infarction on the fourth postoperative day after a five-vessel coronary artery bypass graft procedure and concomitant left upper lobectomy for adenocarcinoma. There were two (4.6%) postoperative complications related to the pulmonary procedure. One patient required reexploration for pleural space bleeding that originated from the apical chest wall, where adhesions had been divided. A second patient underwent pneumonectomy and required ventilator support for 10 days postoperatively; the remaining patients were all extubated within 36 hours of operation. Except for the one patient who died, no other patient had intrapulmonary hemorrhage. Four patients required bronchoscopy during the postoperative period to remove retained secretions. There were no instances of prolonged pulmonary air leak, excessive chest tube drainage, pleural space infection, wound infection, or pleural space complication. One patient had transient postoperative low cardiac output syndrome, and three had minor cardiac dysrhythmias that were successfully managed pharmacologically. None of these events was related to the pulmonary resection. Follow-up was complete in all patients and averaged 3.8 years, ranging from 1.5 months to 14.8 years. There were no late postoperative sequelae from the resections.
Pulmonary resections for bronchogenic carcinoma. Ofthe 10 patients who underwent resection for primary bronchogenic carcinoma, six are currently alive. Five of these have no evidence of disease at postoperative intervals ranging from 3 months to 2.5 years, and one patient is alive with known disease 5.8 years after
Volume 90 Number 5 November, 1985
Concomitant cardiac and pulmonary operations 6 6 5
Table V. Timing ofpulmonary resection in 43 patients undergoing concomitant cardiac and pulmonary operations Resection Timing
Wedge
I
Lobectomy
Before bypass During bypass and before cardiac procedure During bypass and after cardiac procedure After bypass
13
19
1 1 3 2
Total
32
7
0 0
resection of a bronchoalveolar cell carcinoma. Three additional patients have died of metastatic carcinoma from 10 to 30 months postoperatively. Interestingly, two of these patients had undergone wedge resection as the sole surgical treatment for their malignant lesion, although one had nodal metastases knowingly left at operation. The tenth patient died of myocardial infarction in the hospital, and no evidence of bronchogenic carcinoma was detected at postmortem examination. Spared second procedures. Acknowledging the uncertainties of such an analysis, we attempted to determine the number of patients who were spared a second staged operation by this combined approach. Twenty-nine patients (67.4%) had lung lesions that fulfilled currently accepted criteria for early thoracotomy. Most commonly, such a lesion was a noncalcified nodule that was not present on earlier roentgenograms of the chest. Twelve of these patients (41.4%) were found to have malignant tumors. Fourteen patients had lesions for which thoracotomy could have been optional or delayed if the cardiac operation had not been necessary. Thus, the combined approach potentially spared an early thoracotomy in approximately two thirds of the patients.
Discussion Traditionally, pulmonary resection has not been concomitantly performed with cardiac procedures that require extracorporeal circulation, primarily because of potential intrapulmonary bleeding from altered coagulation mechanisms. Of lesser importance have been concerns for compromised pulmonary exposure through the median sternotomy, which is usually mandated by the cardiac procedure, and of disseminated or local infection after resection of infectious nodules, perhaps related to altered immunity associated with cardiopulmonary bypass.' Consequently, many cardiothoracic surgeons have advocated staged procedures, usually first correcting the cardiac disease, as this represents the most immediate threat to the patient. A concomitant approach to both problems is theoretically advantageous
I
Pneumonectomy
0 0
I
Multiple wedge
Total
2
1
1
0
0
16 1 5 21
3
43
0
in that all areas of disease are definitively managed without delay and the patient is spared the significant morbidity of a second thoracotomy. Ideally, the decision to perform concomitant cardiac and pulmonary procedures should be based on a favorable benefit-to-risk ratio. Unfortunately, a review of the literature reveals only a few small groups of patients treated with a combined approach," and thus firm conclusions cannot be reached. The present study suggests that a variety of pulmonary conditions are safely amenable to appropriate resection at the time of elective cardiac procedures that require extracorporeal circulation. With the exception of one patient with intrapulmonary parenchymal hemorrhage, the intraoperative and postoperative pulmonary complications encountered in these patients were few and minor and did not differ significantly from those encountered in isolated routine pulmonary procedures performed through a posterolateral thoracotomy. Moreover, pulmonary complications were independent of the pulmonary disease, the location of the lesion, or the use of the mechanical stapler. That there was no instance of local or disseminated infection after resection of granulomas suggests a less ominous role for altered immunity than has been postulated.' In general, there was no major difficulty with exposure for the pulmonary resections, and this fact has been substantiated by others," some of whom advocate the median sternotomy approach for most elective pulmonary operations." The conclusions of this study, however, are based on experience with a selected group of patients in whom concomitant procedures were performed. At our institution, other patients with combined cardiac and pulmonary disease have been managed with staged operations, the decision usually being based on technical considerations recognized either preoperatively by roentgenographic studies or intraoperatively during the cardiac procedure. A staged posterolateral thoracotomy might be required for complete exposure of tumors with parietal fixation or in patients with adhesions from a previous thoracotomy. Patients in whom significant
The"Journal of Thoracic and Cardiovascular
6 6 6 Piehler et al.
