Combined off-pump coronary artery bypass grafting and living donor liver transplantation

Transcription

1 Korean J Anesthesiol 2009 Jul; 57(1): DOI: /kjae Case Report Combined off-pump coronary artery bypass grafting and living donor liver transplantation A case report Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea In Hoo Kim, Gaab Soo Kim, Justin Sangwook Ko, and Sangmin Maria Lee We report a case of combined off-pump coronary artery bypass grafting (OPCAB) and living-donor liver transplantation (LDLT). Patient was admitted to undergo liver transplantation due to Child C cirrhosis secondary to hepatitis B infection, and incidentally, his preoperative cardiac evaluation revealed silent ischemia due to the two-vessel coronary artery disease (CAD). Patient underwent OPCAB followed by LDLT. There was no perioperative cardiovascular event during the days of hospitalization. From the successful anesthetic experience of a combined OPCAB and LDLT, we cautiously suggest that a combined OPCAB and LDLT could be a surgical treatment for the patients with end-stage liver disease (ESLD) and advanced CAD. (Korean J Anesthesiol 2009; 57: ) Key Words: Coronary artery disease, Liver transplantation, OPCAB. The advancement of surgical techniques together with the change of social prejudice about organ donation has made the liver transplantation expand its indication. As a result, the number of liver transplantation as a surgical treatment of end-stage liver disease is increasing recently. More and more patients can live longer and better life with the help of liver transplantation while postoperative complications and combined cardiovascular risks are challenges to both patients and clinicians. Especially, liver transplantation in the patients with coronary artery disease (CAD) is considered as a very high-risk procedure. Currently, only a limited number of case reports about liver transplantation in the patients with CAD and combined coronary artery bypass grafting (CABG) and living donor liver transplantation (LDLT) are available. In this case, we report a case of combined off-pump coronary artery grafting (OPCAB) and living donor liver transplantation (LDLT) at our hospital. Received: January 13, Accepted: March 30, Corresponding author: Gaab Soo Kim, M.D., Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, Ilwon-dong, Gangnam-gu, Seoul , Korea. Tel: , Fax: , gskim@skku.edu Copyright c Korean Society of Anesthesiologists, 2009 ccthis is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. CASE REPORT Fifty-six years-old male patient (body weight 60.7-kg, height 167-cm) was admitted for elective LDLT. He suffered from Child-Turcotte-Pugh C cirrhosis secondary to hepatitis B infection. His present illness revealed diabetes mellitus diagnosed one year ago and was well managed with sulfonylurea. He had a three-year history of recurrent hematemesis secondary to esophageal varices and the last variceal ligation was performed one month ago. His model for end-stage liver disease (MELD) score was 23 points from preoperative laboratory data (Table 1). No active lung disease was identified in his chest X-ray but moderate restrictive lung disease pattern with forced vital capacity 2.03 L (50% of predicted value) was revealed in pulmonary function tests. He had no history of chest pain or dyspnea. His arterial blood gas analysis showed PaO mmhg under room air. He had overly distended abdomen suggesting large amount of ascites. Unexpectedly, his electrocardiography (ECG) revealed anterior infarction and preoperative echocardiography showed left ventricular ejection fraction 50% and regional wall motion abnormalities like thinning of mid to inferior septum and apex of left ventricle in four-chamber view and severe hypokinesia of inferior, anterior, and anteroseptal left ventricular walls in transgastric view in addition to mild 108

