Coronary artery bypass grafting in inflammatory bowel disease: two case reports | |
DOI: 10.5606/e-cvsi.2016.397 | |
Yüksel Dereli1, Ömer Tanyeli1, Özgür Altınbaş1, İlker Dal2, Niyazi Görmüş1 | |
1Department of Cardiovascular Surgery, Necmettin Erbakan University, Meram Medical Faculty, Konya, Turkey 2Department of Cardiovascular Surgery, Siirt State Hospital, Siirt, Turkey |
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Keywords: Beating heart; Crohn’s disease; inflammatory bowel disease; ulcerative colitis | |
The administration of coronary artery bypass grafting for coronary artery disease with inflammatory bowel disease has been rarely
reported. Patients with inflammatory bowel disease have an increased risk for thrombotic events. Also, inflammatory bowel disease is seen
in the protein-losing enteropathy and development of heparin resistance is associated with a deficiency of antithrombin III. In this article,
we present two cases with ulcerative colitis and Crohn's disease who underwent off-pump coronary artery bypass grafting. |
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Inflammatory bowel disease (IBD) is an inflammatory
condition which predominately affects the
gastrointestinal tract; however it can also affect any
organ outside the gastrointestinal system.[1] Crohn's
disease (CD) and ulcerative colitis (UC) are the two
major forms of IBD. Clinically, IBD is characterized
by multiple relapses and remissions with an unknown
etiology. However, several evidences suggest that gut
tissue injury is the result of an abnormal immune
response and involves multiple non immune cellular
systems, including intestinal microvascular endothelial
cells.[1] Patients with IBD have also an increased
risk for coagulation disorders, such as protein-losing
enteropathy, and development of heparin resistance
is associated with a deficiency of antithrombin-III
(AT-III). Thus, we believe that the off-pump (beating
heart) coronary artery bypass grafting (CABG) is
more appropriate for coroner bypass surgery in these
patients. In this article, we report two IBD cases who
underwent CABG surgery with off-pump technique. |
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CASE PRESANTATION
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Case 1– A 71-year-old male patient was admitted
to our cardiology department with a complaint of
acute chest pain. The patient underwent coronary
angiography which revealed total occlusion of the left
anterior descending (LAD) artery, 80% stenosis in the
first diagonal branch (D1), and 80% proximal stenosis
of the right coronary artery (RCA). The patient was
referred to our clinic for CABG surgery. A year earlier,
the patient was diagnosed with CD. The patient
was under follow-up and recently the CD disease was in remission. Physical examination and routine
laboratory test results were normal. The patient was
consulted to the gastroenterology department. Surgery
was advised to the patient. He was informed about the
procedure and a written informed consent was taken
for surgery. With off-pump technique, a three-vessel
CABG surgery was performed: left internal mammary
artery (LIMA) to the LAD and saphenous vein as a
graft to the D1 and RCA arteries. Thoracic drainage
fluid in the postoperative period was 420 mL. No
postoperative complication was seen and the patient
was discharged uneventfully. Case 2– A 71-year-old male patient was admitted to our emergency department with acute myocardial infarction. The patient was referred to the cardiology department for coronary angiography. Coronary angiography demonstrated triple-vessel disease and the patient was referred to our clinic for CABG surgery. The patient had a diagnosis of UC 10 years ago. The patient was under follow-up and recently the UC disease was in remission. Physical examination and routine laboratory test results were normal. Coronary angiography revealed 90% stenosis of the LAD artery, 80% stenosis in the first obtuse margin branch (OM1), and total occlusion of the RCA. The patient was consulted to the gastroenterology department. Surgery was advised to the patient. He was informed about the procedure and a written informed consent was taken for surgery. With off-pump technique, a three-vessel CABG surgery was performed: LIMA to the LAD and saphenous vein as a graft to OM1 and RCA arteries. Thoracic drainage in the postoperative period was 350 mL. No postoperative complication was seen and the patient was discharged uneventfully. |
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Inflammatory bowel disease encompasses two different
but interrelated disorders: UC and CD. Ulcerative
colitis is characterized by superficial inflammation
which begins in the rectum and extends proximally
along the colon.[2] Crohn's disease is characterized by
transmural patchy inflammation and can involve any
region of the gastrointestinal tract from the mouth
to the anus.[2] Inflammation has a fundamental role
in the development and progression of endothelial
dysfunction. Endothelial dysfunction has been shown
to be associated with reduced nitric oxide and increased
oxidative stress and it has been described in patients
with different inflammatory conditions.[3] Recently, it has become increasingly evident that chronic systemic inflammation plays a critical role in the pathogenesis of atherosclerosis and many studies have suggested a positive correlation between IBD and the occurrence of ischemic heart disease (IHD). Multiple inflammatory mediators such as C-reactive protein, interleukin-6, tumor necrosis factor-alpha (TNF-a), matrix metalloproteinases-2 and 9 are associated with the increased incidence of IHD. In addition, some subclinical atherosclerosis markers such as increased carotid artery intimal medial thickness, increased arterial stiffness, and increased carotidfemoral pulse wave velocity and insulin resistance are higher in prevalence in patients with IBD independent of traditional IHD risk factors, which may suggest a rapid progression of atherosclerosis in this population.[4] Conventional CABG performed using cardioplegic arrest and cardiopulmonary bypass is well-defined in the literature. On-pump CABG is associated with higher cardiac, pulmonary, renal, neurological, bleeding, and other systemic complications. Thus, offpump CABG has gained an increased interest since 1990s as a strategy to prevent complications in highrisk patients, particularly. The main merit of off-pump CABG is the elimination of the many inflammatory insults associated with the use of the extracorporeal circuit and the ischemia-reperfusion injury associated with cardioplegic arrest and non-physiological flow.[5] Heparin resistance is defined as activated clotting time <400 second after full-dose heparinization for open heart surgery.[6] Antithrombin-III and alpha1- antitrypsin are the main inhibitors of the coagulation system. The plasma levels of these proteins decrease in protein-losing enteropathy, such as IBD. The loss of these two main coagulation system inhibitors can, thus, lead to thrombotic complications in patients with IBD.[6] We believe that off-pump CABG is a more appropriate option for these patients, as on-pump CABG requires anticoagulation due to extracorporeal circulation which necessitates high-dose heparin. Herein, both of our patients were operated with offpump technique successfully. In conclusion, patients with chronic inflammatory bowel disease are at high risk for cardiovascular morbidity and mortality. Management of these patients undergoing open heart surgery can be more troublesome associated with coagulation disorders and these patients are also at high risk for on-pump technique. Therefore, we believe that beating heart technique is a more appropriate option for this patient population.
Declaration of conflicting interests
Funding |
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