Braz J Cardiovasc Surg rbccv Brazilian Journal of Cardiovascular Surgery Braz. J. Cardiovasc. Surg. 0102-7638 1678-9741 Sociedade Brasileira de Cirurgia Cardiovascular 10.21470/1678-9741-2018-0055 00014 REVIEW ARTICLE Combined Mitral Valve Replacement and Ravitch Procedures in a Patient with Previous Pneumonectomy: Case Report and Review of the Literature Kayacioglu Ilyas 1 MD Topcu Ahmet Can 1 MD Ozeren Kamile 1 MD Ozden Yasin 1 MD Bolukcu Ahmet 1 MD Yildirim Mehmet 2 MD Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital Department of Cardiovascular Surgery Istanbul Turkey Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey. Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital Department of Thoracic Surgery Istanbul Turkey Department of Thoracic Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey. Correspondence Address: Ahmet Can Topcu, Selimiye Mh. Tibbiye Cd., No: 13, Uskudar, Istanbul, Turkey, Zip code: 34668. E-mail: ahmet.topcu@icloud.com

No conflict of interest.

 Nov-Dec 2018 33 6 608 617 23 02 2018 20 06 2018 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Introduction:

Significant anatomical and functional changes occur following pneumonectomy. Mediastinal structures displace toward the side of the resected lung, pulmonary reserve is reduced. Owing to these changes, surgical access to heart and great vessels becomes challenging, and there is increased risk of postoperative pulmonary complications.

 Methods:

We performed a mitral valve replacement combined with a Ravitch procedure in a young female with previous left pneumonectomy and pectus excavatum.

 Results:

She was discharged on postoperative day 9 and remains symptom-free 3 months after surgery.

 Conclusion:

Thorough preoperative evaluation and intensive respiratory physiotherapy are essential before performing cardiac operations on patients with previous pneumonectomy.

 Keywords: Chest Wall/surgery Heart Valve Prosthesis Implantation Mitral Valve/surgery Funnel Chest Pneumonectomy
Abbreviations, acronyms & symbols
CABG = Coronary artery bypass grafting
CPB = Cardiopulmonary bypass
CT = Computed tomography
Cx = Circumflex
FEV1 = Forced expiratory volume in 1st second
FVC = Forced vital capacity
LAD = Left anterior descending
LITA = Left internal thoracic artery
MRI = Magnetic resonance imaging
INTRODUCTION

Significant anatomical and functional changes occur following pneumonectomy. Mediastinal structures displace toward the side of the resected lung, pulmonary reserve is reduced, and the remaining lung compensatorily enlarges and herniates over the midline with elevation of the diaphragm[1,2]. Owing to these changes, surgical access to the heart and great vessels becomes challenging, and there is an increased risk of postoperative pulmonary complications.

 CASE REPORT

A 24-year-old female patient presented to our clinic with dyspnea. She had undergone a left pneumonectomy for advanced and complicated bronchiectasis 10 years ago.

Clinical Findings

She had marfanoid habitus, pectus excavatum, scoliosis, and a grade 4, pansystolic, high-pitched, blowing murmur best heard at the right sternal border (Figures 1A and B).

Marfanoid habitus and pectus excavatum. A) front view; B) side view.

Diagnostic Assessment

Transthoracic echocardiogram revealed severe mitral regurgitation due to myxomatous mitral valve with bileaflet prolapse and chordal elongation, secondary pulmonary hypertension, and tricuspid regurgitation with a dilated right atrium. Her ejection fraction was 35%, left ventricle end-diastolic diameter was 72 mm, and end-systolic diameter was 59 mm. She also had a borderline ascending aortic aneurysm measuring 40 mm in diameter. Pulmonary function test demonstrated reduced forced vital capacity (FVC), 1.11 L (31.7% of predicted), and reduced forced expiratory volume in 1st second (FEV1), 1.05 L (34.6% of predicted). A contrast-enhanced computed tomography (CT) scan was performed to examine the mediastinal structures and alternative cannulation sites (Figure 2). Heart and great vessels were displaced to the left, and the right lung was enlarged and crossing the midline, anterior to the heart. The proxymal ascending aorta was 40 mm in diameter. Additionally, a chronic type B aortic dissection was present. CT scan revealed that the ascending aorta and the superior and inferior venae cavae were suitable for cannulation.

