• E-mail
• Print
• Comment
• Font Size
• Digg
• del.icio.us
• Discuss article

Off-Pump Coronary Artery Bypass in a Patient With the Antiphospholipid Syndrome

Posted on: Wednesday, 8 June 2005, 03:00 CDT

Patients with antiphospholipid syndrome (APS) are prone to excessive postoperative morbidity and mortality after cardiovascular surgery because of its thromboembolic derangements. We present a case of coronary artery bypass grafting (CABG) in a patient with primary APS. He suffered from repetitive coronary occlusion after percutaneous transluminal coronary angioplasty (PTCA). Since his lupus anticoagulant level was found to be 217 s (normal, <50 s), he was diagnosed as the primary APS. He received steroid pulsation therapy with 1000 mg of prednisolone, double-filtration plasmapheresis (DFPP) and 50 mg of cyclophosphamide to attenuate the antibody activity. Four months after the last PTCA, he experienced chest pain and approximately 90% of stenosis in the left anterior descending (LAD) lesion was apparent, although the titer for the lupus anticoagulant was reduced to the normal range. He had drug allergy to ticlopidine hydrochloride and aspirin. Taken together, his disease was found to be resistant to these medical treatments, and surgical treatment was considered. Since cardiopulmonary bypass is known to exaggerate its coagulatory and fibrinolytic complications, off-pump CABG (OPCAB) was feasible in this case. The left internal thoracic artery (ITA) was anastomosed to the LAD using the off-pump technique. The procedure was successful, and the postoperative course for 3 years has been satisfactory without any cardiovascular complaints.

KEY WORDS: Coronary artery bypass grafting - Antiphospholipid syndrome - Percutaneous transluminal coronary angioplasty.

Antiphospholipid syndrome (APS) is known to present several thromboembolic complications including arterial and/or venous thrombosis, recurrent abortion and thrombocytopenia. Clinical features include stroke, transient ischemic attack, livedo reticularis, pulmonary hypertension and cardiac valve disease.1 Since the cardiopulmonary bypass in cardiovascular surgery is likely to induce thrombotic and/or fibrinolytic derangements,2 careful perioperative management is required for the surgical patients especially with thromboembolic disorders such as APS.3

Herein, we present a case of off-pump coronary artery bypass grafting (OPCAB) in a patient with repetitive coronary occlusion clue to primary APS.

Case report

A 66 year-old male was admitted to the hospital with an acute myocardial infarction. Since his coronary angiography demonstrated 90% stenosis in the left anterior descending (LAD) lesion (segment 6- 7), he immediately underwent plain old balloon angioplasty (POBA). On the next day and 3 days after the first event, however, he suffered from acute coronary occlusion in the same lesion repeatedly. He underwent percutaneous transluminal coronary angioplasty (PTCA) including starting each time. Revasculization by PTCA was successful each event. Then, he was commenced on 3 mg of warfarin potassium, aiming for an international normalized prothrombin time ratio (PT-INR) of 3 to 3.5, 200 mg of cilostazol and intravenous infusion of 20 000 units of heparin. However, 6 days after the induction of this anticoagulation therapy, he experienced chest pain, and coronary angiography demonstrated approximately 90% of stenosis in the LAD lesion. PTCA was successful. His lupus anticoagulant level at this time was found to be 217 s (normal, <50 s) and he was diagnosed as the primary APS. Then, he received steroid pulsation therapy with 1 000 mg of prednisolone and double- filtration plasmapheresis (DFPP) for a consecutive 4 days, and began to take 50 mg of cyclophosphamide, an immunosuppressant, to attenuate the antibody activity. Four months after the last PTCA. he experienced chest pain and approximately 90% of stenosis in LAD lesion was apparent; the lesions in the OM1 and OM2 were not significant in the coronary angiography and at our precise estimation revealed that both lesions have less than 75% of stenoses (Figure 1). The titer for the lupus anticoagulant was reduced to the normal range. He has also been suffering from bronchial asthma, diabetes mellitus type 2 and multiple brain infarctions. In addition, he had drug allergy to tidopidine hydrochloride and aspirin. Eventually, surgical treatment using off-pump technique was considered. The operation was performed through a mediansternotomy. The internal thoracic artery (ITA) graft was anastomosed to the LAD. During the operation, 5 000 units of heparin were infused before snaring the LAD. After sewing the ITA graft to the LAD, neutralization by protamine sulfate was not performed in order to prevent perioperative coagulatory complications. The operation was successfully completed without any complications. On the day after the operation, the DFPP was performed. The administrations of cyclophosphamide (50 mg) and warfarin potassium (3 mg) were also resumed. Coronaiy angiography 1 month after the surgery demonstrated that the ITA graft was patent (Figure 2). The postoperative course for 3 years has been satisfactory with no ischemic symptoms.

