Eur J Cardiothorac Surg 2004;25:537-540
© 2004 Elsevier Science NL
Cardiac operations in patients with hematologic malignancies
Alison M. Fechera*,
Thomas J. Birdasb,
David Haybrona,
Pavlos K. Papasavasa,
Debbie Eversa,
Philip F. Caushaja
a Department of Surgery, Temple University School of Medicine Clinical Campus at the Western Pennsylvania Hospital, 4800 Friendship Ave, Pittsburgh, PA 15224, USA
b Department of Cardiothoracic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
Received 12 October 2003;
received in revised form 1 December 2003;
accepted 3 December 2003.
* Corresponding author. Tel.: +1-412-578-6880; fax: +1-412-578-1434
e-mail: afecher{at}wpahs.org
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Abstract
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Objectives: Patients with hematologic malignancies are frequently in need of major cardiac operations. Previous reports suggest an increased risk for perioperative complications in these immunodeficient patients. Methods: Patients diagnosed with any type of hematologic malignancy who underwent open-heart surgery at our institution between 7/1996 and 6/2002 were identified. Their hospital charts were reviewed; demographics, perioperative data and outcomes were recorded. Results: There were 24 patients (20 men, 4 women); mean age was 68±13 years (range 31–84 years). Ten patients had chronic lymphocytic leukemia, seven non-Hodgkin lymphomas, three multiple myeloma and one Hodgkin's disease, chronic myelocytic leukemia, hairy cell leukemia and cutaneous T-cell lymphoma each. The mean pre-operative duration of the hematologic disease was 6.6 years. Twenty-two patients underwent coronary artery bypass grafting (with valve replacement in three patients) and two patients had isolated valve replacement. There was one in-hospital death (4.1%). Twelve patients (50%) had a minor or major complication. Seven reoperations were required—five during the same admission (one for mediastinal bleeding, one for an expanding femoral pseudoaneurysm, one for acute cholecystitis and two for IACD/pacer insertion) and two within 30 days (one for deep sternal wound infection and one for leg wound infection). Mean post-operative stay was 8.2±5.8 days and mean ICU stay was 1.6±1.1 days. There were three late deaths—two were due to progression of the hematologic disease. The 3-year actuarial survival was 83%. Conclusions: Cardiac operations can be performed with acceptable mortality but significant morbidity rates in patients with hematologic malignancies. Bleeding and infectious complications are most frequently seen and usually lead to reoperations. These findings warrant caution during patient selection.
Key Words: Surgery • Cardiac • Coronary artery disease • Malignancies • Hematologic • Leukemia • Lymphoma • Complications
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1. Introduction
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It has been a common experience that the average age of the adult cardiac surgical population has increased over the last decade. Several series have reported cardiac operations in advanced age [1,2]. Patients with several comorbities commonly seen in older patients are now frequently considered for cardiac surgery. Malignancies of the hematopoietic system are encountered in all age groups, typically in the elderly population. This is particularly true for lymphocytic malignancies, such as chronic lymphocytic leukemias and lymphomas.
Patients with hematologic malignancies may be more immunosuppressed and therefore at an increased risk for infection and bleeding disorders [3]. The outcomes of cardiac surgical procedures in this subset of patients have not been well documented in the surgical literature [4–8]. We report our institutional experience over a 6-year period.
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2. Patients and methods
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The medical records of the Western Pennsylvania Hospital were retrospectively reviewed. From July 1996 to June 2002, 24 patients with one of several hematologic malignancies (Table 1) underwent open-heart surgery. The hematologic malignancy diagnosis was assigned based on ICD-9 coding. Their records were then analyzed for demographics, characteristics of the underlying hematologic malignancy, perioperative data and outcomes. The STS database template was used for data collection. Follow-up was obtained through review of subsequent hospital admissions and survival data were obtained from the SSDI.
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3. Results
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This patient group represented 0.38% (24/6258) of all patients undergoing open-heart surgery at our institution during the study period. The mean age of the 24 patients was 68+13.1 years. Sixteen patients were over 65 years of age. There were 20 men and 4 women.
Table 1 details the clinical data. The mean pre-operative duration for disease was 6.6 years.
Details of previous treatments related to the hematologic disease were available in 15 of the patients. Of those, 12 patients received some form of chemotherapy; four were treated with radiation therapy.
Table 2 details the perioperative data. Twenty-two patients underwent coronary artery bypass grafting (CABG) (along with valve replacement in three patients) and two patients had isolated valve replacements (one patient received a mitral valve and the other an aortic valve). An average of 3.6 grafts was placed in the 19 patients undergoing isolated CABG. Ten patients (10/19—52%) had left main disease and three patients required pre-operative intra-aortic balloon pump (IABP). All but one of these patients had an internal mammary artery (IMA) graft. Two of the 19 patients underwent off-pump CABG. Average stay in the ICU was 1.6+1.1 days. Mean post-operative stay was 8.2+5.8 days. One patient with T-cell lymphoma had acute cholecystitis 10 days after his CABG. He required an urgent open cholecystectomy and a return to the ICU for 1 day. One patient with a post-operative IABP stayed longer in the ICU due to the need to wean from the IABP, which resulted in a femoral pseudoanyeusm.
The two patients with a GI bleed also had return visits to the ICU. One patient with leukemia required plasmapheresis for 3 days due to high pre-operative white count of 251.7x109/l.
