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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 11  |  Issue : 1  |  Page : 46-48
Simultaneous off-pump coronary artery bypass graft surgery and wide glossectomy


1 Department of Cardiac Anaesthesia, Prince Aly Khan Hospital, Mumbai, India
2 Department of Cardiovascular Surgery, Prince Aly Khan Hospital, Mumbai, India
3 Department of Oncology, Prince Aly Khan Hospital, Mumbai, India

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   Abstract 

Patients suffering with significant coronary artery disease undergoing elective noncardiac surgery may benefit by revascularisation prior to noncardiac surgery with high or intermediate risks. Alternatively, combined procedures can be performed. We describe the management of an anaesthetic patient suffering with significant coronary artery disease with left ventricular dysfunction and tumour of the tongue causing difficult intubation.

Keywords: Glossectomy, off-pump coronary artery bypass grafting

How to cite this article:
Bhojraj S, Jain S, Hamdulay Z, Kumar P, Ali M, Pradhan S. Simultaneous off-pump coronary artery bypass graft surgery and wide glossectomy. Ann Card Anaesth 2008;11:46-8

How to cite this URL:
Bhojraj S, Jain S, Hamdulay Z, Kumar P, Ali M, Pradhan S. Simultaneous off-pump coronary artery bypass graft surgery and wide glossectomy. Ann Card Anaesth [serial online] 2008 [cited 2019 Nov 17];11:46-8. Available from: http://www.annals.in/text.asp?2008/11/1/46/38450


Patients suffering with significant coronary artery disease undergoing elective noncardiac surgery may benefit by revascularisation prior to noncardiac surgery with high or intermediate risks. [1] Alternatively, combined procedures can be performed. [2],[3] Favourable outcomes depend upon the advanced perioperative monitoring and management. We present a case report of simultaneous off-pump coronary artery bypass (OPCAB) surgery and wide glossectomy in a patient with significant coronary artery disease and malignant lesion of the tongue causing difficult airway access.


   Case Report Top


A 57-year-old woman suffering with hypertension, diabetes, hypothyroidism and ischemic heart disease was scheduled to undergo wide glossectomy. Six years ago she had the carcinoma of buccal mucosa, for which she underwent left radical neck dissection and mandibulectomy. She had repeated episodes of left ventricular failure (New York Heart Association - class III) and required multiple admissions in the hospital. She currently presented with yet another primary malignant ulcer on the tongue for which she required wide glossectomy. On examination, she demonstrated a restricted opening of mouth with inter-incisor distance of less than 30 mm. Her electrocardiogram was suggestive of anteroseptal myocardial infarction in the past. Coronary angiogram revealed triple vessel disease with significant blocks in the left anterior descending (LAD), circumflex and right coronary arteries. Transthoracic echocardiogram showed severe left ventricular dysfunction with ejection fraction of 15-20% with moderate mitral regurgitation. The results of all laboratory investigations performed were within the normal limits. Haemoglobin level was 12 g/dL.

