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[Simultaneous MIDCAB and subtotal gastrectomy in an elderly patient with severe ischemic heart disease]
M Namba1, K Kooguchi, T Murakami
1Department of Anesthesiology, Kyoto Prefectural University of Medicine.
Insights
Minimally invasive coronary artery bypass grafting (MIDCAB) before gastric cancer surgery improved cardiac function in a high-risk patient. This combined approach may benefit selected patients with severe ischemic heart disease.
Area of Science:
- Cardiology
- Cardiac Surgery
- Gastrointestinal Surgery
Background:
- Severe ischemic heart disease and left ventricular dysfunction pose significant risks for major abdominal surgery.
- Advanced gastric cancer necessitates surgical intervention, such as subtotal gastrectomy.
Observation:
- An 81-year-old male patient with severe cardiac compromise was scheduled for subtotal gastrectomy.
- Minimally invasive coronary artery bypass grafting (MIDCAB) was performed prior to the abdominal procedure to optimize cardiac function.
- Anesthesia involved fentanyl, vecuronium, and sevoflurane, with edrophonium used to maintain heart rate below 60 bpm during coronary occlusion.
Findings:
- MIDCAB procedure was successfully completed, maintaining a heart rate of 50-60 bpm with a permissible hemodynamic decline.
- Post-MIDCAB, cardiac performance improved with low-dose dobutamine.
- Subsequent subtotal gastrectomy proceeded without complications, and the patient had an uneventful postoperative course.
Implications:
- Combined MIDCAB and abdominal surgery can be a viable strategy for selected patients with severe ischemic heart disease undergoing major gastrointestinal surgery.
- This approach may reduce perioperative risks and improve outcomes in high-risk surgical candidates.
- Further research is warranted to establish the broader applicability and long-term benefits of this combined surgical strategy.
Abstract:
An 81 year old man with severe ischemic heart disease and left ventricular dysfunction was scheduled for a subtotal gastrectomy for his advanced gastric cancer. His cardiac function was so poor that we performed minimally invasive coronary artery bypass grafting (MIDCAB; coronary artery bypass grafting without cardiopulmonary bypass for LAD through a small left thoracotomy), just before the abdominal operation. Anesthesia was induced and maintained with fentanyl, vecuronium and sevoflurane. To control heart rate below 60 bpm during local coronary occlusion for bypass grafting, edrophonium 5 mg was administered just before the occlusion. During the bypass grafting procedure, the patient's heart rate was maintained at 50-60 bpm and his hemodynamic profile slightly declined but was permissible. After bypass grafting, his cardiac performance was improved with low dose dobutamine. Subsequently subtotal gastrectomy was carried out. His postoperative course was uneventful. Combined MIDCAB and abdominal operation may be beneficial for selected patients with severe ischemic heart disease.