Figure 1.-Preoperative coronary angiography demonstrates that a significant stenotic lesion in LAD (segment 7) is apparent.

Figure 2.-Coronary angiography 1 month after the surgery demonstrates that the ITA graft is patent.

Discussion

APS is characterized by widespread arterial and/or venous thrombosis in the presence of the antiphospholipid antibodies (aPL). Harris et al. first reported a relationship between aPL and thrombosis in 1983,4 which was later termed the anticardiolipin syndrome.5 The major cardiovascular complications are reported to be valvular disease (particularly mitral valve involvement) and few cases of myocardial infarction.6 Several reports have implicated a relationship between coronary heart disease and APS.7,8 Approximately 20% of patients younger than 45 year-old with myocardial infarction have been shown to present increased levels of aPL titer.7 A correlation between preoperative aPL titer and an incidence of the late vein graft failure was also documented.8

APS is a vascular disease involving the endothelium as a primary target, because the histopathological marker of APS is a bland, noninflammatory thromboembolic occlusion of large or small vessels. Although precise mechanisms of the coagulopathy in APS were not well defined, it is supposed that a complex interaction between aPL, clotting factors, and the vascular endothelium may be involved.'-> A recent study revealed that 32-glycoprotein I (β2GPI) is a requisite co-factor for plasma aPL to activate thrombotic cascade in APS patients. Although β2GPI itself inhibits the thrombotic reaction, aPL-p2GPI complex stimulates vascular endothelial cell adhesion molecules, which, in turn, make monocytes bind to vascular endothelial cells, leading to thrombotic formations.10

In this case, the patient had undergone POBA for myocardial infarction before APS was defined. It is supposed that the balloon injury caused by PTCA may have triggered and accelerated thromhotic cascade, leading to repetitive acute coronary occlusion. In addition, due to his allergic response to aspirin and ticlopidine chloride, these drugs were not prescribed after the revascularization. Although his aPL titer was controlled within normal range by the immunosuppressant and corticosteroid, stenosis in the same lesion of LAD developed. Surgical treatment was therefore undertaken.

For years, there has not been established therapeutic strategy for this disorder. In 1995, Khamashta et al. presented a retrospective and nonrandomized analysis of 247 patients with APS, demonstrating that warfarin, when prescribed to achieve PT-INR of 3 or higher, offers the best protection against recurrent thrombosis for patients who have had a confirmed major thrombosis.

The cardiopulmonary bypass during open-heart surgery is known to activate coagulatory and fibrinolytic cascade through blood-foreign body interactions.11 Moreover, Casati et al. documented that increased levels of plasminogen and D-dimer formation were prominent in patients who underwent onpump CABG compared to those who underwent offpump CABG.12 Therefore, it is supposed that off-pump techniques would be feasible for the patients with APS to reduce the possibility in coagulatory and fibrinolytic complications due to the cardiopulmonary bypass. Ciocca et al. demonstrated that APS patients are prone to excessive postoperative morbidity and mortality after cardiovascular surgery in a retrospective analysis.13 In their literature, of 19 APS patients undergone cardiac surgery, 16 patients (84.2%) presented major postoperative complications including thrombosed grafts, major bleeding and myocardial infarction, and 12 (63.2%) died of complications related to surgery.

