Anesthetic Management of a Patient Undergoing Minimally Invasive Myocardial Revascularization Before Lung Transplantation

[Perioperative treatment of a man receiving a left-lung transplant combined with coronary revascularization without use of extracorporeal circulation: with a brief review of pathophysiology and the literature]

Patients with significant coronary artery disease were once traditionally rejected as candidates for lung transplants because of higher risk of morbidity and mortality. We report the case of a man who received a left lung transplant and coronary revascularization without extracorporeal circulation in a combined surgical procedure after being diagnosed with significant coronary disease during the preoperative study for acceptance as a candidate for lung transplantation. We review the history of such combination procedures, which are changing clinicians' attitudes as to appropriate therapeutic approaches to take for complex patients. We also discuss the possible advantages of performing surgery without extracorporeal circulation. To our knowledge, this is the first report of a combined procedure that took place in a Spanish hospital.

Different CABG methods in patients with chronic obstructive pulmonary disease

BACKGROUND

Pulmonary dysfunction is still a major problem in coronary artery bypass grafting (CABG). The purpose of this randomized study was to determine the effect of different CABG techniques on pulmonary function.

METHODS

Fifty eight patients with severe obstructive pulmonary disease had elective isolated coronary surgery. The surgical methods for the patients with chronic obstructive pulmonary disease (COPD) were standard CABG in 18 patients (group 1), beating heart surgery in 19 patients (group 2), and minimally invasive direct coronary artery bypass grafting (MIDCABG) in 21 patients (group 3).

RESULTS

The earliest extubation time was from group 3 (p < 0.001). The average stay in the intensive care unit was significantly longer in group 1 (2.6 +/- 1.5 days) than in groups 2 (1.4 +/- 0.8 days) and 3 (1.1 +/- 0.8 days) (p < 0.05). The most prevalent respiratory morbidity was atelectasis that developed in 6 patients from group 1, in 2 patients from group 2, and in 3 patients from group 3. Forced expiratory volumes in 1 second (FEV1) obtained in the second postoperative month were significantly lower than preoperative values only in group 1 (p < 0.05). Forced vital capacity (FVC) values were significantly lower than the preoperative values in all three groups (p < 0.05).

CONCLUSIONS

Off-pump bypass surgical procedures are more advantageous than on-pump methods for patients with COPD. These patients can be operated on using the beating heart technique or by using MIDCABG to prevent side effects of CPB on pulmonary function and effects of sternotomy.

[Minimally invasive cardiac surgery: surgical techniques and anesthetic problems]

OBJECTIVE

To review current data on minimally invasive cardiac surgery.

DATA SOURCES

Search through the Medline data base of French or English articles.

DATA EXTRACTION

The articles were analysed to make a synthesis of the various techniques with their main indications and contra-indications.

DATA SYNTHESIS

Minimally invasive cardiac surgery includes various surgical procedures. The usual techniques are described, their major benefits and drawbacks are discussed. The main goals of anaesthetic management are preservation of ventricular function and systemic perfusion, detection and treatment of myocardial ischaemia, prevention of hypothermia in case of coronary artery bypass grafting on the beating heart via sternotomy, intermittent selective ventilation of the collapsed lung using CPAP in case of limited thoracotomy. Expertise in transoesophageal echocardiography is essential for insertion and checking the accurate positioning of the various catheters of the endovascular CPB Heartport system (pulmonary vent, endosinus catheter, venous cannula, endoaortic clamp) allowing coronary artery bypass grafting and mitral valve surgery through limited thoracotomy and finally, detection of retained intracardiac air and assessment of complete clearing of cardiac cavities after mitral valve surgery through limited thoracotomy and aortic valve surgery via ministernotomy. Short-acting anaesthetic agents allow rapid recovery from anaesthesia, early extubation and discharge to the surgical ward within 24 h, whereas overall time spent in the operating room is often longer than with conventional cardiac surgery.