cardiac or pulmonary complications might be anticipated are also probably best managed with staged procedures. Less stringent criteria appear warranted in those patients whose lesion is completely treatable with a simple wedge resection. A simple wedge resection can be safely performed at the time of a cardiac procedure, either before or after extracorporeal circulation. For peripheral nodules removed by wedge resection that prove to be bronchogenic carcinomas, the option of a delayed definitive procedure via a posterolateral thoracotomy could be exercised if a concomitant lobectomy or pneumonectomy were believed to carry excessive risk. Others have raised the question whether wedge resection alone is adequate treatment for peripheral bronchogenic carcinoma without nodal involvement.':" A median sternotomy is associated with less respiratory compromise than is a lateral thoracotomy.' Therefore, concomitant procedures would seem to be particularly advantageous in patients with poor pulmonary function. Intraoperatively, we have not altered the anesthetic management in these cases from that in routine cardiac cases; a double-lumen endotracheal tube has not been used. The pulmonary lesion is evaluated immediately after sternotomy, before the establishment of extracorporeal circulation. The discovery of unsuspected nodal metastasis from bronchogenic carcinoma, for example, might appropriately alter treatment plans and objectives. Technical factors regarding potential resection of the lesion can be assessed. Although the pulmonary resection could be performed before heparinization, it would appear preferable to delay the resection until after the discontinuation of extracorporeal circulation, when hemodynamics and coagulation are acceptable. There was one death in the series-that from intraparenchymal pulmonary hemorrhage, which occurred after multiple wedge resections during cardiopulmonary bypass. Although this was clearly a unique clinical situation, the outcome has led to our belief that pulmonary resections performed during systemic anticoagulation are associated with increased risk and should be avoided if possible. This conclusion is supported by the 37 pulmonary resections uneventfully performed without anticoagulation. Nevertheless, the fact that five major resections were performed without difficulty during cardiopulmonary bypass suggests that careful hilar dissection and divisionof pulmonary fissures can be safely performed with the patient heparinized. Most of the formal resections that were performed during bypass involved the left side. The advantages of performing a left-sided lobectomy or pneumonectomy during cardiopulmonary bypass are the avoidance of unstable hemodynamics, which often occurs with traction upon the left lung through a median sternotomy, and the improved
Surgery
visualization of the pulmonary artery that is obtained with a nonventilated lung. These advantages are far less significant with right-sided resections, in which the pulmonary vessels and fissures are more accessible through the sternotomy. We believe that there is no significant advantage in performing right-sided resections during cardiopulmonary bypass; however, this appears to be an option that could be selectively exercised in left-sided resections. Because the number of patients who underwent pulmonary resection for bronchogenic carcinoma in the series is small and follow-up is short, extensive conclusions cannot be derived. Nevertheless, our experience supports the contention that an appropriate pulmonary resection for lung cancer can be performed via a median sternotomy and that the concomitant performance of a cardiac procedure does not complicate the pulmonary resection. There is no question, however, that complicated hilar and mediastinal dissections are more easily performed through a posterolateral thoracotomy. A potential limitation of resection for cancer through a median sternotomy is the relatively inaccessibility of the posterior mediastinum for lymph node sampling and dissection. Although incomplete lymph node sampling could underestimate the extent of disease and lead to inadequate therapy, there is no reason to believethat the transsternal approach itself compromises the chance of long-term survival. The results of this study substantiate the contention that concomitant cardiac and pulmonary procedurescan be safely performed in many patients. Furthermore, the concomitant performance of these procedures clearly defines all areas of disease, accelerates the definitive correction of both problems, and,in many instances, saves the patient the expense and potential morbidity of a second operation. REFERENCES
2
3
4
5
Peters RM, Swain JA: Management of the patient with emphysema, coronary artery disease, and lung cancer. Am J Surg 143:701-705, 1982 Girardet RE, Masri ZH, Lansing AM: Pulmonary lesions in patients undergoing open heart surgery. Approach and management. J Ky Med Assoc 79:645-648, 1981 Bricker DL, Parker DM, Dalton ML Jr, Mistrot JJ: Open heart surgery with concomitant pulmonary resection. Cardiovasc Dis, Bull Tex Heart Inst 7:411-419, 1980 Dalton ML Jr, Parker TM, Mistrot 11, Bricker DL: Concomitant coronary artery bypass and major noncardiac surgery. J THORAC CARDIOVASC SURG 75:621-624, 1978 Cooper JD, Nelerns JM, Pearson FG: Extended indications for median sternotomy in patients requiring pulmonary resection. Ann Thorac Surg 26:413-419, 1978
Volume 90 Number 5 November. 1985