In this regard, OPCAB was employed in this case, and the postoperative course has been uneventful. Currently developed technology in minimally invasive cardiac surgery, such as OPCAB, has been able to extend surgical indications, resulting in rescuing patients with cerebrovascular and/or renal complications. This report may indicate that OPCAB is also useful for patients with thromhoembolic disorders including APS, although long-term careful observation is needed.

Conclusions

It is concluded that OPCAB was effective in a patient with APS.

References

1. Hughes GRV. The antiphospholipid syndrome: ten years on. Lancet 1993;342:341-4.

2. HorimotoH, Kondo K, Asada K, Sasaki S. Heparin-coated cardiopulmonary bypass circuits in coronary bypass surgery. Artif Organs 1996;20:936-40.

3. Lennon MJ, Thackray NM, Gibbs NM. Anti-factor Xa monitoring of anticoagulation during cardiopulmonary bypass in a patient with antiphospholipid syndrome. Anaesth Intensive Care 200331:95-8.

4. Harris EN, Gharavi AE, Boey ML, Patel BM, Mackworth-Young CG, Loizou S etal. Anticardiolipin antibodies: detection by radioimmunoassay and association with thrombosis in systemic lupus erythematosus. Lancet 1983;2:1211-4.

5. Hughes GRV, Harris NN, Gharavi AE. The anticardiolipin syndrome. J Rheumotol 1986;13:486-9.

6. Sakakibara N, Kawasuji M, Matsumoto Y, Takemura H, Watanabe Y. Coronary artery bypass grafting in a patient with antiphospholipid syndrome. Ann Thorac Surg 1996;61:739-40.

7. Hamsten A, Norberg R, Bjorkholm M, de Faire U, Holm G. Antibodies to cardiolipin in young survivors of myocardial infarction: an association with recurrent cardiovascular events. Lancet 1986;1:113-6.

8. Morton KE, Gavaghan TP, Krilis SA, Daggard GE, Baron DW, Chesterman CN et al. Coronary artery bypass graft failure - an autoimmune phenomenon? Lancet 1986;8520:1353-6.

9. Harris EN, Bos K. An acute disseminated coagulopathy- vasculopathy associated with the antiphospholipid syndrome. Arch Intern Med 1991;151:231-3.

10. McNeil HP, Simpson RJ, Chesterman CN, Krilis SA. Anti- phospholipid antibodies are directed against a complex antigen that includes a lipid-binding inhibitor of coagulation: beta2- Glycoproteinl (apolipoprotein H). Proc Natl Acad Sci USA 1990; 87:4120-4.

11. Tanaka K, Takao M, Yada I, Yuasa H, Kusagawa M, Deguchi K. Alteration in coagulation and fibrinolysis associated with cardiopulmonary bypass during open heart surgery. J Cardiothorac Anesth 19893:181-8.

12. Casati V, Gerli C, Franco A, Delia Valle P, Benussi S, D'Angelo A et al. Activation of coagulation and fibrinolysis during coronary surgery: on-pump versus off-pump techniques. Anesthesiology 2001;95:1103-9.

13. Ciocca RG, Choi J, Graham AM. Antiphospholipid antibodies lead to increased risk in cardiovascular surgery. Am J Surg 1995;170: 198-200.

S. HORIMOTO, H. HORIMOTO, Y. SAWADA, K. KONDO

Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Takatsuki, Japan

Address reprint requests to: Dr. S. Horimoto, Department of Thoracic and Cardiovascular Surgery, Osaka Medical Collage, 2-7 Daigakucho, Takatsuki, 568-8686, Japan. E-mail: tho064@poh.osaka- med.ac.jp

Copyright Edizioni Minerva Medica Feb 2005

Source: Journal of Cardiovascular Surgery

More News in this Category