Contrast-enhanced computed tomography scan.

Therapeutic Intervention

The patient received intensive chest physiotherapy before surgery to reduce postoperative pulmonary complications.

A vertical midline incision on skin, subcutaneous tissues, and pectoralis fascia was made over the sternum. Following elevation of pectoralis muscles from the anterior chest wall, a median sternotomy was performed. Costal cartilages of the 3rd to 8th ribs were removed. The right lung was retracted from the midline. Cardiopulmonary bypass (CPB) was initiated via ascending aortic and bicaval cannulation, and cardiac arrest was obtained. We did not use topical cardiac hypothermia to prevent phrenic nerve injury. Both atria were relatively easy to expose due to leftward shift and rotation of the heart. A mitral valve replacement and a tricuspid ring annuloplasty was performed using biatrial approach. CPB was terminated. A bar was placed behind the sternum and fixed to the pectoralis muscle fibers bilaterally. After completion of the Ravitch procedure, the sternum was closed. The patient was transferred to a dedicated cardiac surgery intensive care unit and she was successfully extubated at the postoperative 6th hour. Her recovery was uneventful and she was discharged on postoperative day 9 (Figures 3A and B).

Early postoperative results. A) front view; B) side view.

Follow-up and Outcomes

The patient remains symptom-free 3 months after surgery and she is scheduled to have a bar removal 3 months later (Figures 4A and B).

Late postoperative results. A) front view; B) side view.

The Figure 5 presents a timeline of interventions and outcomes.

Timeline of interventions and outcomes.

FEV1=forced expiratory volume in 1st second; FVC=forced vital capacity

 DISCUSSION

After conducting a Medline search from 1966 to April 2018 using the search terms "pneumonectomy" and "open heart surgery" or "coronary artery bypass" or "mitral valve" or "aortic valve" or "revascularization", we identified 30 articles in English language[3-34]. A total of 42 cardiac operations were performed on 38 patients, including the current one (Table 1). The mean patient age was 65.2 years (range: 24-83 years). Twenty-one (76.3%) patients were male. There were 20 (47.6%) isolated coronary artery bypass grafting (CABG) procedures, 18 (42.8%) valvular procedures, and 4 (9.5%) combined CABG and valvular procedures. Two of these operations were transapical aortic valve implantation procedures (patients 29 and 30)[26,27].