Her oral medications included 5 mg ramipril, 0.25 mg digoxin, 5 mg nicorandil, 200 mg amiodarone, 40 mg frusemide and 100 µ g thyroxine once and 500 mg metformin twice daily. Tablet metformin was discontinued prior to surgery and human insulin was administered subcutaneously thrice daily as per blood sugar level. All other medications were continued until the surgery. The preoperative heart rate was 72/min and blood pressure 118/76 mmHg. The surgical team decided to perform OPCAB grafting and glossectomy in the same sitting. The patient was premedicated with 1 mg lorazepam orally, 0.02 mg/kg midazolam and 1 µ g/kg fentanyl citrate intramuscularly 1 h prior to surgery. Electrocardiogram and pulse oximetry monitoring was commenced. In addition to the radial arterial cannula for the continuous measurement of the arterial pressure, an 8.5 F sheath was inserted in the femoral artery to facilitate the insertion of intraaortic balloon pump should the need arise. A 7.5 F pulmonary artery catheter was inserted through the right internal jugular vein via a 8.5 F sheath (Edwards Life Sciences, Irvine, CA, USA). All cannulations were performed under local anaesthesia. The arterial pressure was 134/78 mmHg and pulmonary capillary wedge pressure (PCWP) was 26 mmHg. Since the mouth opening was restricted, fiberoptic endotracheal intubation under light general anaesthesia was planned. Nasal mucosa was topically treated with phenylephrine drops and the patient was preoxygenated. General anaesthesia was administered intravenously with 0.05 mg/kg midazolam, 1 µ g/kg fentanyl citrate and 20 mg of propofol. Oxygen-air (50:50) mixture along with isoflurane 1% was 'insufflated' through the nasal airway. A bronchoscope of appropriate size was inserted through the other nostril. After visualising the vocal cords, they were sprayed with 4% xylocaine. A 7-mm endotracheal tube was 'rail roaded' over the bronchoscope into the trachea, while the patient breathed spontaneously. After insertion of the endotracheal tube, neuromuscular blockade was achieved by administering 8 mg of vecuronium intravenously. End-tidal carbon dioxide, urine output and nasopharyngeal temperature were monitored. Anaesthesia was maintained with oxygen-air (50:50) and isoflurane (0.5-0.75%). Midazolam (0.01 mg/kg/h), fentanyl (1 µ g/kg/h) and vecuronium bromide (0.02 mg/kg/h) were infused during the surgery, according to the institution's protocol. We planned to perform coronary revascularisation prior to glossectomy. Accordingly, coronary artery bypass surgery was performed via midsternotomy. After harvesting the conduits, heparinization was achieved with intravenous administration of 2 mg/kg of heparin. This resulted in an activated clotting time (ACT) of more than 250 s. Infusion of nitroglycerin 0.5-1.5 µ g/kg/min, diltiazem 1 mg/h [4] and nicorandil 1 mg/h were administered according to the institution's protocol. Dopamine (3 µ g/kg/min) and dobutamine (5 µ g/kg/min) were infused when necessary. The PCWP gradually decreased to 20 mmHg with time. The left internal mammary artery (LIMA) was grafted to the LAD artery, radial artery to the obtuse marginal-1 and a reverse saphenous vein grafted to the posterior descending artery. After anastomosis of LIMA to LAD, PCWP decreased to 18 mm Hg. Residual action of heparin was reversed with protamine sulphate in a l:1 ratio. After confirming the return of the preoperative ACT value, wide glossectomy was performed, by another team of surgeons. Normothermia was maintained during both the surgeries. Total duration of the procedure was 7 h during which the patient received 1500 ml of lactated Ringer's solution and 1000 ml of 6% hydroxyethyl starch. Total urine output during this period was 800 ml. Blood loss as estimated by gravimetric method was 600 ml (400 ml after OPCAB and 200 after glossectomy). The haemoglobin after surgery was 9 g/dL. Two units of packed cells were transfused in the postoperative period. The patient was extubated after 24 h of elective ventilation and discharged on the 7 th postoperative day.


   Discussion Top


Surgically treatable carcinoma of the tongue should be operated early. [5],[6] The patient in the present study had a second malignant lesion in the tongue. Patients undergoing elective noncardiac surgical procedures with high-risk coronary anatomy (proximal and severe LAD stenosis) and in whom long term outcome would be improved by coronary artery bypass grafting, should undergo revascularisation prior to the elective noncardiac surgical procedure with high or intermediate risk. The benefit derived from the revascularisation has been reported to be long lasting. [1] The patient in the present study demonstrated significant triple-vessel coronary artery disease with severe left ventricular dysfunction. The patient also demonstrated the major clinical predictors of increased perioperative cardiovascular risk, which are unstable coronary syndrome and decompensated heart failure. [1] Thus, it is justified to perform the coronary artery bypass surgery before noncardiac surgery. An ideal wait period of 4 weeks has been recommended for performing noncardiac surgery in a previously revascularized patient. [7] However, we performed glossectomy simultaneously to avoid the risk of spread of metastatic cells. [5],[6] OPCAB was considered because cardiopulmonary bypass has been observed to stimulate growth and spread of tumour. [7] The panendothelial injury associated with cardiopulmonary bypass surgery may promote tumour-cell binding to endothelial cells and extravasation. [8] In addition, the inflammatory process may result in high cytokine concentrations, which may promote tumour growth by stimulating angiogenesis, such substances include vascular endothelial growth factor. [9] OPCAB appears the technique of choice under such circumstances. [10] Blood conservation, prevention of pulmonary insufficiency and decreased incidence of multiple organ failure are some of the advantages associated with the avoidance of cardiopulmonary bypass. [11] The two surgeries may be combined to decrease the overall costs. Most reports on combined surgeries describe the use of the beating heart technique to be preferred more. [2],[3]

