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Concomitant coronary artery bypass and major noncardiac surgery
Concomitant coronary artery bypass and major noncardiac surgery Concomitant cardiac procedures performed in conjunction with coronary bypass have become commonplace, but not concomitant noncardiac procedures. Bernhard and associates were the first to report concomitant coronary bypass and carotid endarterectomy. This series, begun in /97/, consists of 7/ noncardiac procedures performed concomitantly with coronal)' bypass on 68 patients, Thirty-seven procedures were performed for associated vascular disease, including carotid endarterectomy (25 patients) and resection of abdominal aortic aneurysm (three patients). Other concomitant problems included are thymoma, bronchogenic carcinoma, and hiatal hernia. The operative mortality rate of 2.9 percent compares vel}' favorably with that of / .7 percent in our group of patients having isolated coronal)' artery bypass, A plea is made for consideration of concomitant surgery in patients with operable coronal)' heart disease who have an additional serious noncardiac surgical disease.
Martin L. Dalton, Jr., M.D., Thomas M. Parker, M.D., J. Jacques Mistrot, M.D., and Donald L. Bricker, M.D., Lubbock, Texas
With the increasing frequency of coronary bypass operations, cardiac surgeons have been quick to accept major concomitant cardiac surgical procedures such as valve replacement or left ventricular aneurysmectomy. This practice has become acceptable despite the relatively high mortality rate. A recent report from the Mayo Clinic documents a 33 percent operative mortality rate in coronary bypass combined with mitral valve replacement for postinfarction mitral incompe-
renee.' In marked contrast, those patients with major noncardiac problems in need of concomitant surgery have not been so readily accepted. Consequently, references in the literature to concomitant coronary bypass surgery and major noncardiac surgery are sparse. Apparently, Bernhard, Johnson, and Peterson" were the first to espouse this surgical approach, and in 1972, they published their data on concomitant carotid endarterectomy and coronary bypass surgery. In one group of 15 patients with coexisting coronary and carotid occlusive disease, carotid endarterectomy was carried out initially with a mortality rate of 33 percent. Most of the deaths were due to myocardial infarction. In a second Received for publication OCI. 4, 1977, Accepted for publication Dec, 6, 1977, Address for reprints: Martin L. Dahon, Jr., M,D" Southwestern Cardiovascular Surgical Associates, 3420 Twenty-second Place, Lubbock, Texas 79410,
0022-5223/78/0475-0621$00.40/0 © 1978 The C. V. Mosby Co.
group of 15 patients, carotid endarterectomy and concomitant coronary bypass were performed with no cardiac-related deaths or morbidity. This clinical study was repeated by Okies, MacManus, and Starr." These data, published in 1977, document simultaneous carotid endarterectomy and coronary bypass surgery in 16 patients with one death (6.2 percent operative mortality rate). In addition, two of their patients had minimal postoperative cerebral complications. It is widely recognized that myocardial infarction is the most frequent noncerebral cause of both early and late death following carotid endarterectomy. In a series published by Sundt, Sandok, and Whisnant" from the Mayo Clinic, myocardial infarction was the primary complication of carotid endarterectomy. In this study, there was a 7 percent operative mortality rate following carotid endarterectomy in patients with a major medical risk. Javid and associates- have reported that the risk of cerebral complications following cardiopulmonary bypass ranges from 31 to 53 percent. Therefore, it seems safe to assume that those patients with combined carotid and coronary occlusive disease are at a greater risk from postoperative cerebral complications following coronary bypass than are patients without carotid occlusive disease. All of this information serves to validate the concept of concomitant carotid endarterectomy and coronary bypass surgery. Beginning with carotid endarterectomy, we have ex621
The Journal of
622
Dalton et al.
Thoracic and Cardiovascular Surgery
Table I. Associated vascular surgery (37 procedures) Operation
No.
Carotid endarterectomy Abdominal aortic aneurysmectomy Carotid subclavian bypass Femoral aneurysmectomy Brachial artery repair Aorto-femoral bypass Renal artery bypass Resection of false aneurysm, subclavian artery and aorto-sublcavian bypass
25 3
2 2
2 I I I
Table II. Surgery of upper gastrointestinal tract (24 procedures) Operation
No.
