Off-pump myocardial revascularizaton in a Jehovah's Witness patient with pheochromocytoma
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a Division of Cardiothoracic Surgery, Wayne State University, 3990 John R, Suite 2102, Harper, Professional Building, Detroit, MI 48201, USA
b Chief Administrative Surgery Resident, Wayne State University, MI, USA
Abstract
We present a female Jehovah's Witness patient with concomitant severe left main and left anterior descending coronary artery disease and pheochromocytoma who underwent successful off-pump myocardial revascularization. Perioperative management of this patient included alpha-blockade with Doxazosin followed by beta-blockade with Metoprolol. A short-acting Phentolamine was used for alpha-blockade before surgery. Because she refused transfusion of blood and blood products, erythropoietin and iron was used to increase her hemoglobin in both the preoperative and postoperative periods. Intraoperative stategy included off-pump myocardial revascularization, the use of a pulmonary catheter to monitor hemodynamics, the use of norepinephrine and epinephrine to increase blood pressure, the employment of the cell saver, and transesophageal echocardiography.
Key Words: Off-pump CABG; Pheochromocytoma; Jehovah's Witness
1. Introduction
Concomitant coronary artery disease and pheochromocytoma are significant surgical challenges. Combined and staged operative procedures have been detailed in the literature [1–9]. We present a case of an off-pump coronary artery bypass procedure performed in a Jehovah's Witness patient with pheochromocytoma. This is the first report in which myocardial revascularization was achieved without blood products and without resection of the pheochromocytoma.
2. Case report
A 55-year-old Jehovah's Witness female with a past medical history of coronary artery disease, hypertension, non-insulin dependent diabetes, hypercholesterolemia, cerebrovascular disease with transient ischemic attack, and pheochromocytoma, presented to the emergency room with angina. She had a cardiac history significant for 2 myocardial infarctions 2 years previously, leading to stenting of the circumflex coronary artery 3 months previously ago. She had a newly diagnosed right adrenal mass measuring 3 x 2.5 cm. Increased norepinephrine and metanephrine levels in the urine, and elevated plasma levels of norepinephrine, were demonstrated (see Table 1).
The patient's cardiac catheterization demonstrated 80% stenosis of her left main and 85% stenosis of her left anterior descending coronary arteries (see Fig. 1). Her ejection fraction was 20% with severe mitral valve insufficiency. Echocardiography 3 months previously demonstrated normal left ventricular size and systolic function, an ejection fraction of 55%. Her hemoglobin was 9 g/dl. She was a Jehovah's Witness who refused blood and blood products. An intraortic balloon pump (IABP) was placed. The patient was offered off-pump revascularization when her hemoglobin increased. Erythropoietin and ferrous sulfate were started. Her hemoglobin improved to 12 g/dl. Preoperative alpha blockade was accomplished with Doxazosin. A shorter acting drug, Phentolamine, was used the day before surgery. Metoprolol was used for beta blockade. She received a Bupivicaine epidural. Erythropoietin (18,000 units per week) was continued prior to surgery and in the postoperative periods. Norepinephrine and epinephrine would be used to increase blood pressure. Pulmonary artery catheter was placed to accurately monitor cardiac hemodynamics. Cell saver techniques were employed. With medical management the patient became hemodynamically stable and the IABP was removed to avoid complications during the pre-operative period. Preoperaive echocardiogram demonstrated hypokinesis of the inferior wall and distal anterior wall, ejection fraction of 50%, and mild mitral valve regurgitation.
(B) Left main projection in RAO Projection demonstrates distal left main coronary artery stenosis (black arrow) and proximal left anterior descending coronary artery stenosis (white arrow).
The patient was premedicated with Midazolam, Fentanyl, and Bupivicaine. She was induced with Etomidate and Vecuronium was used as a muscle relaxant. The anesthetic agent used was Isoflurane. She underwent off-pump myocardial revascularization with saphenous vein grafts to the left anterior descending and obtuse marginal coronary arteries. Internal mammary artery grafting was not chosen in this patient in order to expedite the procedure and to eliminate the internal mammary artery bed as a potential source of bleeding in this patient. Her operation was uncomplicated. She received 2500 cc in crystalloids. Her urine output was 1080 cc. The cell saver contained 200 cc of blood. The cardiac output post operating room was 3.6 l/min and the cardiac index was 1.95 l/min/m2 with an SVO2 of 71%. Transesophageal echocardiography post surgery demonstrated an ejection fraction of 45% and no wall motion segment defect.
