Coronary Artery Bypass Grafting Nine Years After Cardiac Transplantation John J. Dunning, FRCSEd, Simon W. H. Kendall, FRCSEd, Paul A. Mullins, MRCP, Anoop Chauhan, MRCP, Timothy R. Graham, FRCS, Bojin Biocina, MD, Peter M. Schofield, MRCP, and Stephen R. Large, FRCS Transplant Unit, Papworth Hospital, Cambridgeshire, England
Angina and increasing exertional dyspnea developed in a 53-year-old man 9 years after cardiac transplantation. Left heart catheterization revealed severe proximal triple coronary artery disease, and he underwent surgical revascularization. Now 18 months after the operation he continues to be free of symptoms. (Ann Tkorac Surg 1992;54:571-2)
A
t Papworth Hospital we have performed 441 heart transplantations since 1979, and 14 of these patients have undergone retransplantation. A conservative operation [l,21 for these patients is preferable in view of the shortage of donor organs and the poor outcome of retransplantation [3]. In this report we document the unusual case of a patient in whom angina due to proximal coronary occlusive disease developed 9 years after transplantation and who has been successfully revascularized with relief of his symptoms. In May 1982 a 44-year-old man underwent orthotopic cardiac transplantation for ischemic heart disease. He had had four myocardial infarctions between 1973 and 1982 and undergone coronary bypass grafting on three occasions. His symptoms before transplantation were severe dyspnea associated with pain in his right shoulder on minimum exertion. The donor was a 28-year-old man, a nonsmoker, with no evidence of coronary artery disease. The patient’s postoperative course was uneventful, requiring only one course of intravenous steroids for moderate rejection. He returned to full employment and at yearly review histological examination showed minimal or no rejection. Routine left heart catheterization in 1985 showed the coronary arteries and the left ventricle to be angiographically normal (Fig 1). However, the following year left heart catheterization revealed hypokinesia at the apex of the left ventricle and mild stenoses in the distal left anterior descending artery and diffuse narrowing of the right coronary artery. Subsequent serial angiography up to 1990 showed progression of disease in the left anterior descending artery, the right coronary artery, and also the left circumflex artery, with no further deterioration of Accepted for publication Dec 31, 1991 Address reprint requests to Mr Large, Transplant Unit, Papworth Hospital, Papworth Everard, Cambridgeshire, CB3 8RE, England.
0 1992 by The Society of Thoracic Surgeons
ventricular function. In September 1990 increasing exertional dyspnea developed, associated with pain in his right shoulder identical in nature to his pretransplantation symptoms. Left heart catheterization in December 1990 revealed occlusion of the right coronary artery and the left anterior descending artery with irregular disease of the circumflex artery (Fig 2). Myocardial perfusion scanning demonstrated reversible ischemia in the anterior and lateral regions of the left ventricle. In view of his symptoms he was accepted for conventional revascularization. At operation saphenous vein was harvested from the right thigh, and the left internal mammary artery was dissected off the chest wall. Dense adhesions were present over the recipient right atrium, whereas over the transplanted heart the adhesions were loose. The coronary arteries were small, diffusely diseased, and generally thick walled. Saphenous vein was anastomosed to the posterior descending artery and the second obtuse marginal branch of the circumflex artery. Both these vessels were diffusely diseased, and the obtuse marginal branch had marked distal disease. The left internal mammary artery was anastomosed to the mid third of the left anterior descending artery. The patient was weaned from cardiopulmonary bypass without difficulty after an ischemic time of 40 minutes and a total bypass time of 77 minutes. After initial steady postoperative recovery the patient became febrile with a purulent discharge from the lower aspect of his sternotomy wound associated with instability of the lower sternum. On the 9th postoperative day the wound was reexplored. There was evidence of an infected wound, an unstable sternum, and patent grafts to the posterior descending artery and left anterior descending artery. The flow down the conduit to the obtuse marginal artery was diminished. All infected tissue was debrided and longitudinal wires were placed down the left sternum to allow sternal closure with transverse wires. Retrosternal irrigation with aqueous povidone-iodine solution (Betadine; Purdue Frederick, Norwalk, CT) was commenced and was continued for 5 days. He made steady progress and was discharged home with a stable sternum and an intact wound. Four months after the operation he underwent left heart catheterization and repeat myocardial perfusion scanning. This showed there was a patent left internal mammary artery graft and posterior descending artery graft with occlusion of the obtuse marginal artery graft 0003-4975/92/$5.00
572
CASE REPORT DUNNING ET AL CABG AFTER HEART TRANSPLANTATION
Fig 1. Left coronay angiography, 1985, showing mild irregularity of the proximal left anterior descending artey with no disease of the circurnfrex system.
