Skip to main content
Download PDF

Coronary artery bypass grafting in patients with malignancy: a single-institute case series of eight patients

BMC Surgery volume 22, Article number: 359 (2022) Cite this article

Abstract

Background

The surgical strategy among patients with malignancy and coronary artery disease (CAD) remains controversial. In this study, we present the experiences of coronary artery bypass grafting (CABG) in patients with malignancy and analyzed the treatment outcomes.

Methods

From January 2011 to October 2021, eight patients combined with coronary artery disease and malignancy, six of them with three-vessel disease and two with anterior descending branch lesions on coronary angiography. The age ranged from 54 to 73 years (61.8 ± 7.7years). Four patients underwent CABG and staging for surgical oncology, and 2 patients underwent CABG and surgical oncology simultaneously. Four patients underwent CABG procedure with cardiopulmonary bypass (on-pump CABG), and the other patients underwent the procedure without cardiopulmonary bypass (off-pump CABG). All patients were followed up for 3 to 96 months (40.4 ± 31.5 months) postoperatively.

Results

The mean number of grafts was 2.6 ± 1.1, there was no in-hospital death, postoperative myocardial infarction, and stroke. Among the eight patients, one patient received chemotherapy and radiation before bypass surgery, which occurred postoperatively pulmonary infection, and the rest of 7 patients had no major adverse cardiovascular events during follow-up periods.

Conclusion

Based on the results of the present study, simultaneous or staged CABG and oncologic surgery according to the TNM stage of the tumor and cardiac assessment is an effective treatment for patients with severe CAD combined with malignancy.

Peer Review reports

Background

Cardiovascular disease and malignant disease are the leading causes of death in many parts of the world. Both diseases have similar populations and face the same risk factors (e.g. use of tobacco, aging, and obesity) so the simultaneous presence of both diseases is not rare . The prevalence of malignancy and coronary heart disease among male patients was about 7% [1,2,3]. The presence of malignancy in cardiovascular series ranged between 1.9 and 4.2%, and cardiovascular disease was present in 25% of malignant patients [4,5,6,7]. Meanwhile, radio- and chemo-therapy in malignancy also impacted the heart [8]. Cardiac surgery for patients with malignancy is also a major challenge for cardiac surgeons, and the reduced predictable survival time for malignancy has an impact on their surgical choices. Studies have shown that myocardial revascularization in patients with combined coronary artery disease can make subsequent oncological surgery or chemotherapy safer and increase the patient’s long-term survival [9, 10].

The effect of cardiopulmonary bypass (CPB) on malignant cell growth and dissemination is not clear [11, 12]. Some studies demonstrated that the use of CPB could inhibit both cell-mediated and humoral immunity [13]. For these reasons, there are still many conflicting treatment strategies for patients with coronary artery disease and malignancy.

The aim of this study was to analyze the outcome of surgical treatment of severe coronary artery disease in combination with malignancy, to identify its risk factors and their impact on immediate and long-term outcomes, and to further explore its surgical treatment strategies.

Methods

Patients

This retrospective study was approved by the Ethics Committee of First Hospital of Tsinghua University (No.20,220,008). We reviewed the hospital’s database and analyzed the chart datum, surgical records, and imaging data. From January 2011 to November 2021, a total of 8 cases, including 6 males and 2 females, aged 54–72 (61.8 ± 7.7) years, with malignancy combined with severe coronary artery disease, were treated at the Heart Centre of the First Hospital of Tsinghua University. Malignant tumors include lung, rectum, colon, bladder, esophagus, thymoma, gastric lymphoma, and parotid lymphoma (parotid non-Hodgkin’s lymphoma surgery and tissue diagnosis in another hospital). Three patients had the symptoms of myocardial ischemia, one patient had a history of myocardial infarction. The remaining 4 patients had no symptoms of myocardial ischemia before malignancy was diagnosed. On coronary angiography, six patients had the three-vessel disease, including two cases of combined left main coronary artery disease. Two cases had left anterior descending artery lesions. Four patients had ST-segment downward shift and T-wave hypoplasia or inversion on electrocardiogram (ECG) at presentation, and one case had pathological Q waves. There were two cases with New York Heart Association cardiac function class I, 5 cases with class II, and one case with class III. The echocardiographic examination of the left ventricular end-diastolic diameter was 44–52 (45.6 ± 4.3) mm, and the left ventricular ejection fraction was 31–65% (54.1 ± 10.5%). Preoperative clinical characteristics are shown in Table 1. All patients underwent a routine clinical examination before surgery.