6 Urschel HC Jr: Discussion of Cooper et al' 7 Meng RL, Jensik RJ, Kittle CF, Faber LP: Median sternotomy for synchronous bilateral pulmonary operations. J THORAC CARDlOYASC SURG 80:1-7, 1980 8 Peters RM: The role of limited resection in carcinoma of the lung. Am J Surg 143:706-710, 1982 9 Hoffmann TH, Ransdell HT: Comparison of lobectomy and wedge resection for carcinoma of the lung. J THORAC CARDlOYASC SURG 79:211-215, 1980 10 Shields TW, Higgins GA Jr: Minimal pulmonary resection. In treatment of carcinoma of the lung. Arch Surg 108:420-422, 1974
Discussion DR. HAROLD C. URSCHEL, JR. Dallas, Texas
In combining pulmonary resection with cardiac operations over 15 years ago, we recognized certain advantages of median sternotomy, i.e., less postoperative pain, shorter hospital stay, and ability, at least in our minds, to perform resections in patients with compromised pulmonary function who might not tolerate a lateral thoracotomy. We evolved techniques for improving pulmonary exposure through a median sternotomy, and then about 8 years ago we adopted the median sternotomy as our standard approach for most elective pulmonary resections. Recently we reported on 174 cases of elective pulmonary resection through a median sternotomy to The Society of Thoracic Surgeons. Resections of all lobes, pneumonectomies, and chest wall and bronchoplastic procedures, except for superior sulcus tumors, were included. After evaluating 67 patients with combined lesions of the heart and lung, we performed staged operations in 21, believing that the risk would be less. The more severely affected area, whether heart or lung, determined the initial procedure. We performed concomitant procedures in 46 patients. This decision was based on two principles: (1) We believed the risk would be less if both procedures were done together; (2) we believed one procedure was so minor that it wouldnot increase the risk or prolong the time significantly for the other procedure. Most of these were wedge resections, but there were seven lobectomies. There were no deaths. The lessonswe learned were as follows: A biopsy of the lung lesion should be done first in most cases. If the tumor is carcinoma, mediastinal staging should be performed before heparinization. This allows better planning for both procedures. Pulmonary resection is usually saved until after the cardiac procedure is finished and, again based on the status of the patient, is either executed after protamine reversal or delayed to a later time. The use of the double-lumen tube improves exposure with unilateral ventilation so that cardiopulmonary bypass is not necessary for pneumonectomy or lobectomy. We would never need to extend the incision laterally, as was the case in one of these patients, to get better exposure. Based on our experience, we question two procedures in this paper. First, we question the advisability of combining a
Concomitant cardiac and pulmonary operations
667
pneumonectomy with a cardiac operation, primarily because of the increased mortality and morbidity of the pneumonectomy alone. I think that unless it is a very extenuating circumstance, this would not be an ideal situation. This opinion is substantiated by the 10 day ventilator dependence that the authors reported in this particular case. Also, we question adding a lobectomy after completing five coronary artery bypasses in a 71-year-old woman. This is substantiated by the patient's death in this series. DR. JOHN R. F. PENIDO Pasadena, Calif
We were faced with this problem for the first time 14 years ago. Since then we have had six cases that necessitated concomitant pulmonary and cardiac operations. Three were benign lesions and three were malignant. These cases involved saphenous vein revascularization and valve replacement. There were no complications and no deaths in either the benign or malignant lesions. One of the malignant lesions was a melanoma that had recurred after a 35 year lapse. The patient subsequently died 2 years later of massive recurrence of the disease. The other two were bronchogenic carcinomas. Both patients are alive and well, one patient 1 year and the other patient 7 years after resection. DR. PI EHLER (Closing) I thank the discussants for their kind remarks. Dr. Urschel has been an advocate of the transsternal approach to pulmonary resection for many years, and his excellent results have been an important stimulus to this work. We agree with virtually all of his comments regarding selection of patients for concomitant procedures, intraoperative management, and the benefits of avoiding a lateral thoracotomy. Dr. Urschel appropriately raises the issue of defining the safe limits of pulmonary resection in these patients. In general terms, the safe limits are defined by three factors: the anatomy of the pulmonary lesion, the cardiopulmonary reserve of the patient, and the experience of the surgeon. Given the infinite number of permutations and combinations that these factors can pose, I am wary to set specific limits on the pulmonary resections. Thus, I would emphasize again that the management of these patients must be individualized. There is no question that there are limits to the extent of pulmonary resection that are advisable in any given patient. The fact that limits exist, however, should not deter the use of concomitant procedures in situations that are clearly defined and have been demonstrated to be safe by the experience that we have presented today. I thank Dr. Penido for sharing his experience with us. As revealed by his experience, one of the major benefits of this approach is the biopsy of peripheral lung lesions whose etiology is unknown preoperatively. If the lesion is benign, the need for a second operation is eliminated. If the lesion proves malignant, one has the option of a concomitant or staged definitive resection. Our experience and that of the discussants emphasizes the safety with which excision of these peripheral nodules can be performed.
