IJTCVS 2009; 25: 27–28 Case reports
Trivedi et al 27 CABG in SLE
Coronary artery bypass grafting in patients with systemic lupus erythmatosus – A case report Jaideep Trivedi, MCh, Karunakara Padhy, MCh, Damodar Rao Kodem, DM, Suri Bhaskar Rama Narasimham, MCh, Ponangi Venkata Satyanarayana, MCh Department of Cardiothoracic Surgery and Cardiology, CARE Hospital, Visakhapatnam (A.P.), India Abstract Systemic Lupus Erythmatosis (SLE) is an autoimmune disease that can affect all organ systems. The natural history of the cardiovascular manifestations has been altered by systemic corticosteroids used for treatment of SLE. Thus, young patients with SLE may suffer from angina and myocardial infarction. We report our experience of coronary artery bypass grafting in a case of SLE. In this case vessels were diffusely diseased so we did patch angioplasty in these vessels. In conclusion, although the postoperative complications are common, coronary artery bypass grafting could be performed in patients with SLE. Severity of disease, use of appropriate graft and their long term results are the areas which needs extensive research. (Ind J Thorac Cardiovasc Surg 2009; 25: 27-28) Key words: Myocardial infarction, Pericardium, Coronary artery bypass grafting
Introduction
Case report
SLE is an autoimmune disease that can affect all organ systems. Cardiac involvement in patients with SLE has been recognized since the early 20 th century. SLE involves all components of the heart, including pericardium, conduction system, myocardium, heart valves and coronary arteries.1,2 The natural history of the cardiovascular manifestations has been altered by systemic corticosteroids used for treatment of SLE. Thus young patients with SLE may suffer from angina and myocardial infarction3. In the future, a large number of SLE patients may be candidates for myocardial revascularization. Despite widespread use of myocardial revascularization in the general population, there are few reports of Coronary Artery Bypass Grafting (CABG) in patients with SLE4-6. We report our experience of coronary artery bypass grafting in a case of SLE.
A 42-years-male hypertensive, diabetic, nonsmoker presented with class III angina and dyspnoea. This patient had typical history of fever, weight loss, joint pain and swelling and skin rashes (Fig. 1). He had Antinuclear Antibodies (ANA) and double stranded Deoxy Nucleic Acid (ds DNA) antibodies positive for SLE. Skin biopsy also was positive for SLE. He was on systemic steroids since last 5 years. His coronary angiography was done on 12/12/07 which revealed triple vessel disease with moderate Left
Address for correspondence: Dr P.V. Satyanarayana, MCh Chief Cardiothoracic Surgeon CARE Hospital,Visakhapatnam.A.P., India Cell: 9949991823, Fax: 0891-2714015 E-mail:
[email protected] © IJTCVS 097091342510309/17 CR Received - 10/03/08; Review Completed - 06/10/08; Accepted - 28/12/08.
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Fig. 1. Postoperative photograph with skin rash.