Hiatal hernia Hiatal hernia repair and vagotomypyloroplasty Vagotomy-pyloroplasty Vagotomy-gastrectomy Cholecystectomy
15 4 3 I I
panded our indications for coronary bypass and concomitant vascular surgery to include life-threatening abdominal aortic aneurysms, limb-threatening aortoiliac occlusive disease, and other serious vascular problems. Approximately one half of the patients in the series have had concomitant vascular surgery. Other patients have had associated pulmonary or mediastinal disease, included are patients with resection of a thymoma and concomitant left pneumonectomy for bronchogenic carcinoma. Patients with a history of symptomatic hiatus hernia or with a past history of bleeding peptic ulcer have been managed with a concomitant acid reduction procedure or hiatal hernia repair or both. The present study was undertaken to compare isolated coronary bypass surgery with coronary bypass plus a major noncardiac surgical procedure. In our series of 1,394 consecutive coronary bypass procedures (November, 1970, to April, 1977),68 patients required an additional major noncardiac surgical procedure. These 68 patients were representative of the entire series as regards age, sex, number of grafts, and status of left ventricular function. Because three patients required two concomitant noncardiac surgical procedures, the total number of procedures is 71.
Report of the series Group I: Associated vascular surgery (Table I). Thirty-seven concomitant vascular surgery procedures
were performed, predominately carotid endarterectomy (25 patients). The typical patient in this group had crescendo angina and a carotid bruit. Arteriograms confirmed the presence of severe, critical coronary artery disease and critical carotid occlusive disease. It is our usual procedure to perform the carotid endarterectomy first with a heparin dose of 5,000 units. The carotid endarterectomy incision is approximated with towel clips over an antibiotic-moistened sponge, and coronary bypass is then done with the routine amount of heparin. Following a 2: I protamine dosage, all wounds are closed simultaneously. There was one death in this group of patients, which occurred in an elderly man with moderate compromise of left ventricular function. He died of left ventricular failure in the early postoperative period following concomitant left carotid endarterectomy and double coronary artery bypass. Ironically, because of generalized arteriosclerosis, the intra-artie balloon pump could not be inserted in either femoral artery, and without this support he died.
Group II: Associated surgery of the upper gastrointestinal tract (Table II). There were 24 procedures in this group, performed primarily in patients with a massive, symptomatic hiatal hernia (19 patients). Also included are four patients with a history of recurrent bleeding of the upper gastro-intestinal tract, because two of our early deaths after coronary artery bypass were due to bleeding stress ulcer. Three of these patients had prophylactic vagotomy and pyloroplasty and one patient had vagotomy and gastrectomy. One patient with a history of recurrent cholecystitis and abnormal findings on a cholecystogram underwent concomitant cholecystectomy. There was one operative death in this group of patients. A 64-year-old man died on the eighth postoperative day following concomitant hiatal hernia repair and triple coronary bypass. Death was due to a massive pulmonary embolus and occurred despite our routine, which includes heparinization of all patients following coronary bypass beginning on the third postoperative day. Group III: Associated neoplasia (Table III). Six patients had associated neoplasia. There were three pulmonary resections for bronchogenic carcinoma: one pneumonectomy, one bilobectomy, and one wedge resection. In addition, one patient had a right-sided colectomy for carcinoma of the colon, one patient had resection of a large thymoma, and one patient had a rightsided nephrectomy for carcinoma. There were no deaths in this group of patients. Group IV: Incidental procedures (Table IV). This group consisted of four patients, three with epigastric hernia and one with incisional hernia. These operations
Volume 75 Number 4 April,1978
Concomitant coronary bypass and noncardiac surgery
were done purely as incidental concomitant procedures. All four patients had a hernia in line with the proposed median sternotomy incision in which we divide the linea alba to the midepigastrium. The repair, of course, was quite incidental and, in fact, would have been unavoidable assuming customary surgical closure of the incised tissues. All four of these patients did well with no postoperative problems.