THORAC CARDIOVASC SURG
90:662-667, 1985
Concomitantcardiac and pulmonary operations From 1965 tlu'ough 1983,43 patients underwent concomitant cardiac and pulmonary proceduresat our imtitution. Most patients presented with cardiac symptoms and were incidentally found to have a roentgenographically indeterminate hmg nodule. The pulmoJUlry diagnosis of 38 patients was unknown preoperatively, and nine of these had a malignant lesion. All 43 cardiac procedures necessitated extracorporeal circulation. Thirty-one patients had benign pulmonary disease, 10 had bronchogenic carcinoma, and two had metastatic carcinoma. Concomitant pulmonary procedures were performed via median sternotomy and included single wedge resections in 32 patients, lobectomy in seven, multiple wedge resections in three, and pneumonectomy in one. Most resections were performed either before or after imtitution of bypass, without systemicanticoagulation. Of the two operativedeaths (4.6%), one was related to intraparenchymal pulmonary hemorrhage after multiple wedge resections during anticoagulation. Tbus, pulmonary resectionsperformed during anticoagulationmay be associated with increasedrisk and probably should be avoided. The second death was cardiac in origin and not related to pulmonary resection. The remaining patients recovered uneventfully. Defmitive correction of both cardiac and pulmonary disease can be performed at one operation via a single incisionwith safety and benefit to the carefully selected patient.
Jeffrey M. Piehler, M.D. Peter C. Pairolero, M.D., Hartzell V. Schaff, M.D. Francisco J. Puga, M.D.,
(by invitation), Victor F. Trastek, M.D. (by invitation), James R. Pluth, M.D., Gordon K. Danielson, M.D., (by invitation), Thomas A. Orszulak, M.D. (by invitation), and Rochester, Minn.
concomita~t
Rients with surgical diseases of the heart and lungs are a therapeutic challenge to the cardiothoracic surgeon. Generally, these patients present with surgically correctable cardiac disease and are found to have a pulmonary process, usually an asymptomatic nodule, for which operative management is also appropriate. Less frequently, these patients present with pulmonary disease and are found to have cardiac disease which, if untreated, would significantly increase the risk of the pulmonary operation. The cardiac and pulmonary lesions could be treated at one combined procedure or alternatively with two procedures in a staged fashion, with the sequence based on clinical priority. Historically, there has been generalized reluctance to perform a pulmonary operation at the time of a cardiac procedure that requires extracorporeal circulation, presumably From the Section of Thoracic and Cardiovascular Surgery, Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minn. Read at the Sixth-fifth Annual Meeting of The American Association for Thoracic Surgery, New Orleans, La., April 29-May I, 1985. Address for reprints: Jeffrey M. Piehler, M.D., Mayo Clinic, 200 First St., S.W., Rochester, Minn. 55905.
662
because of coagulation defects related to heparinization and limited pulmonary exposure gained through a median sternotomy. Nevertheless, prompt definitive correction of both disease entities without the need for a second procedure is clearly advantageous, especially if done through the same incision.
Patients The clinical records of all patients who underwent concomitant pulmonary and cardiac procedures that required extracorporeal circulation from January, 1965, through December, 1983, at our institution were reviewed. Excluded were patients who had (l) concomitant pulmonary resections required for iatrogenic intraoperative pulmonary complications, (2) pulmonary resections for congenital sequestration at the time of correction of anomalous pulmonary drainage, and (3) pulmonary procedures performed with extracorporeal circulation without a concomitant cardiac procedure. There were 43 patients (32 male and 11 female) with a mean age of 56.4 years (range 12 to 76). Forty patients (93%) presented with cardiac symptoms and had the pulmonary lesion incidentally discovered. For these patients, cardiac symptoms were predominantly related to coronary artery disease in 25 patients, valvular
Volume 90
Concomitant cardiac and pulmonary operations 6 6 3
Number 5 November. 1985
Table n. Pulmonary disease in 43 patients undergoing concomitant cardiac and pulmonary operations
Table I. Cardiac procedures performedin 43 patients undergoing concomitant cardiac and pulmonary operations Procedure
Patients
No. of patients
CABG Aortic valve replacement Mitral valve replacement Mitral valve repair CABG and left ventricular aneurysm repair Mitral valve repair, CABG, and tricuspid annuloplasty Aortic valve and mitral valve replacement Pulmonary atresia and ventricular septal defect repair Atrial septal defect closure Resection of right ventricular tumor Resection of right atrial tumor
26 4 4 2 I I
Total
43
Diagnosis
No.
