Cardiac surgery
Long-term results after concomitant cardiac surgery and pulmonary resection

Introduction

Concomitant lesions of the heart and lung are uncommon [1], but when present they pose a challenge for cardiac and thoracic surgeons. Patients with lung cancer and heart disease are at high risk of postoperative death or severe cardiovascular complications. The optimal treatment for these patients is unclear and controversial. In 1978 Dalton [2] reported the first experience with a one-stage cardiac operation and lung resection. Several studies have found that either a combined or staged procedure is effective [3]. Regarding safety, cost, hospital stay, and delay in tumor management, each technique has its own benefits and drawbacks in treating these high-risk patients.

Aim of the study

The aim of this study was to review the early and long-term results of concomitant lung resection for cancer and other pulmonary diseases with simultaneous cardiac surgery.

Material and methods

This was a retrospective, observational study, which included prospectively collected data from consecutive patients who had undergone concomitant cardiac surgery and lung resection at a large tertiary university hospital during the 18 years between 1994 and 2012. The data collection forms were entered into a computerized department database, and the Ethics Committee of our Medical Center approved the use of our database as a source of information. In this period, 18 patients (14 men and 4 women, aged 49 to 85 years, mean age 69.6 years) with lung cancer or another lung disease and coronary disease and/or valve disorders were operated on.

All cardiac procedures were performed on cardiopulmonary bypass (CPB). Before initializing CPB, systemic heparinization was accomplished with a heparin dose of 400 U/kg. Additional heparin was administered during CPB to maintain an activated coagulation time of > 480 seconds. The mean arterial pressure was maintained between 60 and 80 mm Hg using boluses of phenylephrine as required. Serum glucose levels were controlled with intermittent administration of insulin. Hematocrit was maintained at 22% with the administration of packed red blood cells as necessary. Cardiac arrest was achieved by antegrade and/or retrograde blood cardioplegia. Topical cooling was not used, and core temperature was between 33° and 35°C. Prior to discontinuation of CPB patients were warmed to 37°C. Lung resection was performed immediately after completion of the cardiac procedure and after reversal of heparin. The approach to the heart and lung were through a median sternotomy.

Results

Twelve patients underwent coronary artery bypass grafting, 3 patients underwent aortic valve replacement, 2 patients underwent combined valve replacement and coronary artery bypass grafting, and 1 patient underwent aortic surgery. In all operations the cardiac procedure on extracorporeal circulation was followed by lung resection after reversing heparin. The pulmonary resections consisted of pneumonectomy in 1 patient, lobectomy in 6 patients, and a wedge excision in 11 patients. One patient underwent a completion lobectomy 3 weeks after the concomitant procedure [coronary artery bypass graft (CABG) + wedge resection]. Three patients with N2 disease received adjuvant chemotherapy.

Pathologic examination confirmed lung malignancy in 12 patients, adenocarcinoma (n = 7), squamous cell carcinoma (n = 3) and carcinoid (n = 2). Five patients were operated on for a non-oncologic pathology and 1 patient underwent lung volume reduction surgery (Table I).

One patient died 20 days after pneumonectomy due to multisystem organ failure. No patient needed re-exploration because of bleeding. Five patients (29%) developed atrial fibrillation in the early postoperative period. Mean ventilator support was 14.6 ±32.4 hours (range 4 to 480 hours) and mean ICU stay was 26.6 ±26.6 hours (range 14 to 480 hours). Mean hospital stay was 6.6 ±2.6 days (range 5 to 22 days).

Follow-up was obtained on all 18 patients. For the whole group of patients mean follow-up was 70.6 ±61.4 months (range 224 to 0.7 months) and the survival rate was 88% and 47% at 1 and 5 years, respectively. In the group of 12 patients with malignant lung disease mean follow-up was

56.2 ±43.8 months (range 120 to 0.7 months) and the survival rate was 92% and 42% at 1 and 5 years, respectively (Fig. 1). Three patients died because of recurrence of malignant disease, 1 after lobectomy and 2 after wedge resection.