Results There were two operative deaths in this group of 68 patients who had concomitant coronary bypass and noncardiac surgery, which accounts for an operative mortality rate of 2.9 percent. Both of these deaths occurred in patients with moderate compromise of left ventricular function. The operati ve mortality rate of 2.9 percent compares very favorably with the over-all mortality rate of our entire series of patients having isolated coronary bypass, which is 1.7 percent. The late death rate in this group of patients, who have been followed from 5 months to 5lf2 years with a mean follow-up of 16 months, is 3.1 percent. This figure also compares very favorably with the entire series figure for a mean follow-up of 2.7 years (5 months to 6lf2 years), with a late death rate of 4.5 percent. There has been no perceptible increase in the morbidity in this group of patients. Indeed, we have had only one instance of appreciable morbidity-sternal dehiscence necessitating secondary closure-but no long-term problems have been encountered.
Discussion Certainly, the idea of concomitant operative procedures is not new. In fact, they are commonplace. Consider the irresistible "incidental appendectomy" that is performed concomitantly with many abdominal procedures. There are several reasons for this surgical approach being applied to the present group of patients, some of which have been previously elucidated: 1. Carotid endarterectomy is accomplished concomitantly to avoid the risk of myocardial infarction when carotid endarterectomy is done alone and, conversely, to avoid the risk of cerebrovascular accident when coronary bypass is done alone. 2. A large, tender abdominal aneurysm is certainly an urgent surgical problem. When this is present in combination with preinfarction angina, the surgeon is faced with a grave dual problem. We have chosen to resolve this surgical dilemma in three patients by means of concomitant coronary bypass and abdominal aortic aneurysmectomy. All three patients have done well with no postoperative complications. The remainder of the patients requiring vascular surgery have been oper-
623
Table III. Associated neoplasia (six procedures) Operation
I
No.
Pulmonary resection Pneumonectomy Bilobectomy Wedge resection Radical nephrectomy Thymoma Colectomy
3
Table IV. Incidental (four procedures) Operation
I----N-O-.----
Epigastric hernia Incisional hernia
3 I
ated upon concomitantly because of fear of loss of life or limb should either procedure be performed separately. 3. The overlapping symptoms of hiatal hernia and coronary artery disease are well known. For this reason, in symptomatic patients with a large hiatal hernia, we have preferred to repair the hiatal hernia concomitantly. This aids us postoperatively in differentiating between the two pain syndromes. Certainly, from the patient's standpoint, it is advantageous to have a slightly more extensive single operation than to undergo two separate major surgical procedures. 4. In the group of patients with carcinoma, the need for concomitant surgery is obvious if feasible. We have individualized the approach to each patient, and in the three patients with pulmonary resection we have proved the absence of distal metastases preoperatively. This was also true in the patient with radical nephrectomy. We examined the patient with colon carcinoma in the company of a general surgeon. Laparotomy was performed before coronary bypass was begun, and definite resectability was ascertained. Only after ascertaining this information and absence of metastases to the liver did we approximate the abdominal wound with a wet dressing and towel clips. We then proceeded with coronary bypass in this patient who had severe preinfarction angina. After coronary bypass, colectomy was completed by the attendant general surgeon. REFERENCES Assad-Morell JL, Connolly DC, Brandenburg RO, Giuliani ER, Schattenberg TT, Pluth JR, Barnhorst DA, Wallace RB, Danielson GK: Aorta-coronary artery saphenous vein bypass grafts. Isolated and combined with other procedures. THORAC CARDIOVASC SURG 69:841-850, 1975 2 Bernhard VM, Johnson WD, Peterson 11: Carotid artery
624
Dalton et al.
stenosis. Association with surgery for coronary artery disease. Arch Surg 105:837-840, 1972 3 Okies JE, MacManus Q, Starr A: Myocardial revascularization and carotid endarterectomy. A combined approach. Ann Thorac Surg 23:560-563, 1977. 4 Sundt TM, Sandok BA, Whisnant JP: Carotid endarterec-
The Journal of Thoracic and Cardiovascular Surgery
tomy. Complications and preoperative assessment of risk. Mayo Clin Proc 50:301-306, 1975 5 Javid H, Tufo HM, Najafi H, Dye WS, Hunter JA, Julian OC: Neurologic abnormalities following open-heart surgery. J THoRAc CARDIOVASC SURG 58:502-509, 1969
Information for authors Most of the provisions of the Copyright Act of 1976 became effective on January 1, 1978. Therefore, all manuscripts must be accompanied by the following statement, signed by each author: "The undersigned author(s) transfers all copyright ownership of the manuscript entitled (title of article) to The C. V. Mosby Company in the event the work is published. The author(s) warrants that the article is original, is not under consideration by another journal, and has not been previously published. " Authors will be consulted, when possible, regarding republication of their material.