Benign Granuloma Chronic inflammation Hamartoma Pulmonary infarct Bullae Malignant Bronchogenic carcinoma Metastatic carcinoma Total
Legend: CABG, Coronary artery bypass grafts.
heart disease in 12, cardiac tumor in two, and congenital heart disease in one. Forty-one of the cardiac procedures were performed electively, and two were performed on an urgent basis (Table I). There were no emergency procedures. Three patients presented with pulmonary signs and symptoms. Two of these patients presented with hemoptysis from bronchogenic carcinoma and developed unstable angina pectoris during their evaluation; the third presented with recurrent pneumothorax from apical pleural bullae and was found to have an asymptomatic atrial septal defect. The pulmonary lesion was identified on the preoperative chest roentgenogram in all patients and appeared as a solitary nodule in 33 patients, infiltrate in five, multiple nodules in three, and emphysematous bullae in two. At the time of operation, the pulmonary diagnosis had been established in two patients (4.6%), was highly suspected in three (7.0%), and was unknown in 38 (88.4%). The diagnosis had been established by preoperative bronchoscopic biopsy in two patients with bronchogenic carcinoma and was highly suspected by the roentgenographic appearance in two patients with emphysematous bullae and by a history of resected metastatic lesions in one patient with metastatic renal cell carcinoma. Thirty-one patients (72.1 %) had benign pulmonary disease, 10 (23.3%) had bronchogenic carcinoma, and two (4.6%) had metastatic carcinoma (Table II). Ofthe 38 patients with undiagnosed pulmonary lesions, nine (23.7%) proved to have malignant lesions. Ten patients (seven males and three females) were found to have bronchogenic carcinomas (Table III). Their mean age was 63.9 years (range 50 to 76). All 10
%
31
72.1 41.9 9.3 9.3 7.0 4.6
18 4 4 3 2
12
27.9 23.3 4.6
10 2 43
100.0
Table m. Cell type, TNM classification, tumor location, and procedure in 10 cases of bronchogenic carcinoma Cell type Squamous cell Adenocarcinoma
Bronchoalveolar
Large cell
TNM TI TI TI TI T2 T2 TI T2 T2 T2
NO MO NO MO NO MO NO MO NO MO NI MO NO MO NO MO NO MO NI MO
Tumor location
Procedure
R upper lobe L upper lobe Rr lower lobe L upper lobe R lower lobe R lower lobe L upper lobe L upper lobe L upper lobe R lower lobe
Lobectomy Lobectomy Wedge Lobectomy Lobectomy Pneumonectomy Wedge Lobectomy Lobectomy Wedge
patients underwent coronary artery bypass grafting, with two to five vessels being bypassed. All patients were in New York Heart Association Class III or IV at the time of operation. Mediastinal and hilar lymph node sampling was done in all patients, and nine patients had curative resections. Most of the patients required only simple wedge excision of the pulmonary lesions (Table IV); eight patients, however, required major resection. Forty-one pulmonary resections were performed via the median sternotomy. One patient who underwent a right upper lobectomy for bronchogenic carcinoma required lateral extension of the sternotomy into the right third intercostal space to facilitate exposure, and a second patient who had the mitral valve replaced via a right thoracotomy had a pulmonary wedge resection performed through the same incision. Standard pulmonary techniques were employed for all resections, the mechanical stapler being utilized for all bronchial closures and for 27 of the 35 wedge excisions.
The Journal of
6 6 4 Piehler et al,
Thoracic and Cardiovascular Surgery
Table IV. Type and location of pulmonary resections in 43 patients undergoing concomitant cardiac and pulmonary operations Resection Wedge
Location Right Upper lobe Middle lobe Lower lobe Lung Left Upper lobe Lower lobe Lung Total
8 4 6
I
Lobectomy
I
Multiple wedge
2 I 0
9 5
4 0
0
Pneumonectomy
0 7 (16.3%)
Most of the pulmonary procedures were performed either before or after bypass (Table V), during which time anticoagulation with heparin either had not been instituted or had been reversed with protamine sulfate. Pulmonary resection was appropriate for the pathological condition in 39 patients (90.7%), in that wedge resections were performed for benign lesions or pulmonary metastasis and formal lobectomies or pneumonectomies were performed for bronchogenic carcinoma. Two additional patients had appropriate wedge resections for bronchogenic carcinoma: One had extensive hilar nodal metastasis and pulmonary function that precluded the necessary pneumonectomy, and the other had a second primary bronchoalveolar cell carcinoma without nodal involvement. In two additional patients (4.6%), however, pulmonary resection could be judged inappropriate for the lesion: One had lobectomy for a granuloma of the right upper lobe, and the other had wedge resection alone for bronchogenic carcinoma.