Summary of 38 patients with previous pneumonectomy who underwent cardiac surgery.
Patientno. Author Publicationyear Sex Age Pneumonectomysite Yearselapsed afterpneumonectomy Indication forpneumonectomy Preoperative data Operation Operative details Complications Length ofhospitalstay(days)
FEV1(percent ofpredictedvalue) FVC (percentof predictedvalue)
1 Berrizbeitia et al.[3] 1994 M 61 Right 42 Bronchiectasis 21 32 CABG - 3 SVGs to LAD, OMB, and PDA - Median sternotomy - On-pump None 8
2 Shibata et al.[4] 1994 M 67 Left 13 Cancer 77 55 CABG - 3 SVGs - Median sternotomy - On-pump None 57
3 Medalion et al.[5] 1994 F 70 Left 40 Tuberculosis 45 52 CABG - LITA and 3 SVGs - Median sternotomy - On-pump None 11
4 Demirtas et al.[6] 1995 M 63 Left 20 Cancer 36 36 CABG - LITA and SVG to LAD and OMB - Median sternotomy - On-pump Prolonged inotropic support, low cardiac output requiring intra-aortic balloon pump insertion, right-sided pneumothorax requiring re-intubation and chest tube insertion, mediastinitis and sternal detachment requiring re-operation, sepsis, and death 12
5 Izzat et al.[7] 1995 M 65 Right 10 Cancer N/A N/A Mitral valve replacement - Approach to mitral valve through left atrial appendage - Median sternotomy - On-pump None 7
6 Soltanian et al.[8] 1998 F 70 Left 19 Cancer N/A N/A CABG - SVG to LAD - Left thoracotomy - Off-pump None 7
7 Lippmann and Au[9] 2000 M 68 Left 15 Cancer 56 60 CABG - SVGs - Median sternotomy - On-pump Bronchopneumonia, pulmonary embolism, respiratory failure requiring re-intubation, and death 6
8 M 73 Left 22 Cancer 53 58 CABG - LITA and SVGs - Median sternotomy - On-pump Postoperative bleeding requiring re-exploration, atrial fibrillation, hemothorax requiring re-intubation, and chest tube insertion 48
9 Gölbasi et al.[10] 2001 M 58 Right 0.75 Cancer 50 44 CABG - SVGs to LAD, OMB, and RCA - Median sternotomy - On-pump None 9
10 Diab et al.[11], Jamaleddine and Obeid[12] 2001 M 64 Right 6 Trauma N/A N/A CABG - SVGs to LAD, Cx, and RCA - Median sternotomy - On-pump Respiratory failure requiring re-intubation 12
11 El-Hamamsy et al.[13] 2003 F 65 Right 51 Tuberculosis 36 44 Mitral valve replacement and tricuspid valve annuloplasty - Standard left atrial approach - Median sternotomy - On-pump Pneumothorax requiring chest tube insertion 20
12 F 71 Right 50 Tuberculosis 28 27 CABG - 3 SVGs - Median sternotomy - Off-pump None 6
13 Kumar et al.[14] 2003 M 70 Left 15 Cancer N/A N/A CABG - LITA and SVG to LAD and PDA - Median sternotomy - Off-pump None 7
14 Erdil et al.[15] 2004 M 51 Right 17 Tuberculosis 45 43 CABG - 2 RAs to LAD, OMB, and RCA - Median sternotomy - On-pump None 5
15 Shanker et al.[16] 2005 M 80 Left 27 Cancer 46 N/A CABG, mitral valve repair, and aortic valve replacement - 1 SVG to LAD and diagonal artery - Approach to both valves via aortotomy - Bioprosthetic aortic valve - Median sternotomy - On-pump None 10
16 Bernet et al.[17] 2006 M 58 Right 3 Cancer 59 59 CABG - LITA and SVG to LAD and OMB - Median sternotomy - Off-pump None 8
17 Hukusi Us et al.[18] 2006 M 74 Left 15 Cancer 45 60 CABG - LITA and SVG to LAD, Cx, and RCA - Median sternotomy - On-pump None 7
18 Stoller et al.[19] 2007 F 54 Left 3 Cancer 61 61 CABG - SVGs to LAD and Cx - Left thoracotomy - Off-pump None 5
19 M 48 Left 18 Cancer N/A N/A CABG - 3 SVGs to LAD, Cx, and RCA - Median sternotomy - On-pump Respiratory failure requiring prolonged mechanical ventilation and extracorporeal membrane oxygenation and pneumonia 26
26 37 42 Mitral and tricuspid valve repair - Right atriotomy and transseptal approach - Re-sternotomy - On-pump, deep hypothermic circulatory arrest Atrial fibrillation 13
20 M 71 Left 7 Cancer 33 40 Mitral valve replacement and tricuspid valve annuloplasty - Right atriotomy and transseptal approach - Median sternotomy - On-pump Renal failure and atrial fibrillation N/A
21 F 74 Left 37 Cancer 75 70 CABG - 4 SVGs to LAD, OMBs, and RCA - Left thoracotomy - On-pump None 6
22 Sleilaty et al.[20] 2007 M 71 Right 20 Trauma 53 48 CABG and aortic valve replacement - SVG to diagonal artery - Bioprosthetic aortic valve - Median sternotomy - On-pump None 13
23 Barreda et al.[21] 2008 M 68 Left 4 Cancer N/A N/A Aortic valve replacement - Left anterior thoracotomy - On-pump Re-exploration for worsening of preoperative mitral insufficiency due to leaflet tethering 1 day after aortic valve replacement N/A
Mitral valve annuloplasty - Left posterior thoracotomy - On-pump
24 Ghotkar et al.[22] 2008 M 71 Left 18 Cancer 42 53 CABG - SVG to LAD and PDA - Median sternotomy - On-pump Postoperative bleeding requiring re-exploration and atrial fibrillation 17
25 F 77 Right 1 Cancer 64 63 Aortic valve replacement - Bioprosthetic aortic valve None N/A
26 Zhao et al.[23] 2008 M 57 Left 7 Cancer 61.9 70.3 CABG - 2 SVGs to LAD, RCA, and OMB - Left posterolateral thoracotomy - Off-pump None 9
27 Us et al. [24] 2010 M 65 Left 8 N/A 45 50 Mitral valve replacement and subaortic membrane resection - transseptal approach and aortotomy - mechanical mitral valve prosthesis - median sternotomy - on-pump None 7
28 Stamou et al. [25] 2010 M 83 Left 8 Cancer 48 N/A CABG and aortic valve replacement - left anterolateral thoracotomy - on-pump None 5
29 Ferrari et al. [26] 2011 M 64 Left 8 Cancer N/A N/A Transapical aortic valve implantation - left anterolateral thoracotomy - off-pump None N/A
30 Raja et al. [27] 2011 F 67 Right 18 Cancer 49 N/A Transapical aortic valve implantation - right anterior thoracotomy - off-pump   None 4
31 Ushijima et al. [28] 2011 M 82 Left 20 Cancer 63.8 63.8 CABG - LITA, RA and RGEA to LAD, PL and PDA - left thoracotomy - off-pump None N/A
32 Wilhelmi et al. [29] 2013 M 68 Right 8 Cancer 56 58 Aortic valve replacement - bioprosthetic aortic valve - right anterolateral thoracotomy - on-pump None 6
33 Dag et al. [30] 2013 M 72 Left 13 Cancer N/A N/A CABG and mitral valve replacement - SVG to LAD and RCA - standard left atrial approach -  mechanical mitral valve prosthesis - median sternotomy - on-pump None N/A
34 Gennari et al. [31] 2014 M 71 Left 4 Cancer 53 54 Mitral and tricuspid valve repair - median sternotomy - on-pump None 11
35 Rose et al. [32] 2015 M 31 Right 8 Cancer N/A N/A Mitral valve repair - left atrial approach - video-assisted right thoracotomy - on-pump None 8
36 Takahashi et al. [33] 2016 M 72 Right 32 Tuberculosis N/A N/A Mitral valve replacement - Right thoracotomy - on-pump Periprosthetic leak N/A
32 N/A N/A Repair of mitral peri-prosthetic leak (2 months after valve replacement) - Right thoracotomy - on-pump None N/A
40 N/A N/A Repair of mitral peri-prosthetic leak (8 years after valve replacement) - Cranial-sided approach to left atrium - median sternotomy - on-pump None N/A
37 Sinha et al. [34] 2016 M 61 Right 47 Scimitar syndrome N/A N/A Mitral valve repair - left atrial approach - video-assisted right thoracotomy - on-pump None 5
38 Current patient 2018 F 24 Left 10 Bronchiectasis 34.6 31.7 Mitral valve replacement and tricuspid valve annuloplasty - standard left atrial approach - median sternotomy combined with Ravitch procedure - on-pump None 9
Summary of 38 patients with previous pneumonectomy who underwent cardiac surgery. Summary of 38 patients with previous pneumonectomy who underwent cardiac surgery. Summary of 38 patients with previous pneumonectomy who underwent cardiac surgery. Summary of 38 patients with previous pneumonectomy who underwent cardiac surgery.