Martin L. Dalton, Jr., M.D., Thomas M. Parker, M.D., J. Jacques Mistrot, M.D., and Donald L. Bricker, M.D., Lubbock, Texas
With the increasing frequency of coronary bypass operations, cardiac surgeons have been quick to accept major concomitant cardiac surgical procedures such as valve replacement or left ventricular aneurysmectomy. This practice has become acceptable despite the relatively high mortality rate. A recent report from the Mayo Clinic documents a 33 percent operative mortality rate in coronary bypass combined with mitral valve replacement for postinfarction mitral incompe-
renee.' In marked contrast, those patients with major noncardiac problems in need of concomitant surgery have not been so readily accepted. Consequently, references in the literature to concomitant coronary bypass surgery and major noncardiac surgery are sparse. Apparently, Bernhard, Johnson, and Peterson" were the first to espouse this surgical approach, and in 1972, they published their data on concomitant carotid endarterectomy and coronary bypass surgery. In one group of 15 patients with coexisting coronary and carotid occlusive disease, carotid endarterectomy was carried out initially with a mortality rate of 33 percent. Most of the deaths were due to myocardial infarction. In a second Received for publication OCI. 4, 1977, Accepted for publication Dec, 6, 1977, Address for reprints: Martin L. Dahon, Jr., M,D" Southwestern Cardiovascular Surgical Associates, 3420 Twenty-second Place, Lubbock, Texas 79410,
0022-5223/78/0475-0621$00.40/0 © 1978 The C. V. Mosby Co.
group of 15 patients, carotid endarterectomy and concomitant coronary bypass were performed with no cardiac-related deaths or morbidity. This clinical study was repeated by Okies, MacManus, and Starr." These data, published in 1977, document simultaneous carotid endarterectomy and coronary bypass surgery in 16 patients with one death (6.2 percent operative mortality rate). In addition, two of their patients had minimal postoperative cerebral complications. It is widely recognized that myocardial infarction is the most frequent noncerebral cause of both early and late death following carotid endarterectomy. In a series published by Sundt, Sandok, and Whisnant" from the Mayo Clinic, myocardial infarction was the primary complication of carotid endarterectomy. In this study, there was a 7 percent operative mortality rate following carotid endarterectomy in patients with a major medical risk. Javid and associates- have reported that the risk of cerebral complications following cardiopulmonary bypass ranges from 31 to 53 percent. Therefore, it seems safe to assume that those patients with combined carotid and coronary occlusive disease are at a greater risk from postoperative cerebral complications following coronary bypass than are patients without carotid occlusive disease. All of this information serves to validate the concept of concomitant carotid endarterectomy and coronary bypass surgery. Beginning with carotid endarterectomy, we have ex621
The Journal of
622
Dalton et al.
Thoracic and Cardiovascular Surgery
Table I. Associated vascular surgery (37 procedures) Operation
No.
Carotid endarterectomy Abdominal aortic aneurysmectomy Carotid subclavian bypass Femoral aneurysmectomy Brachial artery repair Aorto-femoral bypass Renal artery bypass Resection of false aneurysm, subclavian artery and aorto-sublcavian bypass
25 3
2 2
2 I I I
Table II. Surgery of upper gastrointestinal tract (24 procedures) Operation
No.