On postoperative day 1 the patient was awake and alert. Her hemodynamics were a cardiac output of 3.6 l/min, a cardiac index of 1.95 l/min/m2 and a systemic vascular resistance of 1253 dynes/cm5 without the use of vasopressors. Her pulmonary artery catheter was removed and she was transferred to a step-down unit. Her hemoglobin was 9 g/dl and she continued on a regimen of erythropoietin 18,000 units subcutaneous injection every other day and 325 mg orally three times a day. The patient was discharged on postoperative day 5 in good condition.
3. Discussion
Three successful management strategies for the patient with pheochromocytoma and coronary artery disease have been described: (1) Resection of the pheochromocytoma before myocardial revascularization, (2) revascularization before resection of the pheochromocytoma, and (3) combined revascularization and resection of the pheochromocytoma in one procedure. Our patient added to the clinical challenge due to her Jehovah's Witness status and significant comorbidities. It was decided to perform a staged procedure for this patient with myocardial revascularization before laparotomy for resection of the pheochromocytoma. Specific reasons for this decision were: (1) The patient's admitting symptoms were angina, she required an IABP preoperatively, and had an ejection fraction of 20% with severe mitral valve insufficiency. These factors pointed to her cardiac status as requiring initial treatment; (2) The inability to transfuse packed red blood cells or blood products. Bleeding has been a complication of all three management strategies, leading to death of one of the reported cases [3]; (3) The sternotomy and laparotomy would be difficult in a 55-year-old with multiple comorbidities. Reported combined procedures have had longer hospitalizations prior to discharge [4,6].
Blood conservation and surgical techniques previously outlined by the authors were employed [10]. Off-pump techniques were used to avoid excess catecholamine release seen with cardiopulmonary bypass and hypothermia. We agree with Seah et al., and if cardiopulmonary bypass were necessary, aprotonin therapy to minimize peri-operative bleeding is part of our management stategy [4]. The first priority in blood pressure management was blockade of alpha-adrenergic receptors to prevent unopposed vasoconstriction.
References
Kumar P, Walcot N, Carpenter R, Uppal R. Concomittant off-pump myocardial revascularization and pheochromocytoma resection. Ann Thorac Surg Dec 2001; 72:2139–2141.
Roy A, Sinha A, Scholar M, Macleod K, Glenville B. Coronary artery bypass grafting without cardiopulmonary bypass in pheochromocytoma. J Thorac Cardiovasc Surg October 2000; 120:826–828.
Balabaud-Pichon V, Bopp P, Levy F, Thiranos JC, Steib A. Excision of adrenal pheochromocytoma and coronary artery bypass graft surgery with cardiopulmonary bypass. J Cardiothorac Vasc Anesth Jun 2002; 16:344–346.
Seah PW, Costa R, Wolfenden H. Combined coronary artery bypass grafting and excision of adrenal pheochromocytoma. J Thorac Cardiovasc Surg August 1995; 110:559–560.
Dunn EJ, Wolff RK, Wright CB, Callard GM, Flege JB Jr. Presentation of undiagnosed pheochromocytoma during coronary artery bypass surgery. J Cardiovasc Surg 1989;Mar–Apr 30:284–287.
Baillargeon JP, Pek B, Teijeira J, Poisson J, van Rossum N, Langlois MF. Combined surgery for coronary artery disease and pheochromocytoma. Can J Anesth 2000; 47:647–652.
Brown P, Caplan RA. Recognition of an unsuspected phaeochromocytoma during elective coronary artery bypass surgery. Can Anaesth Soc J 1986; 33:789–799.
Fenje N, Lee LW, Jamieson WR, Manning G. Phaeochromocytoma and mitral valve replacement. Can J Anaesth Mar 1989; 36:198–199.
Liem TH, Moll JE, Booij DJ. Thoracic epidural analgesia in a patient with bilateral phaeochromocytoma undergoing coronary artery bypass grafting. Anaesthesia 1991; 46:654–658.
