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    Abstract
   Introduction
   Case Reports
   Discussion
    References

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Table of Contents
CASE REPORT  
Year : 2013  |  Volume : 16  |  Issue : 1  |  Page : 47-50
Management of patients with hematological malignancies undergoing coronary artery bypass grafting


1 Department of Cardiac Anesthesia, P.D. Hinduja National Hospital and Medical Research Centre, Mahim Fortis Hospitals, Mulund, Lilavati Hospital, Bandra, Mumbai, Maharashtra, India
2 Department of Cardiothoracic Surgery, P.D. Hinduja National Hospital and Medical Research Centre, Mahim Fortis Hospitals, Mulund, Lilavati Hospital, Bandra, Mumbai, Maharashtra, India

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Date of Submission10-Apr-2012
Date of Acceptance12-Oct-2012
Date of Web Publication2-Jan-2013
 

   Abstract 

The number of patients with a previously diagnosed malignancy who need cardiac surgery is increasing. Patients with hematological malignancies represent only 0.38% of all patients undergoing cardiac surgery. The literature in this subset of patients is limited to only a few retrospective case series, with limited number of patients undergoing emergency cardiac surgery. We describe three cases with hematological malignancies namely chronic myelogenous leukemia, acute promyelocytic leukemia and chronic lymphocytic leukemia presenting for coronary artery bypass grafting (CABG). Two patients were taken up for emergency CABG in view of ongoing ischemia, one of them was on preoperative intra-aortic balloon pump support. No mortality was observed. Two patients needed transfusion of blood products which was guided by thromboelastography. One patient developed superficial sternal wound infection requiring antibiotic therapy.

Keywords: Acute promyelocytic leukemia (AML-M3), Chronic myelogenous leukemia, Chronic lymphocytic leukemia, Coronary artery bypass grafting, Hematological malignancy

How to cite this article:
Borde D, Gandhe U, Hargave N, Pandey K. Management of patients with hematological malignancies undergoing coronary artery bypass grafting. Ann Card Anaesth 2013;16:47-50

How to cite this URL:
Borde D, Gandhe U, Hargave N, Pandey K. Management of patients with hematological malignancies undergoing coronary artery bypass grafting. Ann Card Anaesth [serial online] 2013 [cited 2019 May 27];16:47-50. Available from: http://www.annals.in/text.asp?2013/16/1/47/105370



   Introduction Top


The number of patients with a previously treated malignancy undergoing cardiac surgery is increasing. Patients with hematological malignancies represent only 0.38% of all patients undergoing cardiac surgery. [1] The literature of cardiac surgical procedures in this subset of patients is limited to only a few retrospective case series. [1],[2],[3],[4],[5],[6] We present three patients with various hematological malignancies undergoing coronary artery bypass grafting (CABG).


   Case Reports Top


Case 1

A 63 year old woman was admitted with acute chest pain. Significant medical history included steroid supplementation for Addison's disease since many years and hypothyroidism since two years. She was diagnosed with acute coronary syndrome (ACS) and started on antiplatelet drugs and low molecular weight heparin (LMWH). Hematological investigation revealed a total leukocyte count (TC) of 1,50,000/μL. After hematologist's opinion and investigations (BCR-ABL fusion, Ph chromosome: t (9; 22) positive), a diagnosis of chronic myelogenous leukemia (CML) was made. Treatment was initiated with oral hydroxyurea 500 mg twice a day. Patient's coronary angiogram (CAG) revealed triple vessel disease (TVD) with lesions in proximal left anterior descending and circumflex artery. A decision of CABG after remission of CML was taken. Patient was re-admitted eight days later with anterior wall myocardial infarction with ST elevation (STEMI) in leads V1-3, aVR and reciprocal ST segment depression in inferior leads. Cardiac biomarkers were elevated, creatine kinase MB isoform (CKMB) was 38 μg/L, troponin T was 0.21 μg/L. She was thrombolysed with intravenous tenecteplase 30 mg. Chest pain recurred within 3 hours and ECG showed STEMI in leads V1-3. In view of failed thrombolysis and ongoing ischemia as evidenced by unstable angina, ECG changes and elevated cardiac biomarkers, intra-aortic balloon pump (IABP) was inserted through right femoral artery. She was taken up for emergency CABG in six hours from insertion of IABP. Her preoperative workup revealed ejection fraction (EF) of 40% with Type II left ventricular diastolic dysfunction (LVDD), hemoglobin (Hb)-12.9 gm%, white cell count (TC)-59,300/μL, platelet count-5,91,000/μL, prothrombin time-INR-1.15, ACT-170s, serum creatinine-1.1mg/dL, TSH-3.75 U/dL, serum cortisol <1 μg/dL, EuroSCORE II was 12.15%.