Results There were two (4.6%) operative deaths (within 30 days or the same hospitalization), only one of which was related to the pulmonary procedure. This occurred in a young woman with a previously resected renal cell carcinoma who presented with multiple bilateral pulmonary metastases and an additional large metastasis to the anterior right ventricular free wall, causing severe right heart failure. A right lower lobectomy with multiple wedge resections in the remaining right lung had been performed previously via a right thoracotomy. At a subsequent procedure employing extracorporeal circulation, the patient had excision of the right ventricular tumor through a median sternotomy and, while still on bypass to facilitate lung mobilization, had seven nodules in the left lung removed by wedge excision. The procedure was complicated by intraparenchymal pulmo-
Total 10 4 7 2
0
0
32 (74.4%)
I
I (2.3%)
2
13 5 2
3 (7.0%)
43
nary hemorrhage, and the patient died of acute respiratory insufficiency the day after the operation. The second death was unrelated to the pulmonary procedure and occurred in a 71-year-old woman who had acute aorta-coronary graft occlusion and died of a myocardial infarction on the fourth postoperative day after a five-vessel coronary artery bypass graft procedure and concomitant left upper lobectomy for adenocarcinoma. There were two (4.6%) postoperative complications related to the pulmonary procedure. One patient required reexploration for pleural space bleeding that originated from the apical chest wall, where adhesions had been divided. A second patient underwent pneumonectomy and required ventilator support for 10 days postoperatively; the remaining patients were all extubated within 36 hours of operation. Except for the one patient who died, no other patient had intrapulmonary hemorrhage. Four patients required bronchoscopy during the postoperative period to remove retained secretions. There were no instances of prolonged pulmonary air leak, excessive chest tube drainage, pleural space infection, wound infection, or pleural space complication. One patient had transient postoperative low cardiac output syndrome, and three had minor cardiac dysrhythmias that were successfully managed pharmacologically. None of these events was related to the pulmonary resection. Follow-up was complete in all patients and averaged 3.8 years, ranging from 1.5 months to 14.8 years. There were no late postoperative sequelae from the resections.
Pulmonary resections for bronchogenic carcinoma. Ofthe 10 patients who underwent resection for primary bronchogenic carcinoma, six are currently alive. Five of these have no evidence of disease at postoperative intervals ranging from 3 months to 2.5 years, and one patient is alive with known disease 5.8 years after
Volume 90 Number 5 November, 1985
Concomitant cardiac and pulmonary operations 6 6 5
Table V. Timing ofpulmonary resection in 43 patients undergoing concomitant cardiac and pulmonary operations Resection Timing
Wedge
I
Lobectomy
Before bypass During bypass and before cardiac procedure During bypass and after cardiac procedure After bypass
13
19
1 1 3 2
Total
32
7
0 0
resection of a bronchoalveolar cell carcinoma. Three additional patients have died of metastatic carcinoma from 10 to 30 months postoperatively. Interestingly, two of these patients had undergone wedge resection as the sole surgical treatment for their malignant lesion, although one had nodal metastases knowingly left at operation. The tenth patient died of myocardial infarction in the hospital, and no evidence of bronchogenic carcinoma was detected at postmortem examination. Spared second procedures. Acknowledging the uncertainties of such an analysis, we attempted to determine the number of patients who were spared a second staged operation by this combined approach. Twenty-nine patients (67.4%) had lung lesions that fulfilled currently accepted criteria for early thoracotomy. Most commonly, such a lesion was a noncalcified nodule that was not present on earlier roentgenograms of the chest. Twelve of these patients (41.4%) were found to have malignant tumors. Fourteen patients had lesions for which thoracotomy could have been optional or delayed if the cardiac operation had not been necessary. Thus, the combined approach potentially spared an early thoracotomy in approximately two thirds of the patients.
Discussion Traditionally, pulmonary resection has not been concomitantly performed with cardiac procedures that require extracorporeal circulation, primarily because of potential intrapulmonary bleeding from altered coagulation mechanisms. Of lesser importance have been concerns for compromised pulmonary exposure through the median sternotomy, which is usually mandated by the cardiac procedure, and of disseminated or local infection after resection of infectious nodules, perhaps related to altered immunity associated with cardiopulmonary bypass.' Consequently, many cardiothoracic surgeons have advocated staged procedures, usually first correcting the cardiac disease, as this represents the most immediate threat to the patient. A concomitant approach to both problems is theoretically advantageous
I
Pneumonectomy
0 0
I
Multiple wedge
Total
2
1
1
0
0
16 1 5 21
3
43
0
in that all areas of disease are definitively managed without delay and the patient is spared the significant morbidity of a second thoracotomy. Ideally, the decision to perform concomitant cardiac and pulmonary procedures should be based on a favorable benefit-to-risk ratio. Unfortunately, a review of the literature reveals only a few small groups of patients treated with a combined approach," and thus firm conclusions cannot be reached. The present study suggests that a variety of pulmonary conditions are safely amenable to appropriate resection at the time of elective cardiac procedures that require extracorporeal circulation. With the exception of one patient with intrapulmonary parenchymal hemorrhage, the intraoperative and postoperative pulmonary complications encountered in these patients were few and minor and did not differ significantly from those encountered in isolated routine pulmonary procedures performed through a posterolateral thoracotomy. Moreover, pulmonary complications were independent of the pulmonary disease, the location of the lesion, or the use of the mechanical stapler. That there was no instance of local or disseminated infection after resection of granulomas suggests a less ominous role for altered immunity than has been postulated.' In general, there was no major difficulty with exposure for the pulmonary resections, and this fact has been substantiated by others," some of whom advocate the median sternotomy approach for most elective pulmonary operations." The conclusions of this study, however, are based on experience with a selected group of patients in whom concomitant procedures were performed. At our institution, other patients with combined cardiac and pulmonary disease have been managed with staged operations, the decision usually being based on technical considerations recognized either preoperatively by roentgenographic studies or intraoperatively during the cardiac procedure. A staged posterolateral thoracotomy might be required for complete exposure of tumors with parietal fixation or in patients with adhesions from a previous thoracotomy. Patients in whom significant
The"Journal of Thoracic and Cardiovascular
6 6 6 Piehler et al.
