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Eur J Cardiothorac Surg 2001;19:362-364
© 2001 Elsevier Science NL

Case report

Coronary artery bypass grafting after pneumonectomy

Karim A. Diab, Mohamad F. Khatib, Mounir Obeid, Ghassan W. Jamaleddine

Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon

Received 11 September 2000; received in revised form 30 November 2000; accepted 29 December 2000.

Corresponding author. Department of Internal Medicine, American University of Beirut Medical Center, P.O. Box 113-6044, Beirut, Lebanon. Tel.: +961-1-353465; fax: +961-1-744464
e-mail: ghassanj{at}aub.edu.lb


   Abstract
Top
 Abstract
1. Introduction
 2. Case report
 3. Discussion
 References
 
The need to perform coronary artery bypass grafting in patients who have a single lung is not uncommon. To date, the safety of such procedures has not been well documented. In this article, we review the literature using the Medline 1966 to September 2000 database to identify patients with pneumonectomy who underwent coronary artery grafting and we provide a compilation of all reported cases. We also present an additional case in whom the use of nasal bilevel positive airway pressure was beneficial in preventing postoperative pulmonary complications.

Key Words: Cardiac surgery • Coronary artery bypass • Pneumonectomy • Mechanical ventilation


   1. Introduction
Top
 Abstract
 1. Introduction
2. Case report
 3. Discussion
 References
 
Pneumonectomy is associated with physiologic changes that interfere adversely with pulmonary function. The fact that post-pneumonectomy patients occasionally require major operations, particularly open-heart surgery, raises a question about the risks and safety of such procedures.

The risk of performing coronary artery bypass grafting (CABG) on a patient with a single lung is unclear from the literature. In this report, we reviewed the literature on patients with a single lung who underwent CABG. In addition, we report a case in which CABG was carried out 6 years after the patient had undergone pneumonectomy.


   2. Case report
Top
 Abstract
 1. Introduction
 2. Case report
3. Discussion
 References
 
A 64-year-old diabetic man with a history of right pneumonectomy 6 years prior to presentation was admitted with unstable angina. The patient was an ex-smoker with 130 pack-years. An electrocardiogram revealed left anterior hemiblock. An echocardiogram showed hypokinesia of the posterobasal and inferior segments of the left ventricle. Cardiac catheterization revealed severe triple-vessel disease. Arterial blood gases showed normal pH (7.38), mild hypercapnea (PaCO2=46 mmHg) and hypoxemia (PaO2=68 mmHg). Pulmonary function tests revealed severe restrictive disease consistent with a history of pneumonectomy. After several days of vigorous chest physiotherapy and bronchodilation, the patient underwent CABG with the use of the right saphenous vein. He was extubated on the first day post-operation but he developed CO2 retention (PaCO2=65 mmHg) that necessitated re-intubation on the second day. Flow-by was added to the mode of ventilation. The effort required for him to breath decreased and he was extubated 70 h post-operation. As he redeveloped respiratory failure with an increase in PCO2, nasal bilevel positive airway pressure (BiPAP; Respironics Inc.; Murrysville, PA) was started at 10/3 cm H2O. His shortness of breath and hypoventilation improved markedly, and he was gradually weaned off BiPAP over 2 days. The patient was discharged home with no BiPAP.


   3. Discussion
Top
 Abstract
 1. Introduction
 2. Case report
 3. Discussion
References
 
Patients with pneumonectomy always present a challenge when they need to undergo thoracic surgery, and in particular CABG. These patients are predisposed perioperatively to a much higher risk of cardiopulmonary complications. Even frequently encountered consequences of surgery such as atelectasis, congestion, and nosocomial infection could lead to lethal outcomes in these patients. No prospective study has been done to evaluate the morbidity and mortality on pneumonectomized patients undergoing CABG.

Using the Medline 1966 to September 2000 database, a review of the literature identified six reported cases of patients who underwent CABG after pneumonectomy (Table 1) [1–6]. All reported patients were elderly with a mean age of 65.6 years. In the entire series, the mortality was 14.3% (1/7 patients). The mean time for successful extubation in all cases was 33.8 h post-operation. The mean interval time between performing pneumonectomy and CABG surgery was 21.7 years.


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  		Table 1. Clinical and laboratory data on patients with pneumonectomy who underwent CABG

 
It is worthwhile noting that no death resulted from respiratory failure despite the compromised pulmonary function in these patients. Pulmonary complications occurred in 42.8% of patients, with pneumothorax being the most common (2/7 patients or 28.6%). Re-intubation was needed in two cases. The patient we reported developed CO2 retention with respiratory failure and was re-intubated on the second postoperative day. He was weaned off successfully to room air after the use of nasal BiPAP.