In the patient of the present study, OPCAB was performed prior to wide glossectomy. Induction and maintenance of anaesthesia were important issues because of the presence of severe triple-vessel disease and the difficulty anticipated in the endotracheal intubation. Fiberoptic intubation was performed under light general anaesthesia. The authors believe that using general anaesthesia to visualise the vocal cords by the fiberoptic equipment and intubate trachea is superior to the use of local anaesthesia because of lesser haemodynamic changes in the anaesthetised patients. Further, injection of topical anaesthetic via cricothyroid membrane, which may be necessary in fiberoptic intubation could be avoided in anaesthetised patients.

In conclusion, we describe the management of an anaesthetic patient suffering with significant coronary artery disease with left ventricular dysfunction and tumour of the tongue causing difficult intubation.

 
   References Top

1.Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery--executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 2002;39:542-53.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Saxena P, Tam RK. Combined off-pump coronary artery bypass surgery and pulmonary resection. Ann Thorac Surg 2004;78:498-501.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Akpinar B, Sanisoglu I, Guden M, Sagbas E, Caynak B, Bayramoglu Z. Combined off-pump coronary artery bypass grafting surgery and ablative therapy for atrial fibrillation: Early and mid-term results. Ann Thorac Surg 2006;81:1332-7.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.He GW, Yang CQ. Comparative study on calcium channel antagonists in the human radial artery-clinical applications. J Thorac Cardiovasc Surg 2000;119:94-100.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Myers, Suen. Carcinoma of the Head and Neck, 3 rd ed. W.B. Saunders and Co: New York; 1997. p. 338-40.  Back to cited text no. 5    
6.Chhetri DK, Rawnsley JD, Calcaterra TC. Carcinoma of the buccal mucosa. Otolarngol Head Neck Surg 2000;123:566-71.  Back to cited text no. 6    
7.Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: Summary article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation 2004;110:1168-76.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Edmunds LH Jr. Why cardiopulmonary bypass makes patients sick: Strategies to control the blood synthetic surface interface. Adv Card Surg 1995;6:131-67.  Back to cited text no. 8  [PUBMED]  
9.Dvorak HF, Detmar M, Claffey KP, Nagy JA, van de Water L, Senger DR. Vascular permeability factor /vascular endothelial growth factor: An important mediator of angiogenesis in malignancy and inflammation. Int Arch Allergy Immunol 1995;107:233-5.  Back to cited text no. 9  [PUBMED]  
10.Ochi M, Yamada K, Fuji M, Ohkubo N, Ogasawara H, Tanaka S. Role of off-pump coronary artery bypass grafting in patients with malignant neoplastic disease. Jpn Circ J 2000;64:13-7.  Back to cited text no. 10    
11.Lachat M, Vogt PR, Niederhauser U, Künzli A, Genoni M, Kunz M, et al. Minimally invasive coronary artery bypass techniques as adjunct to extracardiac procedures. Ann Thorac Surg 1997;63:S61-3.  Back to cited text no. 11    

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Correspondence Address:
Shilpa Bhojraj
Department of Cardiac Anaesthesia, Prince Aly Khan Hospital, Nesbit Road, Mazgaon, Mumbai - 400 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.38450

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