cardiac or pulmonary complications might be anticipated are also probably best managed with staged procedures. Less stringent criteria appear warranted in those patients whose lesion is completely treatable with a simple wedge resection. A simple wedge resection can be safely performed at the time of a cardiac procedure, either before or after extracorporeal circulation. For peripheral nodules removed by wedge resection that prove to be bronchogenic carcinomas, the option of a delayed definitive procedure via a posterolateral thoracotomy could be exercised if a concomitant lobectomy or pneumonectomy were believed to carry excessive risk. Others have raised the question whether wedge resection alone is adequate treatment for peripheral bronchogenic carcinoma without nodal involvement.':" A median sternotomy is associated with less respiratory compromise than is a lateral thoracotomy.' Therefore, concomitant procedures would seem to be particularly advantageous in patients with poor pulmonary function. Intraoperatively, we have not altered the anesthetic management in these cases from that in routine cardiac cases; a double-lumen endotracheal tube has not been used. The pulmonary lesion is evaluated immediately after sternotomy, before the establishment of extracorporeal circulation. The discovery of unsuspected nodal metastasis from bronchogenic carcinoma, for example, might appropriately alter treatment plans and objectives. Technical factors regarding potential resection of the lesion can be assessed. Although the pulmonary resection could be performed before heparinization, it would appear preferable to delay the resection until after the discontinuation of extracorporeal circulation, when hemodynamics and coagulation are acceptable. There was one death in the series-that from intraparenchymal pulmonary hemorrhage, which occurred after multiple wedge resections during cardiopulmonary bypass. Although this was clearly a unique clinical situation, the outcome has led to our belief that pulmonary resections performed during systemic anticoagulation are associated with increased risk and should be avoided if possible. This conclusion is supported by the 37 pulmonary resections uneventfully performed without anticoagulation. Nevertheless, the fact that five major resections were performed without difficulty during cardiopulmonary bypass suggests that careful hilar dissection and divisionof pulmonary fissures can be safely performed with the patient heparinized. Most of the formal resections that were performed during bypass involved the left side. The advantages of performing a left-sided lobectomy or pneumonectomy during cardiopulmonary bypass are the avoidance of unstable hemodynamics, which often occurs with traction upon the left lung through a median sternotomy, and the improved
Surgery
visualization of the pulmonary artery that is obtained with a nonventilated lung. These advantages are far less significant with right-sided resections, in which the pulmonary vessels and fissures are more accessible through the sternotomy. We believe that there is no significant advantage in performing right-sided resections during cardiopulmonary bypass; however, this appears to be an option that could be selectively exercised in left-sided resections. Because the number of patients who underwent pulmonary resection for bronchogenic carcinoma in the series is small and follow-up is short, extensive conclusions cannot be derived. Nevertheless, our experience supports the contention that an appropriate pulmonary resection for lung cancer can be performed via a median sternotomy and that the concomitant performance of a cardiac procedure does not complicate the pulmonary resection. There is no question, however, that complicated hilar and mediastinal dissections are more easily performed through a posterolateral thoracotomy. A potential limitation of resection for cancer through a median sternotomy is the relatively inaccessibility of the posterior mediastinum for lymph node sampling and dissection. Although incomplete lymph node sampling could underestimate the extent of disease and lead to inadequate therapy, there is no reason to believethat the transsternal approach itself compromises the chance of long-term survival. The results of this study substantiate the contention that concomitant cardiac and pulmonary procedurescan be safely performed in many patients. Furthermore, the concomitant performance of these procedures clearly defines all areas of disease, accelerates the definitive correction of both problems, and,in many instances, saves the patient the expense and potential morbidity of a second operation. REFERENCES
2
3
4
5
Peters RM, Swain JA: Management of the patient with emphysema, coronary artery disease, and lung cancer. Am J Surg 143:701-705, 1982 Girardet RE, Masri ZH, Lansing AM: Pulmonary lesions in patients undergoing open heart surgery. Approach and management. J Ky Med Assoc 79:645-648, 1981 Bricker DL, Parker DM, Dalton ML Jr, Mistrot JJ: Open heart surgery with concomitant pulmonary resection. Cardiovasc Dis, Bull Tex Heart Inst 7:411-419, 1980 Dalton ML Jr, Parker TM, Mistrot 11, Bricker DL: Concomitant coronary artery bypass and major noncardiac surgery. J THORAC CARDIOVASC SURG 75:621-624, 1978 Cooper JD, Nelerns JM, Pearson FG: Extended indications for median sternotomy in patients requiring pulmonary resection. Ann Thorac Surg 26:413-419, 1978
Volume 90 Number 5 November. 1985