2 Kim et al:combined OPCAB and LDLT Table 1. Perioperative Laboratory Data Parameters (normal ranges) PreOP ICU arrival POD #1 POD #2 POD #3 POD #10 AST/ALT (0 40 U/L) 161/ / / /241 67/208 68/303 Bilirubin ( mg/dl) Gamma-GT (11 49 U/L) Albumin ( g/dl) BUN (8 22 mg/dl) Creatinine ( mg/dl) Glucose ( mg/dl) INR ( INR) Fibrinogen ( mg/dl) AT III (83 123%) Hemoglobin ( g/dl) Troponin I ( ng/ml) Myoglobin (0 110 ng/ml) CK-MB (0 5 ng/ml) AST: aspartate aminotransferase, ALT: alanine aminotransferase, BUN: blood urea nitrogen, CK: creatinine kinase, INR: international normalized ratio, AT III: antithrombin III, PreOP: preoperative, ICU: intensive care unit, POD: postoperative day. Fig. 1. Preoperative coronary angiography shows total occlusion of left anterior descending artery (A) and right coronary artery (B). tricuspid regurgitation and diastolic dysfunction grade two with left atrial enlargement. Coronary angiography revealed two-vessel disease with totally occluded left anterior descending artery (LAD) and right coronary artery (RCA) (Fig. 1). Cardiac enzymes were within normal ranges. He was diagnosed with silent myocardial ischemia and CABG was recommended. Combined OPCAB-LDLT was decided after multidisciplinary discussion about possible perioperative cardiovascular risks. In the operating room, patient was identified and monitored with pulse oxymeter, noninvasive blood pressure, and 5-lead ECG (II, V5). General anesthesia was induced using etomidate 20 mg and vecuronium 10 mg and maintained with sevoflurane in oxygen-medical air mixture (1 L/min each). Incremental doses of ephedrine 5 mg were administered due to hypotension (systolic blood pressure below 70 mmhg) immediately after induction. After invasive arterial and venous cannulation (right radial artery, femoral artery, and femoral vein), a Swan-Ganz catheter (Edwards lifesciences, Irvine, CA, USA) was inserted through 9-Fr Advanced Venous Access catheter (Edwards lifesciences, Irvine, CA, USA) placed in right internal jugular vein for hemodynamic monitoring and blood sampling. Two units of fresh frozen plasma were administered as a preemptive step to decrease the risk of variceal bleeding (patient s PT was 1.77 INR) and transesophageal echocardiography (TEE) probe was inserted cautiously in order not to tear his esophageal variceal lesions. There was no color change in 109

3 Vol. 57, No. 1, July 2009 nasogastric drainage tube drainage after TEE insertion. We started to infuse dopamine (3 μg/kg/min) and nitroglycerine (0.5 μg/ kg/min) intravenously. OPCAB was started with median sternotomy. Left internal mammary artery and left great saphenous vein grafts were simultaneously harvested for grafting. During the harvesting, TEE findings were not so different from preoperative results. His left ventricular ejection fraction was estimated to be 42% by modified Simpson s method with severe hypokinesia. To assist patient s heart function, we elevated the rate of dopamine infusion to 5 μg/kg/min. Cardiac output and pulmonary capillary wedge pressure (PCWP) measured by pulmonary artery catheter were 8.4 L/min and 10 mmhg, respectively. Heparin 30 mg was injected before main bypass grafting and activated clotting time checked 5 minutes after heparin injection was 292 seconds. End-to-side anastomosis of left internal mammary artery to LAD, end-to-side anastomosis of left great saphenous vein to RCA, and end-to-side anastomosis of left great saphenous vein to ascending aorta under partial clamping of aorta were performed sequentially. At the end of main procedure, heparin effect was reversed with 30 mg of protamine. After bleeding control, chest tube was inserted to patient s mediastinum and sternum was wired without skin closure. Subsequent TEE showed slightly improved regional wall motion in anterior and inferior walls. LDLT began with upper abdominal incision and we changed inhalation agent from sevoflurane to desflurane after the application of abdominal retractor. We choose 0.9% normal saline as a main fluid and its rate was adjusted by mixed venous oxygen saturation and hemodynamic parameters including TEE, central venous pressure (CVP), PCWP, and right ventricular end-diastolic volume. After the removal of large amount of ascites (2,100 ml), we noticed yellow staining of intra-abdominal organs suggesting bile leakage and Cell-Saver was stopped thereafter. During the anhepatic phase, a porto-caval shunt was created to mitigate hemodynamic instability until the beginning of portal vein anastomosis. Partial clamping of inferior vena cava for an anastomosis of graft liver to recipient s vasculature raised femoral venous pressure up to 33 mmhg. Transient hypotension was normalized after adjustment for the extent of clamping and fluid loading