Table 3 details the complications. There was one in-hospital death from a GI bleed resulting in ischemic colitis and death. This same patient also required insertion of a pacemaker. In-hospital mortality was 4.1%. The morbidity was 50%—12 patients had minor or major complications. Six patients required seven subsequent operations: five during the same admission (one for mediastinal bleeding, one for an expanding femoral pseudoaneurysm, one for acute cholecystis and two for IACD/ pacer insertion) and two within 30 days (one for deep sternal wound infection and one for leg wound infection). One patient required two reoperations (exploration for bleeding and subsequent sternal debridement for mediastinitis).
We compared patients who developed complications with those who did not with respect to several perioperative factors. The results are shown in Table 4. No significant differences were identified, although it appeared that patients who developed complications were more likely to be older (P=0.06). The post-operative stay was significantly longer in patients who had complications (11.0±7.0 days vs. 5.3±1.7 days, P=0.01).
There were three late deaths—two were due to progression of the hematologic disease, at 31 and 48 months after surgery. The etiology of the third death, which occurred 4 months after surgery, was not identified. The 3-year actuarial survival was 83%.
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4. Comment
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Hematologic malignant diseases, especially of the lymphocytic type, mainly affect elderly patients. Over the past few years, treatment options have continued to improve and many of the patients afflicted with these disorders survive for several years. The need for cardiac surgery in this population is infrequent; indeed, only small case series have been previously reported [4–8]. The aim of this paper was to review our experience and examine the complications and outcomes in this patient population. From our results it appears that the expected perioperative mortality is acceptable (4.1%). Others have reported 30-day mortality rates ranging from 0 to 17% [5–7,9]. However, there was significant morbidity: 12 of 24 patients (50%) developed a post-operative complication. This is in agreement with prior reports [5–7] which cite complication rates between 23 and 57%. All previous reports focus mainly on infections as the main post-operative morbidity. In our experience, bleeding complications were more common (4 out of 12 of patients with complications). Another interesting observation is that 6 of 12 patients required a reoperation as a result of the complication. Not unexpectedly, the post-operative stay was longer in patients who developed a complication. Unfortunately, no predictive factors for identifying such patients were found.
A reasonable question would be whether these patients might benefit from less invasive techniques, such as off-pump CABG. In the present series only two of the 19 patients undergoing isolated CABG had an off-pump procedure. This most likely reflects the fact that early in our institutional experience the off-pump procedures were offered to patients requiring fewer grafts. In the 19 patients in our study who underwent isolated CABG, the average number of grafts was 3.6 per patient. It remains to be seen whether wider application of minimally invasive techniques will have more favorable results.
One of the limitations of the study involves the unavoidable selection bias: it is possible that other patients with hematologic malignancies and significant cardiac disease were not offered surgery, possibly due to high operative risk and/or advanced stage of their underlying malignancy. Nevertheless, we feel that reporting our current experience with this selected group of patients will help in future decision-making.
In conclusion, patients with hematologic malignancies can undergo cardiac operations with acceptable results. However, the high perioperative morbidity rates should be kept in mind during patient selection. It appears reasonable to consider alternative treatment options when the indications permit. Frequently, this was not the case, as seen by the increased incidence of patients with left main disease, who obviously would not do well with a non-operative treatment. If surgery is unavoidable, the expectations of the patients' families and treating physicians should be appropriately adjusted so that potential complications, including reoperations and prolonged hospital stay are not seen as unexpected outcomes.
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Footnotes
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Presented at the Joint 17th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 11th Annual Meeting of the European Society of Thoracic Surgeons, Vienna, Austria, October 12–15, 2003.
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Appendix A. Conference discussion
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Dr D. Birnbaum (Regensburg, Germany): Did you have any information on the patient data on those who had bleeding, and do you have an overview of the disturbances of the hematological systems in these patients?
Dr Fecher: The two people who had the GI bleeding did not have a significant pre-operative low platelet count or an elevated INR. It seemed to be not associated with that. The two patients that were bleeding were not within the same hematologic malignancy. One patient had CLL and one patient had non-Hodgkins.
Dr Birnbaum: Did you conclude for the future of these patients to take any particular measure before the operation?
Dr Fecher: Well, as I mentioned, the only thing that approached near significance was age, and I don't think you can really correct for that. These patients did seem to be sicker if they had a higher incidence of left main disease. I think the only thing that you need to be prepared for is if they do have a complication, often they will have to be reoperated on for that complication.
Dr M. Guida (Urb Prebo/Valencia, Venezuela): I would like to ask two questions. First of all, were those patients operated on off-pump or on-pump, the coronary patients?
And the second, looking at the deep wound sternal infection, was the possibility of avoiding median sternotomy in selective patients considered or not?
Dr Fecher: To your first question, 22 out of the 24 patients were all on-pump and only two were off-pump.
As to the question of whether or not the high risk patients should have a different type of incision, four patients did have radiation to the chest and none of those patients had any problems with their sternum. So I don't know, based on the amount of patients we had, if we have enough of a number to determine that.
Dr S. Silberman (Jerusalem, Israel): Did you find that heart surgery exacerbated their hematological disease?
Dr Fecher: No. From the data we have, it doesn't look like surgery exacerbated their condition. Two patients died of progression of their disease, over two years out of surgery, and I think it's hard to prove that surgery was the cause for that so far out.
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Abstract
1. Introduction
