Urgent off-pump coronary artery bypass grafting in a patient with HIV

Urgent Off-Pump Coronary Artery Bypass Grafting in a Patient With HIV Mitsuhiro Kawata, MD, Kazuhiko Higuchi, MD, Kenji Koseni, MD, and Hiroyuki Tsukihara, MD Department of Cardiac Surgery, Asahi General Hospital, Asahi City, Chiba, Japan

We report a case of successful urgent off-pump coronary artery bypass grafting (CABG) for unstable angina pectoris in a 54-year-old human with human immunodeficiency virus (HIV) infection. We studied the changes in CD4ⴙ cells and HIV-RNA copy during the perioperative period. The results showed that off-pump CABG did not reduce the CD4ⴙ cell count and did not affect the condition of HIV infection in this patient. (Ann Thorac Surg 2004;77:2189 –90) © 2004 by The Society of Thoracic Surgeons

T

he effects of conventional coronary artery bypass grafting (CABG), using a cardiopulmonary bypass (CPB) in human immunodeficiency virus (HIV) carriers and in patients with acquired immunodeficiency syndrome (AIDS), have been reported [1–3]. But no case of off-pump (CABG) in an HIV carrier has been reported until now. We report the successful treatment of a case of HIV, using an off-pump CABG. The CD4⫹ cell count and the HIV-RNA copy were used as markers of immune system status and infection during the perioperative period, and comparisons were made with reported levels of these markers after a conventional CABG. A 54-year-old human was admitted to our hospital because of unstable angina pectoris. Emergency coronary angiography was performed immediately on admission, and revealed a left-dominant system with a small right coronary artery and severe multivessel coronary artery disease with critical stenoses in the left main trunk and in the left anterior descending, first diagonal, and high lateral branches. Laboratory data showed no evidence of acute myocardial infarction. However, the electrocardiogram and the echocardiogram revealed an old myocardial infarction in the inferior wall. Catheter intervention was ruled out because the lesions included critical left main trunk stenosis and a small right coronary artery. A preoperative blood test showed the patient to be HIV positive. Before admission, he had not been diagnosed as being an HIV carrier. The CD4⫹ cell count was 301/␮L and the HIV-RNA copy was 2.5 ⫻ 104/mL. There was not enough time to administer antiretroviral agents for HIV infection control because of the recurrence of chest pain attacks. Urgent off-pump CABG was performed. The left internal mammary artery was used as an autograft for the left anterior descending artery, and the right gastroepiploic Accepted for publication June 6, 2003. Address reprint requests to Dr Kawata, Department of Cardiac Surgery, Asahi General Hospital, I-1326 Asahi City, Chiba 289-2511, Japan; e-mail: [email protected].

© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc

CASE REPORT KAWATA ET AL URGENT OFF-PUMP CABG IN PATIENT WITH HIV

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artery for the left posterolateral artery. Universal precaution protocols were followed at all times and all places. The operation was carried out in safe conditions. The CD4⫹ cell count and the HIV-RNA copy were evaluated immediately after the operation on the first to the sixth postoperative days (POD), and then 4 and 8 weeks after the operation. Table 1 shows that the CD4⫹ cell count and HIV-RNA copy of this patient did not change significantly during the perioperative period. The postoperative course was uneventful and satisfactory. Routine antibiotic prophylaxis was administered for 1 week. The patient was discharged on the 11th POD in good condition. At a 12-week follow-up, he was doing well. We explained our intended treatment and study procedures to the patient and obtained his consent before commencing.

Comment HIV impairs cell-mediated immunity: T-lymphocytes, especially CD4⫹ cells, decrease in number. The immune status of an HIV-positive patient is evaluated by the CD4⫹ cell count, and the severity of an HIV infection is evaluated by the HIV-RNA copy; these two variables are determined as markers for predicting disease progression in HIV carriers or AIDS patients. The immunosuppressive effects of a CPB, and of the surgical procedure itself, are thought to aggravate the condition of HIV-positive patients. The effects of conventional CABG, using CPB in HIV carriers and in patients with AIDS, have been reported [1–3]. Flum and colleagues 3 stated that statistically significant reductions in T-lymphocyte counts were seen in all HIV-positive patients who underwent conventional CABG. The prognosis is reported to be strongly influenced by the patient’s preoperative condition. If the patient’s HIV infection has been well-controlled by antiretroviral therapy before the operation, a conventional CABG can be performed with good results [1, 2]. In their cases, it was evident that if the HIV-RNA copy was well-controlled to an almost undetectable level preoperatively, it tended to remain undetectable after surgery. Preoperative antiretroviral therapy may have greatly improved the postoperative courses. By contrast, we found in our case that the CD4⫹ cell count did not change during the perioperative period, or at the 4-week or 8-week follow-ups. The CD4⫹ cell count made immediately before surgery was 301/␮L, which was similar to the counts of those suitably treated preoperatively with antiretroviral agents. On the other hand, our patient’s immediately preoperative HIV-RNA copy was 2.5 ⫻ 104/mL. This result was higher than those reported in previous studies because the patient had not been treated with antiretroviral agents before surgery. Nevertheless, the HIV-RNA copy showed no increase during the perioperative period or at the 4- or 8-week follow-up. These findings suggest that an off-pump CABG may have the advantage over a conventional CABG: that it does not suppress cell-mediated immunity, and does not increase the effects of HIV on the patient’s body. If the preoperative condition of the patient had allowed us to treat him before surgery with antiretroviral agents for 0003-4975/04/$30.00 doi:10.1016/S0003-4975(03)01257-8