and decreased perfusion only in the area of this occluded obtuse marginal artery graft. He is now 18 months after Operation with increased exercise tolerance and no recurrence of the angina in his right shoulder.
Comment The worldwide actuarial survival for cardiac transplantation in patients on triple immunosuppression therapy at 5 years is approximately 69%, with coronary occlusive disease being the most common cause of late mortality [4]. With more than 10,000 cardiac transplants performed worldwide the management of coronary occlusive disease will become an increasing clinical problem. Retransplantation is an unsatisfactory option due to relatively poor outcome compared with first-time transplants and due to the limited resource of donor organs [3]. Therefore percutaneous coronary angioplasty [5] and conservative operation may become increasingly common, and successful reports have been published of coronary grafting and mitral valve replacement [l, 21. However this approach
Ann Thorac Surg 1992:54571-2
will be limited due to the poor run-off of the coronary vessels and the general condition of the patients. Our patient had recurrence of his angina, a symptom from a denervated heart. The symptom was identical to his pretransplantation pain and was reproducible on exertion. The mechanism for this pain is not understood but coincided with his exertional dyspnea and serious stenoses in the coronary arteries. Previous reported theories for this phenomenon include sympathetic reinnervation of the myocardium [6]. In view of these symptoms and the progression of the disease it was decided to attempt conventional revascularization using the remaining piece of saphenous vein and the left internal mammary artery. Bilateral internal mammary artery grafting was not considered due to the previous sternotomies, the moderate obesity, and longterm steroid therapy. Technically the operation was similar to a normal redo operation although dissection of the recipient right atrium (fourth operation) was difficult. The anastomoses were satisfactory although distal disease in the obtuse marginal artery was the probable reason for the early occlusion of this graft. Obesity, steroids, and redo operation were all predisposing factors to sternal infection. The median sternotomy was debrided and rewired before the onset of mediastinitis and septicemia, and this aggressive management may well account for his eventual recovery. This complication considerably prolonged his rehabilitation. However, his exercise tolerance was improved and it was no longer associated with pain in his right shoulder. Angiography and ventricular isotope studies have shown revascularization of the anterolateral aspect of the ventricle but with an area of infarction in the area of the obtuse marginal graft. Coronary occlusive disease is becoming a more common problem with the increasing population of cardiac transplant patients. With a shortage of donor organs and the poor results of retransplantation these patients should be considered for conventional intervention. However, the role of percutaneous coronary angioplasty and coronary artery bypass grafting as a method of revascularization is limited due to the fact that the disease process commonly affects the distal vessels.
References
Fig 2. Left coronary angiography, 1990, showing two areas of stenosis in the irregular left anterior descending artery and disease in the second 0btu.x marginal artery.
1. Copeland JG, Rosado LJ, Sethi G. Mitral valve replacement six years after cardiac transplantation. Ann Thorac Surg 1991;51: 10146. 2. Copeland JG, Butman SM, Sethi G. Successful coronary artery bypass grafting for high-risk left main coronary artery atherosclerosis after cardiac transplantation. Ann Thorac Surg 1991; 49:106-10. 3. Mullins PA, Scott JP, Dunning JJ, et al. Cardiac transplant waiting lists, donor shortage and retransplantation: implications for using donor hearts. Am J Cardiol 1991;68:408-9. 4. Kriett JM, Kaye MP. The Registry of the International Society for Heart and Lung Transplantation 1991. J Heart Lung Transplant 1991;10:491-8. 5. Mullins PA, Shapiro LM, Aravot DJ, et al. Experience of transluminal coronary angioplasty in orthotopic cardiac transplant recipients. Eur Heart J (in press). 6. Schroeder JS, Hunt SA. Chest pain in heart transplant patients. N Engl J Med 1991;324:18054.
Angina and increasing exertional dyspnea developed in a 53-year-old man 9 years after cardiac transplantation. Left heart catheterization revealed severe proximal triple coronary artery disease, and he underwent surgical revascularization. Now 18 months after the operation he continues to be free of symptoms. (Ann Tkorac Surg 1992;54:571-2)
A
t Papworth Hospital we have performed 441 heart transplantations since 1979, and 14 of these patients have undergone retransplantation. A conservative operation [l,21 for these patients is preferable in view of the shortage of donor organs and the poor outcome of retransplantation [3]. In this report we document the unusual case of a patient in whom angina due to proximal coronary occlusive disease developed 9 years after transplantation and who has been successfully revascularized with relief of his symptoms. In May 1982 a 44-year-old man underwent orthotopic cardiac transplantation for ischemic heart disease. He had had four myocardial infarctions between 1973 and 1982 and undergone coronary bypass grafting on three occasions. His symptoms before transplantation were severe dyspnea associated with pain in his right shoulder on minimum exertion. The donor was a 28-year-old man, a nonsmoker, with no evidence of coronary artery disease. The patient’s postoperative course was uneventful, requiring only one course of intravenous steroids for moderate rejection. He returned to full employment and at yearly review histological examination showed minimal or no rejection. Routine left heart catheterization in 1985 showed the coronary arteries and the left ventricle to be angiographically normal (Fig 1). However, the following year left heart catheterization revealed hypokinesia at the apex of the left ventricle and mild stenoses in the distal left anterior descending artery and diffuse narrowing of the right coronary artery. Subsequent serial angiography up to 1990 showed progression of disease in the left anterior descending artery, the right coronary artery, and also the left circumflex artery, with no further deterioration of Accepted for publication Dec 31, 1991 Address reprint requests to Mr Large, Transplant Unit, Papworth Hospital, Papworth Everard, Cambridgeshire, CB3 8RE, England.
0 1992 by The Society of Thoracic Surgeons
ventricular function. In September 1990 increasing exertional dyspnea developed, associated with pain in his right shoulder identical in nature to his pretransplantation symptoms. Left heart catheterization in December 1990 revealed occlusion of the right coronary artery and the left anterior descending artery with irregular disease of the circumflex artery (Fig 2). Myocardial perfusion scanning demonstrated reversible ischemia in the anterior and lateral regions of the left ventricle. In view of his symptoms he was accepted for conventional revascularization. At operation saphenous vein was harvested from the right thigh, and the left internal mammary artery was dissected off the chest wall. Dense adhesions were present over the recipient right atrium, whereas over the transplanted heart the adhesions were loose. The coronary arteries were small, diffusely diseased, and generally thick walled. Saphenous vein was anastomosed to the posterior descending artery and the second obtuse marginal branch of the circumflex artery. Both these vessels were diffusely diseased, and the obtuse marginal branch had marked distal disease. The left internal mammary artery was anastomosed to the mid third of the left anterior descending artery. The patient was weaned from cardiopulmonary bypass without difficulty after an ischemic time of 40 minutes and a total bypass time of 77 minutes. After initial steady postoperative recovery the patient became febrile with a purulent discharge from the lower aspect of his sternotomy wound associated with instability of the lower sternum. On the 9th postoperative day the wound was reexplored. There was evidence of an infected wound, an unstable sternum, and patent grafts to the posterior descending artery and left anterior descending artery. The flow down the conduit to the obtuse marginal artery was diminished. All infected tissue was debrided and longitudinal wires were placed down the left sternum to allow sternal closure with transverse wires. Retrosternal irrigation with aqueous povidone-iodine solution (Betadine; Purdue Frederick, Norwalk, CT) was commenced and was continued for 5 days. He made steady progress and was discharged home with a stable sternum and an intact wound. Four months after the operation he underwent left heart catheterization and repeat myocardial perfusion scanning. This showed there was a patent left internal mammary artery graft and posterior descending artery graft with occlusion of the obtuse marginal artery graft 0003-4975/92/$5.00
572
CASE REPORT DUNNING ET AL CABG AFTER HEART TRANSPLANTATION
Fig 1. Left coronay angiography, 1985, showing mild irregularity of the proximal left anterior descending artey with no disease of the circurnfrex system.
and decreased perfusion only in the area of this occluded obtuse marginal artery graft. He is now 18 months after Operation with increased exercise tolerance and no recurrence of the angina in his right shoulder.