with 500 ml of hetastarch and 1,300 ml of 0.9% normal saline during the time without liver. Immediately before the reperfusion, while suturing posterior wall of portal vein, inhalation anesthetic agent was stopped Korean J Anesthesiol and FiO 2 was increased to 1.0. Dopamine was infused continuously at a rate of 5 μg/kg/min and emergency medications such as bolus epinephrine and atropine were prepared. During the reperfusion, cardiac functions were continuously monitored with TEE and leftward deviation of interatrial septum and large amount of microbubbles were observed. The shape of left ventricle was deformed slightly to D-shape suggesting right ventricular volume loading. Systolic blood pressure was dropped to about 60 mmhg and 20 μg epinephrine followed by 30 μg was immediately injected to restore blood pressure. There was no change in his ECG and heart rate did not change significantly. After five minutes, vital signs were all stabilized and TEE showed minimal tricuspid regurgitation and moderate hypokinesis of anterior, inferior, and inferoseptal left ventricular walls. Total operation time was 11.5 h. Cold and warm liver ischemic times were 88 and 23 minutes, respectively. Total amount of infused fluid and blood components were: normal saline 10,897 ml, hydroxyethylstarch 1,500 ml, 5% dextrose 150 ml, 8 leukocyte-depleted red blood cell units (2 units during OPCAB and 6 during LDLT), 4 fresh frozen plasma units (2 units during induction and 2 units during LDLT) and 1 unit of platelet obtained by plateletpheresis. Cell saver blood 235 ml was re-infused to the patient during OPCAB. The amount of chest tube drainage was 420 ml of bloody fluid, and total urine output was 332 ml averaging about 30 ml/h. Estimated blood loss was 4,500 ml. The laboratory and hemodynamic data as the course of procedures were summarized in Table 2. Patient was transferred to intensive care unit postoperatively and was extubated on the next day. Vital signs were all stable without inotropic support and pulmonary artery catheter was removed on the second postoperative day. There were patent vascular and biliary structures in abdominal sonography and no remarkable ECG and echocardiographic changes comparing to preoperative data on fifth postoperative day. Elevated cardiac enzymes immediate postoperative period were normalized on the next postoperative day. Postoperative urine output was maintained at a rate of 100 ml/hr. After eight ICU days, he was transferred to general ward and was discharged on the 54th postoperative day without any cardiovascular complication. DISCUSSION Although CAD has been thought to be a contraindication for liver transplantation because high perioperative mortality and 110

4 Kim et al:combined OPCAB and LDLT Table 2. Intraoperative Laboratory and Hemodynamic Data After induction End of OPCAB End of 5 minutes after Peritoneum anhepatic phase reperfusion closure Na/K/Ca (meq/l) 136.4/4.04/ /4.36/ /4.55/ /4.44/ /4.77/0.93 Glucose (mg/dl) Hb (g/dl)/hct (%) 9.3/27 9.4/28 8.3/24 9.7/ /36 Plt (/μl)/fib (mg/dl) 42k/205 48k/121 75k/117 76k/112 58k/113 INR (INR) aptt (sec) ACT (sec) HR (/min) BP (S/M/D) 110/77/60 105/71/52 104/72/50 114/82/58 89/60/43 CVP/IVCP 9/14 3/5 6/8 9/11 6/8 PAP (S/M/D) 29/19/14 23/13/8 27/17/10 33/21/14 25/17/10 PCWP/RVEDV 10/193 3/154 13/162 9/213 /207 CO/RVEF 5.3/44 4.6/43 4.5/40 3.8/33 4.4/23 Hb: hemoglobin, Plt: platelet, INR: international normalized ratio, aptt: activated partial thromboplastin time, ACT: activated clotting time, HR: heart rate, BP: blood pressure (S: systolic, M: mean, D: diastolic), CVP: central venous pressure, IVCP: inferior vena cava pressure, PAP: pulmonary artery pressure pressure (S: systolic, M: mean, D: diastolic), PCWP: pulmonary capillary wedge pressure, RVEDV: right ventricular end diastolic volume, CO: cardiac output, RVEF: right ventricular ejection fraction. morbidity are expected [1], we could find several reports about successful outcomes of staged or combined CABG and liver transplantation [2,3]. After advanced 2-vessel CAD was detected in this patient, we should decide whether or not to proceed with liver transplantation and make priority-based choices related to the technical issues. Our patient had totally occluded coronary anatomy and he was not suitable for percutaneous revascularization. In