CASE REPORTS

Ann Thorac Surg 2004;77:2189 –90

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CASE REPORT SRINIVASAN ET AL ROUNDED ATELECTASIS AFTER CORONARY SURGERY

Ann Thorac Surg 2004;77:2190 –2

Table 1. Changes in CD4⫹ Cells and HIV–RNA Copy CD4⫹(␮/L) HIV–RNA copy (⫻ 104/mL)

Pre-op

Op

1 POD

2 POD

3 POD

4 POD

5 POD

6 POD

4 week

8 week

301 2.5

242 1.2

381 1.9

281 4.0

243 2.0

201 2.0

216 2.4

161 2.8

314 1.5

437 7.1

CD4⫹ ⫽ cluster differentiation; day; Pre-op ⫽ pre-operative.

HIV-RNA ⫽ human immunodeficiency virus-ribonucleic acid;

CASE REPORTS

HIV infection, we should have done so. However, this was not possible and the operation had to be performed with urgency. For patients with coronary artery disease, we usually select off-pump CABG as the first-choice surgical procedure in order to avoid cerebrovascular events caused by establishing a CPB and cross-clamping the ascending aorta. We therefore selected an off-pump CABG in this case. An off-pump CABG is safe for the medical staff to perform, because the patient’s blood does not pass through an extracorporeal circuit. The risk of infection by contact with the patient’s blood is thus minimized. In conclusion, for HIV-positive patients suffering from unstable angina, especially in cases in which preoperative antiretroviral therapy is insufficient, off-pump CABG may well be the technique of preference. Studies involving larger numbers of patients and longer follow-up periods will be necessary to confirm this impression.

References 1. Mahan VL, Balaguer JM, Pezzella AT, et al. Successful coronary artery bypass surgery in a patient with AIDS. Ann Thorac Surg 2000;70:1698 –9. 2. Imanaka K, Takamoto S, Kimura S, et al. Coronary artery bypass grafting in patient with human immunodeficiency virus: role of perioperative active anti-retroviral therapy. Jpn Circ J 1999;63:423–4. 3. Flum DR, Tyras DH, Wallack MK. Coronary artery bypass grafting in patients with human immunodeficiency virus. J Card Surg 1997;12:98 –101.

Two Cases of Rounded Atelectasis Presenting After Coronary Artery Surgery Arun K. Srinivasan, MD, John A. Holemans, FRCR, and Richard D. Page, FRCS(CTh) Departments of Thoracic Surgery and Radiology, The Cardiothoracic Centre, Thomas Drive, Liverpool, United Kingdom

Rounded atelectasis developed in two patients after coronary artery bypass grafting. Although both lesions led to the suspicion of a primary pulmonary tumor on initial assessment, malignancy was excluded by biopsy and radiologic observation in the first patient and excision biopsy in the second. (Ann Thorac Surg 2004;77:2190 –2) © 2004 by The Society of Thoracic Surgeons Accepted for publication June 6, 2003. Address reprint requests to Dr Page, The Cardiothoracic Centre, Thomas Drive, Liverpool L14 3PE, UK; e-mail: [email protected].

© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc

Op ⫽ operation;

POD ⫽ post-operative

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ounded atelectasis is a rare form of lung collapse. It usually presents as an incidental finding on a chest roentgenogram but can present with dyspnea. A limited decortication may be necessary to ensure full-lung expansion and to exclude other pathologies in some patients. Asymptomatic lesions can be observed radiologically without intervention. We describe two patients with rounded atelectasis, who fall into each of these two groups, and good examples of each treatment plan.

Case Reports Patient 1 A 70-year-old male underwent coronary artery bypass grafting (CABG). Two years later, although he was asymptomatic, chest roentgenogram and computed tomographic (CT) scan revealed a persistent right pleural effusion and a right cardiophrenic angle mass (Figure 1, panels 1A and 1B). He was a nonsmoker and was not exposed to asbestos. Percutaneous biopsy and bronchoscopy were unhelpful. On repeat CT 2 months later the mass and effusion had become smaller. Twelve months later he remains well and the mass continues to resolve radiologically.

Patient 2 A 71-year-old ex-smoker underwent uneventful CABG. On follow-up 6 months after surgery dyspnea and cough developed. Chest roentgenogram showed an opacity at the left base and left-sided pleural effusion. Aspiration of the fluid was nonspecific. A CT scan showed a left lower lobe mass 3 cm in diameter involving the visceral pleura with smooth thickening of the parietal pleura and an adjacent small loculated pleural effusion (Figure 1, panels 2A and 2B). The options of percutaneous biopsy, surgical resection, or radiologic observation were discussed and after being advised of the possibility of malignancy the patient chose to have a thoracotomy. At surgery the left pleural cavity was obliterated by adhesions with a loculated basal pleural effusion. There was gross thickening of the visceral and the parietal pleurae and a vague mass was palpable in the lung. A wedge resection of the abnormal area was performed, frozen section of which showed no evidence of malignancy. A limited decortication was carried out and after removing the adhesions and draining the fluid the lung expanded fully. Paraffin sections of the specimen showed dense, fibrotic, folded pleura, with collapse and fibrosis of subpleural lung. There was no evidence of neoplasia either in the resected specimen or in the cytology of the effusion 0003-4975/04/$30.00 doi:10.1016/S0003-4975(03)01431-0