Discussion

Concomitant operations are surgical procedures performed simultaneously on two or more sites for different unrelated diseases. The main purpose of these operations is to free the patient from several diseases simultaneously and to achieve a long-lasting remission or cure. Advances in surgical techniques, resuscitation and anesthesiology support over the years have allowed concomitant cardiac operations and lung resections to be performed for simultaneous heart and pulmonary disease. Danton and coworkers [4] presented their own results and reviewed 290 patients who were operated on in the years 1965-1997. Their study showed an immediate postoperative mortality between 0 and 6.7%, and 5-year survival for oncologic patients between 35% and 80%. More recently a number of nonrandomized studies [5, 6-15] have been published. In these studies (Table II) the results of 161 patients operated on in the years 1990-2011 were examined. Perioperative mortality and oncologic 5-year survival practically did not change, remaining at the level 0-6% and 9-86% respectively. As in our study, most operations [3, 10-16] were performed in one stage with the cardiac procedure followed by lung resection. Voets et al. [3] compared one-stage versus two-stage procedures and concluded that there was no difference between the two groups regarding mortality; however, greater perioperative risk makes concomitant procedures less attractive.

Ciriaco et al. [5] and Ambrogi et al. [6] reported 17 patients who had a two-stage procedure. Lung surgery was performed with a mean interval of 5 weeks after cardiac surgery. Ciriaco et al. [5] compared two-stage surgical revascularization with two-stage percutaneous coronary intervention (PCI) and pulmonary resection. There was no reported difference between the groups regarding mortality or complication rate. The problem after PCI is the need to receive long-term aspirin and IIb/IIIa inhibitors which can cause excessive bleeding, during an invasive procedure or cardiovascular events in case of cessation. Albaladejo et al. [17] reported that patients after PCI undergoing operations are at high risk of major bleeding (9.5%) or perioperative myocardial infarction including stent thrombosis (10.6%) irrespective of the stent type.

In patients with a recently implanted drug-eluting stent and high risk for stent thrombosis (e.g. within the first weeks after implantation) needing surgery, a ‘bridging strategy’ using tirofiban or eptifibatide may allow temporary withdrawal of oral clopidogrel without increasing the risk of bleeding [7, 8]. Guidelines on Myocardial Revascularization [9] also advocated this approach and do not recommend using low-molecular weight heparin.

Voets et al. [3] and Hosoba et al. [16] reported that a number of patients underwent a lung resection through a separate thoracotomy after the sternum was closed. Dyszkiewicz et al. [10, 14] and Saxena et al. [11] advocate concomitant one-stage off-pump coronary revascularization and lung resection. However, Schoenmakers et al. [12] found no significant difference in using an on-pump or off-pump technique to perform combined cardiac and lung surgery in relation to postoperative complications and hospital survival. In our series the decision to perform the operation off- or on-pump was made by the operating surgeon, but all isolated coronary artery bypass grafting (CABG) was performed on-pump, and it is not possible to compare the results, although off-pump technique may have advantages in this group of patients.

Zhang et al. [18] reported 86% 5-year survival in patients after concomitant resection of benign lung tumors, compared to 60% in our patients. One patient underwent AVR and lung volume reduction. Schmid et al. [19] reported 22% early postoperative mortality after concomitant cardiac surgery and lung volume reduction.

There are two main limitations of this study. First, we present observation retrospective analysis rather than a randomized control trial. This heterogeneous group of patients includes a mixture of pathologies such as coronary disease (13), valvular heart disease (5), aortic disease (1), lung cancer of different types (12), hamartoma (3), granuloma (2) and emphysema (1), and therefore our results must be interpreted with caution. Second, the difficulty with longitudinal studies such as ours is that overall mortality has been decreasing over time.

Conclusions

Lung resection carried out concomitantly with cardiac surgery is safe and effective. A combined one-stage procedure avoids the need for a second major thoracic procedure and may improve clinical outcome.

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