Table 1 Preoperative characteristics of the patients
Full size table

Surgical approach

Indications for CABG: (i) according to the preoperative tumor, node, and metastasis (TNM) stage, if the tumor was in an early stage (stage I or II) or in patients who were amenable to radical surgery, and the estimated prognosis is > 1 year, and/or (ii) when CAD precluded oncologic treatment (surgery or chemotherapy) and that was mandatory to improve the patient’s prognosis [10]. Exclusion criteria: tumor metastasis; other concomitant cardiovascular diseases; important organ failure; and other contraindications to surgery. The CABG procedure was performed using on-pump or off-pump as determined by the patient’s condition and the surgeon’s experience.

Conventional coronary artery bypass grafting (CABG) was conducted via a standard median sternotomy and CPB was established between the aorta and right atrium. Cardioplegia was given in an antegrade manner. Off-pump CABG procedure was performed via either small anterolateral thoracotomy for revascularization of the left anterior descending artery (LAD) using the left internal mammary artery (LIMA), or median sternotomy for multiple revascularizations. The LIMA was used as a bypass graft for the left anterior descending branch in all patients, and the saphenous veins as bypass grafts for the other target vessels. The off-pump CABG procedure was performed using a coronary target vessel local stabilization device (Medtronic Inc., Minneapolis, MN, USA) for compression and fixation, and the proximal coronary artery was blocked with a silicone band. A 7 − 0 polypropylene suture was used for the distal coronary artery anastomosis and a 6 − 0 suture for the proximal end.

Postoperative treatment and follow-up

After coronary artery bypass grafting surgery, all patients received appropriate anti-tumor therapy and were analyzed for cardiac adverse events. The current status of the patients was recorded using outpatient visit notes or telephone follow-up.

Results

Four patients underwent conventional CABG and 4 patients underwent off-pump CABG. Four patients underwent the staged technique, and the lapse time between cardiac operations and cancer operations varied from 1 to 3 months. One patient with malignant gastric lymphoma and one patient with parotid non-Hodgkin’s lymphoma received standardized chemotherapy before cardiac operations. The tumor location and histological diagnosis are described in Table 2. One patient with a postoperative sternal fracture was healed after the re-fixation of the sternum. There were no mediastinal infections and no in-hospital deaths, and all patients were discharged from the hospital. The perioperative and postoperative conditions are shown in Table 3.

Table 2 Patient profiles
Full size table
Table 3 Intraoperative and postoperative variables
Full size table

One patient with malignant non-Hodgkin’s lymphoma who received radiation therapy and also had pulmonary interstitial fibrosis and poor respiratory function had several postoperative pulmonary infections and later died of pulmonary infection. Seven patients recovered well without tumor recurrence or metastasis, and no cardiovascular adverse events such as angina pectoris, acute myocardial infarction, ventricular arrhythmias, sudden cardiac death, or heart failure occurred during follow-up periods.

Discussion

With an aging population and improved diagnostic techniques, a significant increase in patients with malignancy combined with coronary artery disease has been found, but perioperative cardiac complications are a major cause of death in patients undergoing non-cardiac surgery for severe coronary artery disease, the treatment strategy for patients with malignancy combined with coronary artery disease remains a challenge for cardiac surgeons [14]. Firstly, for patients with tumors treated with cytotoxic chemotherapy before cardiac surgery, this can easily cause cardiotoxicity and result in cardiac injury. The studies have found that chemotherapy drug-related cardiotoxicity is one of the main causes of death in patients, especially with anthracyclines (e.g. adriamycin) being the most common [2]. In the present study, one patient with gastric lymphoma underwent coronary artery bypass grafting after 3 months of chemotherapy, the preoperative assessment revealed a significant decrease in cardiac function compared to pre-chemotherapy, with an ejection fraction of less than 30%. In addition, radiation therapy is prone to complications of pericarditis, myocardial injury, valve injury, lung injury, and adverse cardiac events, especially for patients with ischemic heart disease [15,16,17]. One patient in our study with non-Hodgkin’s lymphoma with chemo- and radiotherapy-related pulmonary interstitial disease, recurrent respiratory insufficiency, and pulmonary infections after coronary artery bypass surgery. For oncology patients with combined unstable angina and acute myocardial infarction, they can receive coronary stenting before oncology surgery, but all patients require antiplatelet therapy after stent implantation and complete re-endothelialization after stenting takes approximately 4 weeks to 1 year, and antiplatelet drugs must meet the needs of the regimen or they are prone to in-stent thrombosis [18]. Studies have shown that patients who undergo non-cardiac surgery early after stenting have a significantly higher mortality rate due to in-stent thrombosis [19, 20].