Hiatal hernia Hiatal hernia repair and vagotomypyloroplasty Vagotomy-pyloroplasty Vagotomy-gastrectomy Cholecystectomy
15 4 3 I I
panded our indications for coronary bypass and concomitant vascular surgery to include life-threatening abdominal aortic aneurysms, limb-threatening aortoiliac occlusive disease, and other serious vascular problems. Approximately one half of the patients in the series have had concomitant vascular surgery. Other patients have had associated pulmonary or mediastinal disease, included are patients with resection of a thymoma and concomitant left pneumonectomy for bronchogenic carcinoma. Patients with a history of symptomatic hiatus hernia or with a past history of bleeding peptic ulcer have been managed with a concomitant acid reduction procedure or hiatal hernia repair or both. The present study was undertaken to compare isolated coronary bypass surgery with coronary bypass plus a major noncardiac surgical procedure. In our series of 1,394 consecutive coronary bypass procedures (November, 1970, to April, 1977),68 patients required an additional major noncardiac surgical procedure. These 68 patients were representative of the entire series as regards age, sex, number of grafts, and status of left ventricular function. Because three patients required two concomitant noncardiac surgical procedures, the total number of procedures is 71.
Report of the series Group I: Associated vascular surgery (Table I). Thirty-seven concomitant vascular surgery procedures
were performed, predominately carotid endarterectomy (25 patients). The typical patient in this group had crescendo angina and a carotid bruit. Arteriograms confirmed the presence of severe, critical coronary artery disease and critical carotid occlusive disease. It is our usual procedure to perform the carotid endarterectomy first with a heparin dose of 5,000 units. The carotid endarterectomy incision is approximated with towel clips over an antibiotic-moistened sponge, and coronary bypass is then done with the routine amount of heparin. Following a 2: I protamine dosage, all wounds are closed simultaneously. There was one death in this group of patients, which occurred in an elderly man with moderate compromise of left ventricular function. He died of left ventricular failure in the early postoperative period following concomitant left carotid endarterectomy and double coronary artery bypass. Ironically, because of generalized arteriosclerosis, the intra-artie balloon pump could not be inserted in either femoral artery, and without this support he died.
Group II: Associated surgery of the upper gastrointestinal tract (Table II). There were 24 procedures in this group, performed primarily in patients with a massive, symptomatic hiatal hernia (19 patients). Also included are four patients with a history of recurrent bleeding of the upper gastro-intestinal tract, because two of our early deaths after coronary artery bypass were due to bleeding stress ulcer. Three of these patients had prophylactic vagotomy and pyloroplasty and one patient had vagotomy and gastrectomy. One patient with a history of recurrent cholecystitis and abnormal findings on a cholecystogram underwent concomitant cholecystectomy. There was one operative death in this group of patients. A 64-year-old man died on the eighth postoperative day following concomitant hiatal hernia repair and triple coronary bypass. Death was due to a massive pulmonary embolus and occurred despite our routine, which includes heparinization of all patients following coronary bypass beginning on the third postoperative day. Group III: Associated neoplasia (Table III). Six patients had associated neoplasia. There were three pulmonary resections for bronchogenic carcinoma: one pneumonectomy, one bilobectomy, and one wedge resection. In addition, one patient had a right-sided colectomy for carcinoma of the colon, one patient had resection of a large thymoma, and one patient had a rightsided nephrectomy for carcinoma. There were no deaths in this group of patients. Group IV: Incidental procedures (Table IV). This group consisted of four patients, three with epigastric hernia and one with incisional hernia. These operations
Volume 75 Number 4 April,1978
Concomitant coronary bypass and noncardiac surgery
were done purely as incidental concomitant procedures. All four patients had a hernia in line with the proposed median sternotomy incision in which we divide the linea alba to the midepigastrium. The repair, of course, was quite incidental and, in fact, would have been unavoidable assuming customary surgical closure of the incised tissues. All four of these patients did well with no postoperative problems.
Results There were two operative deaths in this group of 68 patients who had concomitant coronary bypass and noncardiac surgery, which accounts for an operative mortality rate of 2.9 percent. Both of these deaths occurred in patients with moderate compromise of left ventricular function. The operati ve mortality rate of 2.9 percent compares very favorably with the over-all mortality rate of our entire series of patients having isolated coronary bypass, which is 1.7 percent. The late death rate in this group of patients, who have been followed from 5 months to 5lf2 years with a mean follow-up of 16 months, is 3.1 percent. This figure also compares very favorably with the entire series figure for a mean follow-up of 2.7 years (5 months to 6lf2 years), with a late death rate of 4.5 percent. There has been no perceptible increase in the morbidity in this group of patients. Indeed, we have had only one instance of appreciable morbidity-sternal dehiscence necessitating secondary closure-but no long-term problems have been encountered.