Williams M, Blocksom JM, Baciewicz FA. Coronary artery bypass in a dialysis dependent Jehovah's Witness. Tex Heart Int J 2004; 31:181–183.(Frank A. Baciewicz, and M)
b Chief Administrative Surgery Resident, Wayne State University, MI, USA
Abstract
We present a female Jehovah's Witness patient with concomitant severe left main and left anterior descending coronary artery disease and pheochromocytoma who underwent successful off-pump myocardial revascularization. Perioperative management of this patient included alpha-blockade with Doxazosin followed by beta-blockade with Metoprolol. A short-acting Phentolamine was used for alpha-blockade before surgery. Because she refused transfusion of blood and blood products, erythropoietin and iron was used to increase her hemoglobin in both the preoperative and postoperative periods. Intraoperative stategy included off-pump myocardial revascularization, the use of a pulmonary catheter to monitor hemodynamics, the use of norepinephrine and epinephrine to increase blood pressure, the employment of the cell saver, and transesophageal echocardiography.
Key Words: Off-pump CABG; Pheochromocytoma; Jehovah's Witness
1. Introduction
Concomitant coronary artery disease and pheochromocytoma are significant surgical challenges. Combined and staged operative procedures have been detailed in the literature [1–9]. We present a case of an off-pump coronary artery bypass procedure performed in a Jehovah's Witness patient with pheochromocytoma. This is the first report in which myocardial revascularization was achieved without blood products and without resection of the pheochromocytoma.
2. Case report
A 55-year-old Jehovah's Witness female with a past medical history of coronary artery disease, hypertension, non-insulin dependent diabetes, hypercholesterolemia, cerebrovascular disease with transient ischemic attack, and pheochromocytoma, presented to the emergency room with angina. She had a cardiac history significant for 2 myocardial infarctions 2 years previously, leading to stenting of the circumflex coronary artery 3 months previously ago. She had a newly diagnosed right adrenal mass measuring 3 x 2.5 cm. Increased norepinephrine and metanephrine levels in the urine, and elevated plasma levels of norepinephrine, were demonstrated (see Table 1).
The patient's cardiac catheterization demonstrated 80% stenosis of her left main and 85% stenosis of her left anterior descending coronary arteries (see Fig. 1). Her ejection fraction was 20% with severe mitral valve insufficiency. Echocardiography 3 months previously demonstrated normal left ventricular size and systolic function, an ejection fraction of 55%. Her hemoglobin was 9 g/dl. She was a Jehovah's Witness who refused blood and blood products. An intraortic balloon pump (IABP) was placed. The patient was offered off-pump revascularization when her hemoglobin increased. Erythropoietin and ferrous sulfate were started. Her hemoglobin improved to 12 g/dl. Preoperative alpha blockade was accomplished with Doxazosin. A shorter acting drug, Phentolamine, was used the day before surgery. Metoprolol was used for beta blockade. She received a Bupivicaine epidural. Erythropoietin (18,000 units per week) was continued prior to surgery and in the postoperative periods. Norepinephrine and epinephrine would be used to increase blood pressure. Pulmonary artery catheter was placed to accurately monitor cardiac hemodynamics. Cell saver techniques were employed. With medical management the patient became hemodynamically stable and the IABP was removed to avoid complications during the pre-operative period. Preoperaive echocardiogram demonstrated hypokinesis of the inferior wall and distal anterior wall, ejection fraction of 50%, and mild mitral valve regurgitation.
(B) Left main projection in RAO Projection demonstrates distal left main coronary artery stenosis (black arrow) and proximal left anterior descending coronary artery stenosis (white arrow).
The patient was premedicated with Midazolam, Fentanyl, and Bupivicaine. She was induced with Etomidate and Vecuronium was used as a muscle relaxant. The anesthetic agent used was Isoflurane. She underwent off-pump myocardial revascularization with saphenous vein grafts to the left anterior descending and obtuse marginal coronary arteries. Internal mammary artery grafting was not chosen in this patient in order to expedite the procedure and to eliminate the internal mammary artery bed as a potential source of bleeding in this patient. Her operation was uncomplicated. She received 2500 cc in crystalloids. Her urine output was 1080 cc. The cell saver contained 200 cc of blood. The cardiac output post operating room was 3.6 l/min and the cardiac index was 1.95 l/min/m2 with an SVO2 of 71%. Transesophageal echocardiography post surgery demonstrated an ejection fraction of 45% and no wall motion segment defect.