such case of advanced CAD, the patient was deemed not to endure dramatic hemodynamic and metabolic changes during liver transplantation. Although there were several reports about successful anesthetic and surgical experience with various methods, OPCAB technique requires less heparin and was thought to be more physiologic procedure than conventional CABG procedures using cardiopulmonary bypass pump and full heparinization. Therefore, OPCAB was planned prior to LDLT. There were several anesthetic and surgical considerations intraoperatively. First, we should regulate appropriate anticoagulation status during OPCAB. Although the usually required dose of heparin is 1.5 mg/kg, we reduced the dose to 0.5 mg/kg (30 mg) in our patient because preoperative coagulopathy in patients with end stage liver disease could result in over derangement of coagulation even with the recommended dose of heparin. Although visual inspection of mediastinal structures can give many information to anesthesiologists about the causes of acute hemodynamic instability and on-site estimation of blood coagulation status [4], sternum was closed by metal wire without skin closure to prevent possible mediastinitis that was possible if there was spillage of contaminated bile or spontaneous bacterial peritonitis. Second, we should find the surgical modification for hemodynamic stability. With the extensively developed collateral vessels in patients with ESLD and modified surgical techniques like piggy-back procedure, acute hemodynamic changes do not occur frequently in anhepatic phase. However, patients with ischemic heart disease secondary to CAD usually have limited cardiac reserves and even subtle hemodynamic derangements can precipitate severe intraoperative complications. Therefore, in our patient, a porto-caval shunt was created to preserve certain amount of preload from portal blood flow during anhepatic phase. Third, in addition to routine monitoring procedures in liver transplantation at out hospital, we used TEE in this patient. Real time updating by direct visualization was the most useful merit of TEE during critical period such as reperfusion phase and it can detect regional wall dysfunctions from the dynamic rather than pressure changes [5,6]. However, TEE monitoring requires experienced hands in addition to the risks of orogastric injury, variceal bleeding, and recurrent laryngeal nerve damage. In this patient, we infused 2 units of fresh frozen plasma before insertion of TEE because preoperative laboratory data showed thrombocytopenia. TEE findings were monitored throughout the operation and very useful information about cardiac functions 111

5 Vol. 57, No. 1, July 2009 Korean J Anesthesiol especially during reperfusion phase could be obtained. Direct visualization of heart function and volume status guided us to manage patient s hemodymics appropriately. In conclusion, we cautiously suggest that combined OPCAB- LDLT can be a surgical option for the patients with ESLD and high-risk CAD. However, clinical outcomes of the combined procedures are remained yet to be evaluated. REFERENCES 1. Plotkin JS, Scott VL, Pinna A, Dobsch BP, De Wolf AM, Kang Y. Morbidity and mortality in patients with coronary artery disease undergoing orthotopic liver transplantation. Liver Transpl Surg 1996; 2: Ben Ari A, Elinav E, Elami A, Matot I. Off-pump coronary artery bypass grafting in a patient with Child class C liver cirrhosis awaiting liver transplantation. Br J Anaesth 2006; 97: Axelrod D, Koffron A, Dewolf A, Baker A, Fryer J, Baker T, et al. Safety and efficacy of combined orthotopic liver transplantation and coronary artery bypass grafting. Liver Transpl 2004; 10: Massad MG, Benedetti E, Pollak R, Chami YG, Allen BS, DeCastro MA, et al. Combined coronary bypass and liver transplantation: technical considerations. Ann Thorac Surg 1998; 65: Burtenshaw AJ, Isaac JL. The role of trans-oesophageal echocardiography for perioperative cardiovascular monitoring during orthotopic liver transplantation. Liver Transpl 2006; 12: Donovan CL, Marcovitz PA, Punch JD, Bach DS, Brown KA, Lucey MR, et al. Two-dimensional and dobutamine stress echocardiography in the preoperative assessment of patients with end-stage liver disease prior to orthotopic liver transplantation. Transplantation 1996; 61: