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Interact CardioVasc Thorac Surg 2009;9:788-792. doi:10.1510/icvts.2009.208512 © 2009 European Association of Cardio-Thoracic Surgery
The impact of previous or concomitant myocardium revascularization on the outcomes of patients undergoing major non-cardiac surgery
a Department of Anaesthesia and Critical Care Medicine, Peking University First Hospital, 8 Xishiku Street, 10034 Beijing, China Received 28 March 2009; received in revised form 15 July 2009; accepted 15 July 2009
*Corresponding author. Tel.: +86-010-83571122; fax: +86-010-66551796.
The aim of this study was to analyze the results of major non-cardiac surgery in patients with severe coronary arterial disease who underwent concomitant vs. previous myocardial revascularization (MR) in terms of operative complications and hospital stay. Between June 1999 and October 2008, 37 patients with coronary arterial disease underwent neoplastic resection at our hospital. Fourteen patients with a curable left-main or multiple-vessel disease received surgical MR concomitantly, while 23 patients previously underwent surgical or transluminal MR. Univariate analysis determined the impact of the timing of MR on operative complications and hospital stay. The overall mortality and morbidity rates were 3% and 65%, respectively. Compared with simultaneous MR, neoplastic surgery with previous MR had shorter postoperative hospital stay. Occurrence of postoperative complications was influenced by surgical duration (P=0.014). Postoperative length of hospital stay was affected by the timing of revascularization (P=0.008) and surgical duration (P=0.007). Previous MR can shorten postoperative hospital length of stay for current major non-cardiac surgeries in patients with severe coronary artery disease (CAD). For patients with concomitant severe CAD and clinically rapidly progressive malignant neoplasm, simultaneous neoplastic resection and MR is associated with acceptable operative mortality.
Key Words: Neoplasms; Coronary artery bypass; Off-pump
Coronary artery disease (CAD) is a frequent comorbidity in patients undergoing major thoracic or abdominal surgery [1, 2]. It has been shown that previous myocardial revascularization (MR) is helpful to improve outcomes in high-risk patients such as those with an unstable angina or recent myocardial infarction (MI) [3]. On the other hand, some high-risk patients have to undergo concomitant MR and non-cardiac surgery. And these patients are considered to be at increased risk of postoperative complication and mortality [4]. The effects of the timing of MR on the outcomes of the high-risk patients are, however, not fully evaluated [5]. The aim of our study was to clarify the impact of previous or simultaneous MR on the outcomes of patients undergoing major non-cardiac surgery.
The project was approved by the Ethics Committee of Peking University First Hospital. This is a retrospective cohort study. All patients undergoing lung, renal or suprarenal, esophageal or cardial neoplastic surgery with simultaneous or previous MR between June 1999 and October 2008, were enrolled in the study. Thirty-seven patients with mean age of 68 years (range 50–81) underwent the above three kinds of neoplastic surgeries. The majority (30 patients) were male and the stage of malignant neoplasm from respective organ was predominantly TNM stage 1–3 while two benign neoplasms with lung hamartoma and lung epithelioid granulomatous crytococcus pneumonia, respectively. Ten patients had a history of MI and the entire population of patients received the daily use of nitrates or beta-blocking agents to control myocardium ischemia. Twenty-three patients had MR performed including 21 transluminal stent placements and two coronary artery bypass graftings (CABG). The mean interval between MR and current neoplastic surgery was 33 months with a range from 9 days to 10 years. These patients had good control of myocardium ischemia before current surgery. Fourteen patients received simultaneous CABG and neoplastic surgery with mean conduit of 2.2 per patient. Unstable coronary artery syndrome and lower functional capacity were found in the majority of these 14 patients. The most common coexistent disease was arterial hypertention, chronic obstructive pulmonary disease (COPD), diabetes, and cerebral vascular stroke. A summary of the clinical data is presented in Table 1.
Fourteen patients underwent concomitant neoplastic surgery and MR. Among them, 13 patients were performed CABG followed by neoplastic surgery and one patient was performed surgery in converse sequence. Eleven patients were applied off-pump coronary artery bypass grafting (off-pump CABG) and cardiopulmonary bypass was used in three patients. General anesthesia was administered in all these patients to lower the risk of epidural hematoma from possible heparinization and subsequent anticoagulant therapy. Twenty-three patients were directly performed neoplastic surgery with previous MR. General anesthesia or general combined epidural anesthesia was administered in this group of patients according to weighing the risk against benefit. The type of non-cardiac surgery in both groups is shown in Table 2. Medical records during hospitalization were reviewed. Peri-operative factors that might be associated with the occurrence of postoperative complications were collected. Duration of hospital stay and occurrence of postoperative complications involving heart, lung, brain, liver, kidney, surgery and infection were documented. The definitions for postoperative complications are shown in Table 3. Deaths which occurred within 30 days of surgery, or later but during the same hospitalization period, were considered as surgery-related deaths.
Data are presented as mean±standard deviation (S.D.), number (percentage) or median (interquartile range) as indicated. Continuous data were analyzed using unpaired t-test or Mann–Whitney U-test when two sets were compared. One-way ANOVA and Kruskal–Wallis test were used for three sets comparison. Categorical variables were analyzed using  2 or Fisher's exact test when expected cell frequencies were <5. Univariate analysis was performed to identify factors associated the occurrence of postoperative complications and postoperative hospital stay. P<0.05 were considered statistically significant. The statistical analysis was carried out using SPSS version 14.0 for Windows program (SPSS, Chicago, Illinois, USA).
Overall mortality and morbidity was 3% and 65%, respectively. Postoperative complications occurred in 12 of the 23 patients who had prior MR (52%), and in 12 of the 14 patients who underwent simultaneous MR (86%) (P=0.074). Concerning surgical type, postoperative complications developed in 8 of the 14 patients who were performed renal surgery (57%), and in 11 of 16 patients who underwent lung surgery (69%), and in 5 of 7 patients who experienced esophageal surgery (71%) (P=0.74). Fourteen patients (38%) experienced intra-operative or postoperative cardiac complications such as acute MI, heart failure or arrhythmia; eleven (30%) suffered pulmonary complications consisting of acute respiratory failure, pneumonia and pleural effusion. There were four (11%) neurological complications including cerebral infarction (one case in each group) and postoperative delirium (one case in each group), three (8%) sepsis, three (8%) upper gastrointestinal bleeding, one (3%) acute renal failure, two (5%) postoperative bleeding and one (3%) incision infection. Nineteen patients with cardiopulmonary complications accounted for 79% of patients with postoperative complications. There was one operative death among patients who underwent previous MR. This patient was performed left upper lobectomy with lymphadenectomy, and died because of intra-operative MI and postoperative sepsis. There were no deaths among the patients who had MR simultaneously with neoplastic surgery. The distribution of peri-operative variables between the two groups regarding timing of MR is shown in Table 1. Overall occurrence of postoperative complications was influenced by surgical duration (P=0.014). Univariate analysis for postoperative complications is shown in Table 4.
Postoperative hospital stay was longer for patients who underwent MR simultaneously than those who underwent MR previously (27±19 vs. 14±7 days, P=0.008). Postoperative hospital stay for patients who had renal or suprarenal, lung, esophageal or cardial surgery were 16±7, 18±10, 27±27 days, respectively (P=0.20). Postoperative hospital stay was longer for patients who performed MR simultaneously with neoplastic surgery (P=0.008) and for patients who had a long time surgery (P=0.007).