6 Urschel HC Jr: Discussion of Cooper et al' 7 Meng RL, Jensik RJ, Kittle CF, Faber LP: Median sternotomy for synchronous bilateral pulmonary operations. J THORAC CARDlOYASC SURG 80:1-7, 1980 8 Peters RM: The role of limited resection in carcinoma of the lung. Am J Surg 143:706-710, 1982 9 Hoffmann TH, Ransdell HT: Comparison of lobectomy and wedge resection for carcinoma of the lung. J THORAC CARDlOYASC SURG 79:211-215, 1980 10 Shields TW, Higgins GA Jr: Minimal pulmonary resection. In treatment of carcinoma of the lung. Arch Surg 108:420-422, 1974
Discussion DR. HAROLD C. URSCHEL, JR. Dallas, Texas
In combining pulmonary resection with cardiac operations over 15 years ago, we recognized certain advantages of median sternotomy, i.e., less postoperative pain, shorter hospital stay, and ability, at least in our minds, to perform resections in patients with compromised pulmonary function who might not tolerate a lateral thoracotomy. We evolved techniques for improving pulmonary exposure through a median sternotomy, and then about 8 years ago we adopted the median sternotomy as our standard approach for most elective pulmonary resections. Recently we reported on 174 cases of elective pulmonary resection through a median sternotomy to The Society of Thoracic Surgeons. Resections of all lobes, pneumonectomies, and chest wall and bronchoplastic procedures, except for superior sulcus tumors, were included. After evaluating 67 patients with combined lesions of the heart and lung, we performed staged operations in 21, believing that the risk would be less. The more severely affected area, whether heart or lung, determined the initial procedure. We performed concomitant procedures in 46 patients. This decision was based on two principles: (1) We believed the risk would be less if both procedures were done together; (2) we believed one procedure was so minor that it wouldnot increase the risk or prolong the time significantly for the other procedure. Most of these were wedge resections, but there were seven lobectomies. There were no deaths. The lessonswe learned were as follows: A biopsy of the lung lesion should be done first in most cases. If the tumor is carcinoma, mediastinal staging should be performed before heparinization. This allows better planning for both procedures. Pulmonary resection is usually saved until after the cardiac procedure is finished and, again based on the status of the patient, is either executed after protamine reversal or delayed to a later time. The use of the double-lumen tube improves exposure with unilateral ventilation so that cardiopulmonary bypass is not necessary for pneumonectomy or lobectomy. We would never need to extend the incision laterally, as was the case in one of these patients, to get better exposure. Based on our experience, we question two procedures in this paper. First, we question the advisability of combining a
Concomitant cardiac and pulmonary operations
667
pneumonectomy with a cardiac operation, primarily because of the increased mortality and morbidity of the pneumonectomy alone. I think that unless it is a very extenuating circumstance, this would not be an ideal situation. This opinion is substantiated by the 10 day ventilator dependence that the authors reported in this particular case. Also, we question adding a lobectomy after completing five coronary artery bypasses in a 71-year-old woman. This is substantiated by the patient's death in this series. DR. JOHN R. F. PENIDO Pasadena, Calif
We were faced with this problem for the first time 14 years ago. Since then we have had six cases that necessitated concomitant pulmonary and cardiac operations. Three were benign lesions and three were malignant. These cases involved saphenous vein revascularization and valve replacement. There were no complications and no deaths in either the benign or malignant lesions. One of the malignant lesions was a melanoma that had recurred after a 35 year lapse. The patient subsequently died 2 years later of massive recurrence of the disease. The other two were bronchogenic carcinomas. Both patients are alive and well, one patient 1 year and the other patient 7 years after resection. DR. PI EHLER (Closing) I thank the discussants for their kind remarks. Dr. Urschel has been an advocate of the transsternal approach to pulmonary resection for many years, and his excellent results have been an important stimulus to this work. We agree with virtually all of his comments regarding selection of patients for concomitant procedures, intraoperative management, and the benefits of avoiding a lateral thoracotomy. Dr. Urschel appropriately raises the issue of defining the safe limits of pulmonary resection in these patients. In general terms, the safe limits are defined by three factors: the anatomy of the pulmonary lesion, the cardiopulmonary reserve of the patient, and the experience of the surgeon. Given the infinite number of permutations and combinations that these factors can pose, I am wary to set specific limits on the pulmonary resections. Thus, I would emphasize again that the management of these patients must be individualized. There is no question that there are limits to the extent of pulmonary resection that are advisable in any given patient. The fact that limits exist, however, should not deter the use of concomitant procedures in situations that are clearly defined and have been demonstrated to be safe by the experience that we have presented today. I thank Dr. Penido for sharing his experience with us. As revealed by his experience, one of the major benefits of this approach is the biopsy of peripheral lung lesions whose etiology is unknown preoperatively. If the lesion is benign, the need for a second operation is eliminated. If the lesion proves malignant, one has the option of a concomitant or staged definitive resection. Our experience and that of the discussants emphasizes the safety with which excision of these peripheral nodules can be performed.