In critical patients with left main coronary artery or three-vessel disease, coronary artery bypass surgery has significant advantages in reducing the incidence of adverse cardiac events during oncologic surgery and preventing thrombosis. Simultaneous coronary artery bypass operation and tumor resection have the advantages of economic benefits, less reoperation trauma, and no delay in tumor surgery, but also have the disadvantages of prolonged operative time and easy co-infection. One study found that simultaneous CABG and lung tumor resection is a safe and effective method, while also allowing earlier completion of lung surgery and avoiding complications caused by delayed surgery [21]. Zhang and colleagues [22] found that simultaneous surgery for CABG and esophageal cancer is safe and reliable. In our study, two cases of simultaneous CABG and tumor surgery, including one case each of colon cancer and malignant thymoma, were performed without complications related to perioperative incisional infection, severe bleeding, or a lung infection. Patients with tumors undergoing staged CABG and tumor surgery had the advantage of a low incidence of adverse cardiovascular events, the interval between the two procedures ranged from 5 to 60 days, and it was also considered that there was no significant correlation between the recurrence or metastasis of the tumor and no correlation to the time between staged procedures [23]. In this study, four patients underwent coronary artery bypass surgery (esophageal cancer, bladder cancer, lung cancer, and rectal cancer) and staged radical tumor surgery, with an interval of approximately 1–3 months between the two procedures, and there were no in-hospital deaths, and no tumor metastasis or recurrence was found during the follow-up periods, and no cardiovascular adverse events such as angina pectoris, acute myocardial infarction, ventricular arrhythmia, sudden cardiac death or heart failure occurred.

The effect of extracorporeal circulation on the growth and spread of malignant tumor cells is not fully understood. It has been suggested that extracorporeal circulation directly suppresses humoral and cellular immunity in patients, thereby affecting the spread of tumor cells. Tønnesen’s study demonstrated that extracorporeal circulation inhibits the cytotoxic function of natural killer (NK) cells against tumor cells and causes a decrease in complement, lymphocytes, and neutrophils [24]. Chen and colleagues [25] found that extracorporeal circulation was acceptable for the risk of distant metastases after complete resection of thoracic malignancies in 14 cases of massive thoracic tumors resected under extracorporeal circulation with long-term follow-up. In addition, several reports comparing on-pump and off-pump CABG in cancer patients have shown no significant major adverse effect of extracorporeal circulation on cancer recurrence and late-stage survival [10, 11, 26].

In our study, four patients underwent myocardial revascularization under extracorporeal circulation and four patients without extracorporeal circulation. All patients had no postoperative distant metastases. This study demonstrated that complete myocardial revascularization under extracorporeal circulation can reduce the incidence of cardiac adverse events in the perioperative period and surgical oncology. However, the absence of distant metastases may also be related to the early TNM stage of the tumor in this study.

There were several limitations to the study. First, this is a retrospective study with a small sample number. Recall bias in the clinical course cannot be denied. More cases of the malignant disease combined with CAD are needed to confirm clinical data. Secondly, the distribution of diseases in this study is scattered, including gastrointestinal, respiratory, urinary, and thymic malignancies, and malignant lymphoma and further classification studies are a challenge. The value of TNM staging of tumors in the selection of treatment strategies for patients with malignancy combined with coronary artery disease requires further research.

Conclusion

Coronary artery bypass surgery can reduce the incidence of cardiovascular adverse events in patients with malignancy on antineoplastic therapy and its perioperative period. Depending on the patient’s condition, simultaneous coronary artery bypass grafting surgery and surgical oncology treatment is a safe and effective treatment option.

Data Availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

CAD:

Coronary artery disease.

