CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 4, May 2012
196
AFRICA
According to the advice of our infections committee, we
used only cephazolin Na for prophylactic antibiotic therapy.
Mediastinitis was observed in one patient and it was the only
infection-related complication encountered in our cases. This
was an acceptable infection rate and comparable with that of
open-heart surgery in the general population.
White blood cell count generally increases after open-heart
surgery, and CPB may stimulate a leucomoid reaction, which can
lead to a relapse in an otherwise quiescent illness.
6,7
In our study,
white blood cell count increased between acceptable ranges, as
seen in Table 1. The general opinion on cardiac surgery is that
it does not exacerbate haematological malignancies in low-risk
patients or those with low-grade disease (in the remission
period). However patients with an intermediate to high risk or
grade of disease may show progression and this may be the cause
of late death.
5
Our patients were all in complete remission and
there was no leucomoid reaction or relapse of the disease in the
follow-up period, as confirmed by the Haematology Department.
Bleeding is another potential complication in this group of
patients. Fecher
et al
.
5
reported a 16.6% rate of bleeding and it
was the main postoperative complication they observed. They
had only one mediastinal bleeding that led to re-operation,
and two cases of gastrointestinal and one of femoral artery
haemorrhage. They were not group related.
In our series, three patients (20%) had excessive bleeding in
the early postoperative period, showing a similar rate to that of
Fecher
et al
.
5
However, all were of mediastinal origin and led to
re-operation and all were patients with NHL. One of the cases
of haemorrhage was surgery related while a general leakage
was observed in the other two cases. We did not detect any
significantly low platelet count or elevated INR peri-operatively.
Bleeding was the only statistically significant difference
observed between the patients with CLL and NHL. We did not
find any reports in the literature regarding NHL and tendency to
haemorrhage and we felt that statistical analysis was not feasible
for some factors because of the small size of our study group.
However, it may be valuable in future clinical decisions.
This article has some limitations. It was retrospective and
lacked a control group of standard patients with CABG. The
number of patients and types of malignancies were different
among different institutions, therefore it was difficult to find a
large series of patients to determine the morbidity and mortality
rates in a homogeneous group.
Incomplete follow-up data was another shortcoming. In
previous reports, 30-day mortality rates ranged from zero to
17%.
2,5,9
In our series, there was no early mortality, but late
mortality was somewhat higher (33%). Three patients died
because of intracranial bleeding and two others due to unknown
reasons.
Samuels
et al
. pointed out that these patients’ long-term
outcomes are variable and non-cardiac related.
2
The high late-
mortality rate of our patients may be partially related to our
limited experience in this specific group of patients. Appropriate
long-term anti-aggregant therapy should be designed in
collaboration with haematology departments.
We surmise that the small number of patients seriously
affected the late-period outcomes and no predictive factors
for identifying such high-risk patients were found. Although
intracranial bleeding was a significant mortality factor,
prothrombin time, bleeding time and thrombocyte level were
in the normal range in all patients. Aspirin 100 mg was the
anti-aggregant therapy and it may have been responsible for
intracranial bleeding. However, there is no evidence and future
guidelines should describe a detailed approach and treatment.
It is reasonable to use less-invasive techniques (percutaneous
coronary interventions) in high-risk patients when they meet
the operative indications. However, these procedures require
heavy post-intervention anti-agregant therapy, and the risk for
intracranial bleeding would therefore remain high.
Predictive scores such as the Euroscore or the Society of
Thoracic Surgeons’ score have no predictive values for mortality
and morbidity in patients with haematological malignancies
undergoing cardiac surgery. Therefore, future studies giving
accurate rates of post-operative morbidity or mortality would
be of great use to provide a general approach for these patients.
Conclusion
Cardiac surgery can be undergone with acceptable early
postoperative outcomes in patients with haematological
malignancies. The expectations of the patient and surgeon
should be appropriately discussed and the medical team should
be focused on potential complications such as bleeding, infection
and prolonged hospital stay. Long-term multidisciplinary follow
up and adequate medical treatment are essential in prolonging
survival.
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