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IJTCVS 2009; 25: 27–28
Ventricle dysfunction. His routine blood investigations, liver function tests, kidney function tests were within normal limits and his antinuclear antibody test was negative. His coronary artery bypass grafting on cardiopulmonary bypass was done on 26/12/07. Left internal mammary graft was anastomosed to Left Anterior Descending (LAD) and saphenous vein grafts were anastomosed to Obtuse Marginals (OMs) and Posterior Descending Artery (PDA). The OM s were diffusely diseased and so patch angioplasty was done in these vessels. Intraoperatively solumedrol was added on pump and pressures were kept above 80 mm Hg on Cardiopulmonary Bypass (CPB). There was no intraoperative complication and systemic steroids were continued postoperatively. Patient had no postoperative complications and all investigations and Electrocardiogram (ECG) were within normal limits. Patient was discharged on 8th postoperative day. Discussion Coronary artery disease in SLE appears to be multifactorial and includes 1. Premature atherosclerosis3 2. Coronary vasculitis 3. Hypercoagulability. Coronary artery bypass grafting in SLE patients is a surgical challenge because these patients have unique patient characteristics of multiple organ involvement and longterm use of steroids. Because of a co-existing medical disease such as diabetes mellitus, Hyperlipidemia and lupus nephropathy in SLE patients, grafts appear to deteriorate early4-6. Coronary disease is severe, progressive and related to the duration of SLE rather than to the age of the patient. The occurrence of acute myocardial infarction is common in SLE patients less than 40 years of age, and even teenagers are affected2,3. Heart failure, sudden death, angina pectoris, acute myocardial infarction are the most common initial cardiac manifestation and contribute, along with the other cardiac (endocarditis, myocarditis and pericarditis) 1,2 and noncardiac manifestations of SLE, to a drastically shortened life expectancy. Reports of coronary revascularization in patients with SLE are few7. Several problems complicate the issue like whether to use myocardial revascularization in patients with SLE, whether coronary artery bypass surgery should be performed in a patient who has compromised life expectancy due to multisystem involvement and concomitant likelihood of postoperative complications, such as poor healing due to steroid use. The type of conduit to use for the bypass operation is also important to consider. Literature does not provide meaningful conclusion about use of saphenous vein graft, internal mammary
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artery7. In the present case we have used both, and left internal mammary artery was found to be free of palpable occlusive disease and with excellent flow. The obtuse marginals were diffusely diseased and we had to do patch angioplasty. Normally in coronary artery bypass grafting the anastomosis is 2-3 times the diameter of involved coronary artery. But when the artery is diffusely diseased the plaques will not give healthy margins required for anastomosis Thus, chances of restenosis is more if anastomosis performed over plaques. So the length of anastomosis is extended 4-5 times to get normal healthy margin and take large patch of conduit to perform a good quality anastomosis i.e. patch angioplasty. Continued long term follow-up of this patient will be most illustrative. Advances in medical therapy and better understanding of SLE have contributed to a dramatic improvement in the long term survival of patients. However, large –dose, long-term corticosteroid therapy appears to raise the incidence of coronary involvement8. Consequently, a large number of patients may be candidates for myocardial revascularization in future. Conclusion Although the postoperative complications are common, coronary artery bypass grafting could be performed safely in patients with SLE with minimal morbidity. Severity of disease, use of appropriate graft and their long term results are the areas which needs extensive research. References 1. Doherty NE, Siegel RJ.Cardiovascular manifestations of systemic lupus erythematosus. Am heart J 1985; 110: 1257–65. 2. Moder KG, Miller TD, Tazelaar HD. Cardiac involvement in systemic lupus erythematosus. Mayo clin Proc 1999; 74: 275–84. 3. Asanuma Y, Oeser A, Shintani AK, et al. Premature coronaryartery atherosclerosis in systemic lupus erthematosus. N Engl J Med 2003; 349: 2407–15. 4. Rinaldi RG, Carballido J, Betancourt B, Sartori M, Almodovar EA. Coronary artery bypass grafting in patients with systemic lupus erythematosus. Report of 2 cases. Tex Heart Inst J 1995; 22: 185– 88. 5. Bozbuga N, Erentug V, Kaya E, Akinci E, Yakut C. Coronary artery bypass grafting in patients with systemic lupus erythematosus. J Card Surg 2004; 19: 471–72. 6. Bossert T, Falk V, Gummert JF, Rahmel A, Mohr FW. Coronary artery bypass grafting in patients with systemic lupus erythematosus. Z kardiol 2003; 92: 219–21. 7. Sakamoto S, Shimizu T, Kaneto Y, Toyoda T. (A case of coronary artery bypass grafting using bilateral mammary arteries in a patient with systemic lupus erythematosus.) Nippon kyobu Geka Gakkai Zasshi 1990; 38: 116–20. 8. Petri M, Perez-Gutthann S, Spence D, Hochberg M C.Risk factrors for coronary artery disease in patients with systemic lupus erythmatosis. Am J Med 1992; 93: 513–19.
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