General anesthesia was induced with midazolam (0.04 mg/kg), fentanyl (2 μg/kg), etomidate (0.4 mg/kg) and rocuronium (0.9 mg/kg) and maintained with sevoflurane and titrated infusions of midazolam, fentanyl and rocuronium. Injection methyl prednisolone 500 mg was given as a single bolus after induction as per protocol. Antibiotic prophylaxis was given with cefazolin and teicoplanin. The cardiopulmonary bypass (CPB) was established with aorto-caval cannulation after heparin administration 300 U/kg and achieving an ACT-540s. Normothermia was maintained all throughout. Roller pump and membrane oxygenator was used during CPB. Two grafts were performed. Right coronary artery was non-dominant, small and non graftable. Total CPB and aortic cross clamp (ACC) times were 98 and 27 minutes, respectively. Thromboelastography (TEG) revealed coagulation factor deficiency and platelet dysfunction (R = 15 minutes, α angle 38°, MA = 45 mm). Four units each of fresh frozen plasma and platelets were transfused. Threshold hemoglobin level for packed red blood cells (PRBC) transfusion was ten in view of recent MI. Two units of PRBCs were transfused in ICU with chest tube drainage of 500 mL in 24 hours. On postoperative day (POD) 1, the investigations showed Hb-11.5 gm%, TC-18,120/μL and platelet count-2,26,000/μL. The patient was weaned off ventilator in 14 hours. IABP support was tapered after 24 hours. Care was taken to maintain normovolemia guided by pulmonary artery wedge pressure and maintain mean arterial pressure more than 60 mmHg. Patient was shifted out of ICU on POD 3 with Hb-9 gm%, TC-23,100/μL, platelet count-2,26,000/μL, and serum creatinine-1.4mg/dL. She was discharged on POD 7 after an uneventful course.

Case 2

A 47 year old female, denying any medical disease was admitted with a history of petechial rashes, gum bleeding and ecchymosis. Bone marrow examination revealed acute promyelocytic leukemia (AML-M3) with chromosomal translocation t (15;17). She was started on induction phase of chemotherapy with all-trans retinoic acid (ATRA). On post-induction day 4, she developed unstable angina with raised cardiac enzymes. CAG showed severe triple vessel disease with left main coronary artery showing 80% narrowing. Two-dimensional transthoracic echocardiography (2D TTE) revealed EF of 55% with Type I LVDD. She was scheduled for an emergency CABG. Preoperative workup revealed Hb-9.2 gm%, TC-2,200/μL, platelets-86,000/μL, PT-INR-1.5 and serum creatinine-0.7 mg/dL. Anesthesia and CPB technique were similar to the previous case. One unit PRBC was added to the CPB prime to maintain hematocrit around 24%. Four vessel CABG was performed. CPB and ACC times were 95 and 61 minutes, respectively. She was weaned off CPB with adrenalin 0.04 μg/kg/min infusion. Post CPB, one single donor platelet, four cryoprecipitate and two PRBC units were transfused as guided by TEG (R = 12 minutes, α angle 40°, MA = 42 mm). Postoperative investigations showed Hb-11.6 gm%, TC-3,300/μL, platelet count-1,01,000/μL, and serum creatinine-0.9 mg/dL. She was extubated after 24 hours. The chest tube drain was 475 ml in 24 hours. Chemotherapy was restarted on POD 1. She was shifted out of ICU on the POD 4. No thrombotic or hemorrhagic complications were observed during her postoperative stay. Patient developed superficial sternal wound infection as evidenced by sternal tenderness and discharge from wound but sternal stability was maintained. She required prolonged hospital stay in view of her antibiotic therapy and chemotherapy for AML.

Case 3

A 65 year old male, a treated case of chronic lymphocytic leukemia (CLL) 3 years back presented for elective CABG for stable angina after positive stress test for inducible ischemia. His CAG revealed TVD, 2-D TTE revealed EF of 41%, Type I LVDD and mild MR. His preoperative investigations showed Hb-11.9 gm% TC-30,000/μL, platelet count-2,62,000/μL, and serum creatinine-1.22 mg/dL. Anesthesia and CPB technique were similar to previously described cases. Four vessel CABG was performed. CPB and ACC times were 95 and 53 minutes, respectively. Patient was extubated after 24 hours. The total chest tube drainage was 750 mL and Hb-6.7 gm%, patient received one PRBC. He was shifted out of ICU on POD 3 and discharged on POD 7.