CABG:

Coronary artery bypass grafting.

CPB:

Cardiopulmonary bypass.

ECG:

Electrocardiogram.

LAD:

Left anterior descending artery.

LM:

Left main coronary artery disease.

VD:

Vessel disease.

LIMA:

left internal mammary artery.

ARDS:

Acute respiratory distress syndrome.

ICU:

Intensive care unit.

MI:

Myocardial infarction.

References

  1. Tuzovic M, Yang EH, Sevag Packard RR, Ganz PA, Fonarow GC, Ziaeian B. National outcomes in hospitalized patients with cancer and comorbid heart failure. J Card Fail. 2019;25:516–21.

    Article  Google Scholar 

  2. Totzeck M, Schuler M, Stuschke M, Heusch G, Rassaf T. Cardio-oncology- strategies for management of cancer-therapy related cardiovascular disease. Int J Cardiol. 2019;280:163–75.

    Article  Google Scholar 

  3. Reicher-Reiss H, Jonas M, Goldbourt U, Boyko V, Modan B. Selectively increased risk of cancer in men with coronary heart disease. Am J Cardiol. 2001;87:459–62.

    Article  CAS  Google Scholar 

  4. Vieira RD, Pereira AC, Lima EG, Garzillo CL, Rezende PC, Favarato D, et al. Cancer-related deaths among different treatment options in chronic coronary artery disease: results of a 6-year follow-up of the MASS II study. Coron Artery Dis. 2012;23:79–84.

    Article  Google Scholar 

  5. Mistiaen WP, Van Cauwelaert P, Muylaert P, Wuyts F, Harrisson F, Bortier H. Effect of prior malignancy on survival after cardiac surgery. Ann Thorac Surg. 2004;77:1593–7.

    Article  Google Scholar 

  6. Chan J, Rosenfeldt F, Chaudhuri K, Marasco S. Cardiac surgery in patients with a history of malignancy: increased complication rate but similar mortality. Heart Lung Circ. 2012;21:255–9.

    Article  Google Scholar 

  7. Mistiaen WP. Cancer in heart disease patients: what are the limitations in the treatment strategy? Future Cardiol. 2013;9:535–47.

    Article  CAS  Google Scholar 

  8. Curigliano G, Cardinale D, Suter T, Plataniotis G, de Azambuja E, Sandri MT, et al. Cardiovascular toxicity induced by chemotherapy, targeted agents and radiotherapy: ESMO Clinical Practice Guidelines. Ann Oncol. 2012;23(Suppl 7):vii155–66.

    Article  Google Scholar 

  9. Donisan T, Balanescu DV, Palaskas N, Lopez-Mattei J, Karimzad K, Kim P, et al. Cardiac interventional procedures in cardio-oncology patients. Cardiol Clin. 2019;37:469–86.

    Article  Google Scholar 

  10. Garatti A, D’Ovidio M, Saitto G, Daprati A, Canziani A, Mossuto E, et al. Coronary artery bypass grafting in patients with concomitant solid tumours: early and long-term results. Eur J Cardiothorac Surg. 2020;58:528–36.

    Article  Google Scholar 

  11. Suzuki S, Usui A, Yoshida K, Matsuura A, Ichihara T, Ueda Y. Effect of cardiopulmonary bypass on cancer prognosis. Asian Cardiovasc Thorac Ann. 2010;18:536–40.

    Article  Google Scholar 

  12. Darwazah AK, Shehata S. Detrimental effect of cardiopulmonary bypass (CPB) on malignant disease. J Cardiothorac Surg. 2011;6:13.

    Article  Google Scholar 

  13. Knudsen F, Andersen LW. Immunological aspects of cardiopulmonary bypass. J Cardiothorac Anesth. 1990;4:245–58.

    Article  CAS  Google Scholar 

  14. Duceppe E, Parlow J, MacDonald P, Lyons K, McMullen M, Srinathan S, et al. Canadian cardiovascular society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery. Can J Cardiol. 2017;33:17–32.

    Article  Google Scholar 

  15. Armanious MA, Mohammadi H, Khodor S, Oliver DE, Johnstone PA, Fradley MG. Cardiovascular effects of radiation therapy. Curr Probl Cancer. 2018;42:433–42.