Surgery still offers the best treatment for patients with resectable neoplasm. If, however, there is a coexisting severe coronary arterial disease, operative mortality and morbidity increase significantly [7, 8]. It is a real dilemma for related clinicians to decide how to manage this kind of patient who was found to have malignant neoplasm with concomitant unstable CAD. There may be only two ways that we can choose: staged surgery or combined surgery. Operative risk may be reduced if the cardiac problem is addressed properly by performing prophylactic treatment of the coronary arterial disease either by percutaneous transluminal coronary angioplasty (PTCA) or CABG. Two to six weeks lag for neoplastic therapy [5], side-effects of antiplatelet therapy, two general anesthesias, two surgical risks and two separate incisions resulting in increased peri-operative stress and pain are usually criticized for this two-stage therapeutic strategy. Although one-stage surgery could completely or partially avoid the above drawbacks it is still uncertain whether this comprehensive procedure could provide enough cardiovascular protection from CABG against surgical trauma induced by two kinds of surgery. Our research answers this question from two aspects. Firstly, it is hard to say if simultaneous MR provides the same protection as previous MR does in terms of over 30% higher incidence of complications after neoplastic surgery, though there is no statistical significance. Secondly, concerning no peri-operative death in one-stage group it is reasonable to be applied in selected patients with concomitant severe coronary arterial disease and rapidly progressive malignant neoplasm. The short-term and long-term results of combined CABG and neoplastic surgery have been increasingly reported, especially in lung cancer patients [3, 4, 9–12]. These researches were mostly presented as case series or case reports and found one-stage surgery is safe and feasible [9–12]. Ciriaco et al. compared 19 patients who underwent surgical or transluminal MR and followed by lung surgery about one month later with 31 patients who underwent lung surgery directly without previous MR. They showed postoperative outcomes of patients with MR were better than that of patients without MR although there were no statistical significances [3]. To our knowledge, there is a few reports on comparing the outcome of one-stage therapeutic strategy with two-stage therapeutic strategy in patients with concomitant CAD and neoplasm. Kamiike et al. found that simultaneous procedures of CABG and gastric surgery can be performed safely compared with two-stage approach in a study involving only nine patients [4]. The complication rate in our study is similar to that reported by Kamiike et al., while the postoperative hospital stay is enormously reduced by 20 days or so [4]. This disparity may be attributable to the introduction of off-pump CABG technique and different surgical type composition. Our research retrospectively collected the patients with severe CAD who underwent neoplastic surgery with previous or simultaneous MR. The interval between previous MR and current surgery ranged from nine days to 10 years. What we really count is the protective effects by previous MR not the long-term outcome of postponing cancer therapy for 10 years. However, the mean nearly 3 years' interval between previous MR and current neoplastic surgery overlooked the risk of MR itself. Morbidity such as bleeding and stent thrombosis caused by peri-operative stent-related antiplatelet therapy will increase in a real situation even using a bare metal stent in preoperative MR according to the recent guideline [5]. In fact, we still find three patients with MI and two patients with postoperative bleeding though there was a mean interval of 33 months. We find that operation time has an impact on postoperative complications, at least to some extent, and on hospital stay, and that timing of MR influences postoperative hospital stay. The fact that longer surgery associates with higher incidence of postoperative complications is supported by several researches [13, 14]. Probably, prolonged intraoperative mechanical ventilation and intensive systemic inflammatory response induced by comprehensive procedures play a role in such a relationship. Operation time would be reduced by the development of surgical technique. Previous MR can shorten postoperative hospital stay of current surgery but cannot reduce morbidity and mortality. Regarding no hospital death, simultaneous MR and neoplastic surgery could be applied in selected patients with concomitant severe CAD and rapidly progressive malignant neoplasm. The incidence of complications in patients in our research is much higher than that of similar patients in other studies [3, 12]. Several causes are considered. We include much more minor complications such as postoperative delirium, pleural effusion, wound infection, and upper gastrointestinal bleeding. In the concomitant MR group, two patients out of seven who had cardiac complications only suffered atrial fibrillation and another patient only suffered hypotension. Many esophagus and cardial surgeries with high morbidity enter into analysis in contrast to several researches only including lung surgery [3, 12]. Small sample size may also contribute to this strikingly high morbidity. Finally, our peri-operative care and management should be further improved. The recent research points out that CABG remains the standard of care for patients with three-vessel or left main CAD as compared with PCI [15]. The guideline of ACC/AHA 2007 also states that PCI before non-cardiac surgery is of no value in preventing peri-operative cardiac events, especially for stable CAD. So, the choice between staged or simultaneous CABG for patients with concomitant severe CAD and malignant neoplasm may increasingly be faced by surgical teams. With the progress in surgical skills and in peri-operative management there may be a cline of choosing one stage procedure for selected patients with concomitant severe CAD and rapidly progressive malignant neoplasm. Although our paper has some limitations, such as retrospective study and a relatively small number of patients, it partially fills the gap of paucity of comparing previous MR with simultaneous MR in patients undergoing three kinds of neoplastic surgery. We need to further follow-up the long-term outcome for these patients so as to provide more convincing evidence and we also need to prospectively collect data to validate our results.
We would like to thank Dr Wei-ming Huang, Jun Zhang and Cheng Chen for their help in the malignant neoplasm pathological staging and preparation of the manuscript.
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Abstract
1. Introduction