Discussion Certainly, the idea of concomitant operative procedures is not new. In fact, they are commonplace. Consider the irresistible "incidental appendectomy" that is performed concomitantly with many abdominal procedures. There are several reasons for this surgical approach being applied to the present group of patients, some of which have been previously elucidated: 1. Carotid endarterectomy is accomplished concomitantly to avoid the risk of myocardial infarction when carotid endarterectomy is done alone and, conversely, to avoid the risk of cerebrovascular accident when coronary bypass is done alone. 2. A large, tender abdominal aneurysm is certainly an urgent surgical problem. When this is present in combination with preinfarction angina, the surgeon is faced with a grave dual problem. We have chosen to resolve this surgical dilemma in three patients by means of concomitant coronary bypass and abdominal aortic aneurysmectomy. All three patients have done well with no postoperative complications. The remainder of the patients requiring vascular surgery have been oper-
623
Table III. Associated neoplasia (six procedures) Operation
I
No.
Pulmonary resection Pneumonectomy Bilobectomy Wedge resection Radical nephrectomy Thymoma Colectomy
3
Table IV. Incidental (four procedures) Operation
I----N-O-.----
Epigastric hernia Incisional hernia
3 I
ated upon concomitantly because of fear of loss of life or limb should either procedure be performed separately. 3. The overlapping symptoms of hiatal hernia and coronary artery disease are well known. For this reason, in symptomatic patients with a large hiatal hernia, we have preferred to repair the hiatal hernia concomitantly. This aids us postoperatively in differentiating between the two pain syndromes. Certainly, from the patient's standpoint, it is advantageous to have a slightly more extensive single operation than to undergo two separate major surgical procedures. 4. In the group of patients with carcinoma, the need for concomitant surgery is obvious if feasible. We have individualized the approach to each patient, and in the three patients with pulmonary resection we have proved the absence of distal metastases preoperatively. This was also true in the patient with radical nephrectomy. We examined the patient with colon carcinoma in the company of a general surgeon. Laparotomy was performed before coronary bypass was begun, and definite resectability was ascertained. Only after ascertaining this information and absence of metastases to the liver did we approximate the abdominal wound with a wet dressing and towel clips. We then proceeded with coronary bypass in this patient who had severe preinfarction angina. After coronary bypass, colectomy was completed by the attendant general surgeon. REFERENCES Assad-Morell JL, Connolly DC, Brandenburg RO, Giuliani ER, Schattenberg TT, Pluth JR, Barnhorst DA, Wallace RB, Danielson GK: Aorta-coronary artery saphenous vein bypass grafts. Isolated and combined with other procedures. THORAC CARDIOVASC SURG 69:841-850, 1975 2 Bernhard VM, Johnson WD, Peterson 11: Carotid artery
624
Dalton et al.
stenosis. Association with surgery for coronary artery disease. Arch Surg 105:837-840, 1972 3 Okies JE, MacManus Q, Starr A: Myocardial revascularization and carotid endarterectomy. A combined approach. Ann Thorac Surg 23:560-563, 1977. 4 Sundt TM, Sandok BA, Whisnant JP: Carotid endarterec-
The Journal of Thoracic and Cardiovascular Surgery
tomy. Complications and preoperative assessment of risk. Mayo Clin Proc 50:301-306, 1975 5 Javid H, Tufo HM, Najafi H, Dye WS, Hunter JA, Julian OC: Neurologic abnormalities following open-heart surgery. J THoRAc CARDIOVASC SURG 58:502-509, 1969
Information for authors Most of the provisions of the Copyright Act of 1976 became effective on January 1, 1978. Therefore, all manuscripts must be accompanied by the following statement, signed by each author: "The undersigned author(s) transfers all copyright ownership of the manuscript entitled (title of article) to The C. V. Mosby Company in the event the work is published. The author(s) warrants that the article is original, is not under consideration by another journal, and has not been previously published. " Authors will be consulted, when possible, regarding republication of their material.