Pulmonary complications in patients undergoing CABG can result from diaphragmatic dysfunction secondary to a compromise of blood perfusion to the diaphragm, as well as from alterations in chest wall mechanics due to the surgical incision. Van Belle et al. [7] reported a significant impairment in pulmonary function post-CABG and demonstrated that respiratory muscle weakness contributed to this immediate postoperative restrictive lung function loss.

Pulmonary insufficiency post-CABG can also result from other factors than respiratory muscle disturbances, such as lung edema, which is a potential consequence of cardiopulmonary bypass (CPB). The use of CPB in patients with a single lung may increase the risk of cardiac surgery. Although this has not been used in any of the reported cases, it would be interesting in such patients to assess the benefit of off-pump CABG in reducing postoperative respiratory dysfunction by avoiding CPB. Off-pump CABG has been shown in previous reports to reduce morbidity and hospital stay in high risk and elderly patients [8].

The use of IMA versus SV grafts is also of concern in patients with a single lung. Despite previous reports of increased pulmonary morbidity in patients who had IMA grafts compared to those who had SV grafts, a recent study [9] indicates that the use of one or two IMA grafts does not increase respiratory dysfunction compared to the use of vein grafts. In the pneumonectomized patients we reviewed, those who underwent IMA grafts (2/7 patients) did not have a higher incidence of respiratory failure compared to those who received SV grafts alone (5/7 patients). However, in patients with pneumonectomy, it is prudent to avoid IMA harvest on the side of the intact lung to prevent serious consequences of phrenic nerve injury. In both reported patients who had IMA grafts, these grafts were performed on the same side of pneumonectomy.

On the other hand, the use of thoracic epidural anesthesia during CABG in pneumonectomized patients might also be of potential benefit in shortening the time of intubation. This procedure, though not tried in any of the reported cases, has been used in patients undergoing CABG to facilitate early extubation [10].

In summary, patients with pneumonectomy who undergo CABG are at increased risk for postoperative complications. At the present time, based on the available data published in the literature, we believe that a previous pneumonectomy is not a contraindication to CABG. With optimal preoperative chest physiotherapy and bronchodilation, and adequate postoperative management including the use of noninvasive mechanical ventilation, CABG can be performed in these patients with a single lung with acceptable morbidity and mortality.


   References
Top
 Abstract
 1. Introduction
 2. Case report
 3. Discussion
 References
 

  1. Berrizbeita L.D., Anderson W.A., Laub G.W., McGrath L.B. Coronary artery bypass grafting after pneumonectomy. Ann Thorac Surg 1994;58:1538-1540.[Abstract]
  2. Soltanian H., Sanders J.H., Robb J.C., Marrin C.A. Hybrid myocardial revascularization after previous left pneumonectomy. Ann Thorac Surg 1998;65:259-260.[Abstract/Free Full Text]
  3. Medalion B., Elami A., Milgalter E., Merin G. Open heart operation after pneumonectomy. Ann Thorac Surg 1994;58:882-884.[Abstract]
  4. Shibata T., Suehiro S., Kimura E., Nishizawa K., Minamimura H., Kinoshita H. Coronary artery bypass grafting 13 years after pneumonectomy. Nippon-Kyobu-Geka-Gakkai-Zasshi 1994;42(7):1105-1107.
  5. Lecharpentier Y., Zerr C., Merrille C., Lebreton P., Khayat A. Chirurgie cardiaque chez deux patients anterieurement pneumonectomises. Cah-Anesthesiol 1988;36:645-647.
  6. Demirtas M.M., Akar H., Kaplan M., Dagsali S. Coronary artery bypass operation after pneumonectomy. Ann Thorac Surg 1995;60:232-233.[Free Full Text]
  7. Van Belle A.F., Wesseling G.J., Penn O.C., Wouters E.F. Postoperative pulmonary function abnormalities after coronary artery bypass surgery. Resp Med 1992;86:195-199.[Medline]
  8. Koutlas T.C., Elbeery J.R., Williams J.M., Moran J.F., Francalancia N.A., Chitwood W.R., Jr. Myocardial revascularization in the elderly using beating heart coronary artery bypass surgery. Ann Thorac Surg 2000;69:1042-1047.[Abstract/Free Full Text]
  9. Taggart D.P. Respiratory dysfunction after cardiac surgery: effects of avoiding cardiopulmonary bypass and the use of bilateral internal mammary arteries. Eur J Cardio-thorac Surg 2000;18:31-37.[Abstract/Free Full Text]
  10. Joachimsson P.O., Nystrom S.O., Tyden H. Early extubation after coronary artery surgery in efficiently rewarmed patients: a postoperative comparison of opioid anesthesia versus inhalational anesthesia and thoracic epidural analgesia. J Cardiothorac Anesth 1989;3:444-454.[Medline]



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