   Discussion Top


Two important issues while managing patients with hematological malignancies undergoing cardiac surgery are: Whether the cardiac surgery is justified despite increased perioperative risk, and how can we manage the specific perioperative problems in such patients? Cases 1 and 2 presented for emergency CABG. According to 2011 ACC/AHA Guideline for CABG, emergency CABG is recommended in patients with acute myocardial infarction in whom persistent ischemia of a significant area of myocardium at rest and/or hemodynamic instability refractory to nonsurgical therapy is present (Class I). [7] Fecher, et al., reported 24 patients with hematological malignancies undergoing cardiac surgeries (19 CABG, two valve replacements, and three combined surgeries; five surgeries were emergency) with acceptable mortality (4%) but with significant morbidity (50%). Bleeding and infectious complications were most frequently encountered. [1] Recently, Sommer, et al., reported 54 patients with hematological malignancies (50% being Non-Hodgkin's Lymphoma) presenting for cardiac surgery. They demonstrated increased rates of vascular (5.4%), pulmonary (7.1%) and infectious complications and transfusion requirements. The long-term survival was significantly impaired, particularly in patients with a history of irradiation or chemotherapy. [2] In a report by Chan, et al., 83 patients among 4474 patients were identified with malignancy. Cases were matched to 216 controls based on age, gender, major medical comorbidities and type of surgery. About 68.7% had a solid organ tumour, and 31.3% had a haematological malignancy. There were no significant between-group differences in hospital or 30-day mortality. However, there were significantly higher rates of transfusion, reintubation, pneumonia, septicemia, arrhythmias and anticoagulant related complications in patients with malignancies. [3] Arguably, the patients with hematological malignancies should not be denied the opportunity to benefit from major surgery; however, an integrative therapeutic plan balancing the risk and benefit of each intervention should be designed. As far as the risk of perioperative bleeding and coagulation problems are concerned, TEG guidance and correction of deficient clotting factors is useful in such patients. Previous reports have not documented the use of TEG. In our study, TEG had an important role in transfusion of specific blood products in cases 1 and 2. Samuels, et al., in their 12 patient series concluded that mortality and morbidity in patients with CLL undergoing open heart surgery were high, infection being the commonest complication and the leading cause of mortality. [6] In another series of nine patients, Christiansen, et al., assessed the impact of hematological malignancies on cardiac surgery, and reported maximum complications caused by cytopenia or impaired function of blood cells, which is aggravated by cell damaging properties of CPB. [4]

Since no specific recommendation exists about antibiotic therapy in this cohort, standard society of thoracic surgeons' guidelines were followed. [8] In the present report, incidence of infection in form of superficial sternal wound infection was one in three patients which required additional antibiotic therapy. Case 1 was at higher risk of infection as she was receiving steroid supplementation for Addison's disease. Here, it is important to remember that TC is not a reliable indicator of infection in this patient cohort. Another important consideration is the accentuated risk of infections due to immunosuppression by chemotherapeutic agents. Case 1 was on chemotherapy with hydroxyurea which is usually well tolerated and case 2 was receiving ATRA which may produce complication like retinoic acid syndrome within 3 weeks of therapy, characterized by fever, chest pain, pulmonary infiltrates, pleural and pericardial effusions for which treatment with steroids is required. [9] Case 3 was not on chemotherapy at the time of surgery. In a recent report of 48 patients with malignancy undergoing CABG, hematological malignancies were noted in 5 (10%) patients. The authors recommended CABG surgery in these patients with malignancy with short CPB time, and paying maximum attention to preserve renal functions. [4] In the present study, all three cases had reasonably short CPB time and none developed renal dysfunction.

To conclude, cardiac surgery can be reasonably safely conducted in patients with various hematological malignancies; however, caution is required for postoperative increased morbidity, particularly bleeding and infectious complications.

 
   References Top

1.Fecher AM, Birdas TJ, Haybron D, Papasavas PK, Evers D, Caushaj PF. Cardiac operations in patients with hematologic malignancies. Eur J Cardiothorac Surg 2004;25:537-40.  Back to cited text no. 1
[PUBMED]    
2.Somer SP, Lange V, Yildirim C, Schimmer C, Aleksic I, Wagner C, et al. Cardiac surgery and hematological malignancies: A retrospective single-center analysis of 56 consecutive patients. Eur J Cardiothorac Surg 2011;40:173-8.  Back to cited text no. 2
    
3.Chan J, Rosenfeldt F, Chaudhuri K, Marasco S. Cardiac surgery in patients with history of malignancy: Increased complication rate but similar mortality. Heart Lung Circulation 2012;21:255-9.  Back to cited text no. 3
    
4.Christiansen S, Schmid C, Loher A, Scheld HH. Impact of malignant hematological disorders on cardiac surgery. Cardiovasc Surg 2000;8:149-52.  Back to cited text no. 4
    
5.Kucukarslan N, Tatar T, Uzun M, Yavuz I, Ozal E, Tatar H. Coronary artery bypass surgery in patients with malignancy. J Card Surg 2009;24:151-5.  Back to cited text no. 5
[PUBMED]    
6.Samuels LE, Kaufman MS, Morris RJ, Styler M, Brockman SK. Open heart surgery in patients with chronic lymphocytic leukemia. Leuk Res 1999;23:71-5.  Back to cited text no. 6
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7.Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. J Am Coll Cardiol 2011;58;e123-210.  Back to cited text no. 7
    
8.Engelamn R, Shanin D, Shemin R, Guy ST, Bratzler D, Edwards F, et al. The Society of Thoracic Surgeons Practice Guidelines Series: Antibiotic Prophylaxis in Cardiac surgery, Part II: Antibiotic choice. Ann Thorac Surg 2007;83:1569-76.  Back to cited text no. 8
    
9.Kasper, Braunwald, Fauci, Hauser, Longo, Jameson, et al. Harrison's Principles of Internal Medicine, 16 th ed. New York: McGraw Hill; 2005.  Back to cited text no. 9
    

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Correspondence Address:
Deepak Borde
Department of Anesthesia, P.D. Hinduja National Hospital and Medical Research Centre, Mahim, Mumbai -400 016, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.105370

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