Comment The worldwide actuarial survival for cardiac transplantation in patients on triple immunosuppression therapy at 5 years is approximately 69%, with coronary occlusive disease being the most common cause of late mortality [4]. With more than 10,000 cardiac transplants performed worldwide the management of coronary occlusive disease will become an increasing clinical problem. Retransplantation is an unsatisfactory option due to relatively poor outcome compared with first-time transplants and due to the limited resource of donor organs [3]. Therefore percutaneous coronary angioplasty [5] and conservative operation may become increasingly common, and successful reports have been published of coronary grafting and mitral valve replacement [l, 21. However this approach
Ann Thorac Surg 1992:54571-2
will be limited due to the poor run-off of the coronary vessels and the general condition of the patients. Our patient had recurrence of his angina, a symptom from a denervated heart. The symptom was identical to his pretransplantation pain and was reproducible on exertion. The mechanism for this pain is not understood but coincided with his exertional dyspnea and serious stenoses in the coronary arteries. Previous reported theories for this phenomenon include sympathetic reinnervation of the myocardium [6]. In view of these symptoms and the progression of the disease it was decided to attempt conventional revascularization using the remaining piece of saphenous vein and the left internal mammary artery. Bilateral internal mammary artery grafting was not considered due to the previous sternotomies, the moderate obesity, and longterm steroid therapy. Technically the operation was similar to a normal redo operation although dissection of the recipient right atrium (fourth operation) was difficult. The anastomoses were satisfactory although distal disease in the obtuse marginal artery was the probable reason for the early occlusion of this graft. Obesity, steroids, and redo operation were all predisposing factors to sternal infection. The median sternotomy was debrided and rewired before the onset of mediastinitis and septicemia, and this aggressive management may well account for his eventual recovery. This complication considerably prolonged his rehabilitation. However, his exercise tolerance was improved and it was no longer associated with pain in his right shoulder. Angiography and ventricular isotope studies have shown revascularization of the anterolateral aspect of the ventricle but with an area of infarction in the area of the obtuse marginal graft. Coronary occlusive disease is becoming a more common problem with the increasing population of cardiac transplant patients. With a shortage of donor organs and the poor results of retransplantation these patients should be considered for conventional intervention. However, the role of percutaneous coronary angioplasty and coronary artery bypass grafting as a method of revascularization is limited due to the fact that the disease process commonly affects the distal vessels.
References
Fig 2. Left coronary angiography, 1990, showing two areas of stenosis in the irregular left anterior descending artery and disease in the second 0btu.x marginal artery.
1. Copeland JG, Rosado LJ, Sethi G. Mitral valve replacement six years after cardiac transplantation. Ann Thorac Surg 1991;51: 10146. 2. Copeland JG, Butman SM, Sethi G. Successful coronary artery bypass grafting for high-risk left main coronary artery atherosclerosis after cardiac transplantation. Ann Thorac Surg 1991; 49:106-10. 3. Mullins PA, Scott JP, Dunning JJ, et al. Cardiac transplant waiting lists, donor shortage and retransplantation: implications for using donor hearts. Am J Cardiol 1991;68:408-9. 4. Kriett JM, Kaye MP. The Registry of the International Society for Heart and Lung Transplantation 1991. J Heart Lung Transplant 1991;10:491-8. 5. Mullins PA, Shapiro LM, Aravot DJ, et al. Experience of transluminal coronary angioplasty in orthotopic cardiac transplant recipients. Eur Heart J (in press). 6. Schroeder JS, Hunt SA. Chest pain in heart transplant patients. N Engl J Med 1991;324:18054.