    Article  Google Scholar 

  16. Reshko LB, Kalman NS, Hugo GD, Weiss E. Cardiac radiation dose distribution, cardiac events and mortality in early-stage lung cancer treated with stereotactic body radiation therapy (SBRT). J Thorac Dis. 2018;10:2346–56.

    Article  Google Scholar 

  17. Atkins KM, Rawal B, Chaunzwa TL, Lamba N, Bitterman DS, Williams CL, et al. Cardiac radiation dose, cardiac disease, and mortality in patients with lung cancer. J Am Coll Cardiol. 2019;73:2976–87.

    Article  Google Scholar 

  18. Ge J, Yu H, Li J. Acute coronary stent thrombosis in modern era: etiology, treatment, and prognosis. Cardiology. 2017;137:246–55.

    Article  Google Scholar 

  19. Armstrong EJ, Graham L, Waldo SW, Valle JA, Maddox TM, Hawn MT. Patient and lesion-specific characteristics predict risk of major adverse cardiovascular events among patients with previous percutaneous coronary intervention undergoing noncardiac surgery. Catheter Cardiovasc Interv. 2017;89:617–27.

    Article  Google Scholar 

  20. Rodriguez A, Guilera N, Mases A, Sierra P, Oliva JC, Colilles C. Management of antiplatelet therapy in patients with coronary stents undergoing noncardiac surgery: association with adverse events. Br J Anaesth. 2018;120:67–76.

    Article  CAS  Google Scholar 

  21. Li Z, Liu B, Ge W, Zhang W, Gu C, Liu J, et al. Effect of simultaneous surgical treatment of severe coronary artery disease and lung cancer. J Int Med Res. 2019;47:591–9.

    Article  Google Scholar 

  22. Zhang W, Liu B, Zhou Y, Wang F, Gu C, Wang Q, et al. Combined surgical treatment of esophageal cancer and coronary heart diseases in elderly patients. World J Surg Oncol. 2018;16:213.

    Article  Google Scholar 

  23. Darwazah AK. Surgical management of coronary artery disease associated with malignancy. J Card Surg. 2012;27:581–8.

    Article  Google Scholar 

  24. Tønnesen E, Brinkløv MM, Christensen NJ, Olesen AS, Madsen T. Natural killer cell activity and lymphocyte function during and after coronary artery bypass grafting in relation to the endocrine stress response. Anesthesiology. 1987;67:526–33.

    Article  Google Scholar 

  25. Chen L, Zhu X, Zhu R, Jin X, Tan L, Chen Y. Cardiopulmonary bypass does not consequentially contribute to postoperative distant metastasis of giant refractory thoracic tumors: A retrospective study with long-term follow-up. Thorac Cancer. 2021;12:2990–5.

    Article  Google Scholar 

  26. Schoenmakers MC, van Boven WJ, van den Bosch J, van Swieten HA. Comparison of on-pump or off-pump coronary artery revascularization with lung resection. Ann Thorac Surg. 2007;84(2):504–9.

    Article  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

This work was supported by the Chaoyang District Science and Technology Foundation (No. CYSF1711).

Author information

Authors and Affiliations

  1. Heart Center, First Hospital of Tsinghua University, No.6, 1st street, Jiuxianqiao, Chaoyang District, 100016, Beijing, China

    Ming-Kui Zhang, Han-Wen Zhang, Qing-Yu Wu, Hui Xue & Li-Xin Fan

Authors
  1. Ming-Kui Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Han-Wen Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Qing-Yu Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hui Xue
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Li-Xin Fan
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Ming-Kui Zhang and Qing-Yu Wu performed the surgical procedures. Hui Xue, and Li-Xin Fan were involved in the patients’ care. Han-Wen Zhang collected clinical the clinical data. Ming-Kui Zhang prepared the manuscript. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Ming-Kui Zhang.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of First Hospital of Tsinghua University (No.20220008), and informed consent was waived by the Ethics Committee of First Hospital of Tsinghua University. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no conflicts of interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zhang, MK., Zhang, HW., Wu, QY. et al. Coronary artery bypass grafting in patients with malignancy: a single-institute case series of eight patients. BMC Surg 22, 359 (2022). https://doi.org/10.1186/s12893-022-01805-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12893-022-01805-7

Keywords

BMC Surgery

ISSN: 1471-2482

Contact us