On postoperative day 1 the patient was awake and alert. Her hemodynamics were a cardiac output of 3.6 l/min, a cardiac index of 1.95 l/min/m2 and a systemic vascular resistance of 1253 dynes/cm5 without the use of vasopressors. Her pulmonary artery catheter was removed and she was transferred to a step-down unit. Her hemoglobin was 9 g/dl and she continued on a regimen of erythropoietin 18,000 units subcutaneous injection every other day and 325 mg orally three times a day. The patient was discharged on postoperative day 5 in good condition.
3. Discussion
Three successful management strategies for the patient with pheochromocytoma and coronary artery disease have been described: (1) Resection of the pheochromocytoma before myocardial revascularization, (2) revascularization before resection of the pheochromocytoma, and (3) combined revascularization and resection of the pheochromocytoma in one procedure. Our patient added to the clinical challenge due to her Jehovah's Witness status and significant comorbidities. It was decided to perform a staged procedure for this patient with myocardial revascularization before laparotomy for resection of the pheochromocytoma. Specific reasons for this decision were: (1) The patient's admitting symptoms were angina, she required an IABP preoperatively, and had an ejection fraction of 20% with severe mitral valve insufficiency. These factors pointed to her cardiac status as requiring initial treatment; (2) The inability to transfuse packed red blood cells or blood products. Bleeding has been a complication of all three management strategies, leading to death of one of the reported cases [3]; (3) The sternotomy and laparotomy would be difficult in a 55-year-old with multiple comorbidities. Reported combined procedures have had longer hospitalizations prior to discharge [4,6].
Blood conservation and surgical techniques previously outlined by the authors were employed [10]. Off-pump techniques were used to avoid excess catecholamine release seen with cardiopulmonary bypass and hypothermia. We agree with Seah et al., and if cardiopulmonary bypass were necessary, aprotonin therapy to minimize peri-operative bleeding is part of our management stategy [4]. The first priority in blood pressure management was blockade of alpha-adrenergic receptors to prevent unopposed vasoconstriction.
References
Kumar P, Walcot N, Carpenter R, Uppal R. Concomittant off-pump myocardial revascularization and pheochromocytoma resection. Ann Thorac Surg Dec 2001; 72:2139–2141.
Roy A, Sinha A, Scholar M, Macleod K, Glenville B. Coronary artery bypass grafting without cardiopulmonary bypass in pheochromocytoma. J Thorac Cardiovasc Surg October 2000; 120:826–828.
Balabaud-Pichon V, Bopp P, Levy F, Thiranos JC, Steib A. Excision of adrenal pheochromocytoma and coronary artery bypass graft surgery with cardiopulmonary bypass. J Cardiothorac Vasc Anesth Jun 2002; 16:344–346.
Seah PW, Costa R, Wolfenden H. Combined coronary artery bypass grafting and excision of adrenal pheochromocytoma. J Thorac Cardiovasc Surg August 1995; 110:559–560.
Dunn EJ, Wolff RK, Wright CB, Callard GM, Flege JB Jr. Presentation of undiagnosed pheochromocytoma during coronary artery bypass surgery. J Cardiovasc Surg 1989;Mar–Apr 30:284–287.
Baillargeon JP, Pek B, Teijeira J, Poisson J, van Rossum N, Langlois MF. Combined surgery for coronary artery disease and pheochromocytoma. Can J Anesth 2000; 47:647–652.
Brown P, Caplan RA. Recognition of an unsuspected phaeochromocytoma during elective coronary artery bypass surgery. Can Anaesth Soc J 1986; 33:789–799.
Fenje N, Lee LW, Jamieson WR, Manning G. Phaeochromocytoma and mitral valve replacement. Can J Anaesth Mar 1989; 36:198–199.
Liem TH, Moll JE, Booij DJ. Thoracic epidural analgesia in a patient with bilateral phaeochromocytoma undergoing coronary artery bypass grafting. Anaesthesia 1991; 46:654–658.
Williams M, Blocksom JM, Baciewicz FA. Coronary artery bypass in a dialysis dependent Jehovah's Witness. Tex Heart Int J 2004; 31:181–183.(Frank A. Baciewicz, and M)