CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 8, September 2013
AFRICA
e1
Case Report
Mitral valve and coronary artery bypass surgeries
13 years after pneumonectomy for lung cancer
OZGUR DAG, MEHMET ALI KAYGIN, UMIT ARSLAN, ADEM KIYMAZ, NAIL KAHRAMAN, BILGEHAN ERKUT
Abstract
We successfully performed coronary artery bypass grafting
and mitral valve replacement in a 72-year-old man who had
undergone a left pneumonectomy 13 years previously due to
a malignant mass.The patient was admitted to our clinic with
symptoms of dyspnoea, palpitations, chest pain and fatigue.
He was diagnosed with mitral valve disease and two-vessel
coronary artery disease, as seen from echocardiography
and catheterisation studies. Conventional cardiopulmonary
bypass grafting was performed following sternotomy. The
patient’s heart was completely displaced to the left hemitho-
rax. Saphenous vein grafts were harvested. Distal anastomo-
ses were performed with the use of the on-pump beating-
heart technique without cross clamping. Afterwards a cross
clamping was placed and a left atriotomy was performed.
The mitral valve was severely calcific. A mitral valve replace-
ment was performed using number 27 mechanical valve
after the valve had been excised. The patient’s postoperative
course was uneventful. Cardiac contractility was seen to be
normal and the mitral valve was functioning on echocardiog-
raphy done in the second postoperative month.
Keywords:
cardiac surgery after pneumonectomy, mitral valve
replacement, coronary artery bypass grafting, lung mass
Submitted 27/9/12, accepted 24/4/13
Cardiovasc J Afr
2013;
24
: e1–e4
DOI: 10.5830/CVJA-2013-031
When open-heart operations are necessary in patients who
have undergone pneumonectomy, the unavoidable shift of
mediastinal structures should be carefully considered. Surgical
access, revascularisation procedures, and the institution of
cardiopulmonary bypass may all require approaches that differ
from the usual.
Pneumonectomy is a condition that may be problematic for
future open-heart surgery, which may be fraught with anatomical
and physiological problems. In patients with pneumonectomy,
severe pulmonary complications that may develop after open-
heart surgery cannot be well tolerated due to the limited
pumonary function and reserves of these patients.
1,2
Pneumonectomy results in anatomical and physiological
changes, which can have a deleterious effect on the performance
of subsequent open-heart operations, especially where it involves
multiple procedures. We report on a case of coronary artery
disease with valvular heart disease in a 72-year-old patient who
had undergone pneumonectomy 13 years before.
Case report
A 72-year-old man, who had undergone left pneumonectomy 13
years earlier for epithelial squamous-cell carcinoma, presented
with symptoms of unstable angina, palpitations and shortness
of breath. However, he had no clinical symptoms at rest and had
appeared fit for his age until the last six months.
On chest examination, respiratory sounds could not be heard
on the left hemithorax and precordial pulsation was detected on
the left sternal border. The apex beat was displaced laterally. On
auscultation, a mitral opening snap and diastolic rulman were
heard at the fifth intercostal space at the apex.
An electrocardiogram revealed atrial fibrillation of between
80 and 120 beats/min. Chest radiography and computed
tomography of the chest revealed that the cardiac silhouette was
displaced to the left hemithorax and there was intestinal gas in
the left hemithorax (Figs 1, 2). The right lung was fully expanded
and clear.
Department of Cardiovascular Surgery, Erzurum Regional
Training and Research Hospital, Erzurum, Turkey
OZGUR DAG, MD
MEHMET ALI KAYGIN, MD
UMIT ARSLAN, MD
ADEM KIYMAZ, MD
NAIL KAHRAMAN, MD
BILGEHAN ERKUT, MD,
Fig. 1. Pre-operative chest X-ray study showing marked
displacement of the heart shadow into the left pneumo-
nectomy space.