CABG=Coronary artery bypass grafting; Cx=circumflex; FEV1=forced expiratory volume in 1st second; FVC=forced vital capacity; LAD=left anterior descending; LITA=left internal thoracic artery; OMB=obtuse marginal branch; PDA=posterior descending artery; RAs=radial arteries; RCA=right coronary artery; SVG=saphenous vein graft

Fifteen (39.4%) patients had a previous right pneumonectomy. The most common indication for pneumonectomy was cancer (n=27, 71%), followed by tuberculosis (n=5, 13.1%), trauma (n=2, 5.2%), bronchiectasis (n=2, 5.2%), scimitar syndrome (n=1, 2.6%), and unknown etiology (n=1, 2.6%). Preoperative FEV1 values were available for 28 patients and averaged 49% of predicted (range: 21-77%). Preoperative FVC values were available for 25 patients and averaged 49.2% of predicted (range: 27-70.3%).

The preferred surgical incision was a median sternotomy in 26 (61.9%) cases, a left thoracotomy in 9 (21.4%) cases, a right thoracotomy in 6 (14.2%) cases, and it was not specified in 1 (2.3%) case. Patients 35 and 37 underwent surgery utilizing video-assisted right thoracotomy[32,34]. Among 24 CABG operations, a left internal thoracic artery was used as a bypass conduit in 7 (29.1%) cases. The use of a right internal thoracic artery was not reported. Complete arterial revascularization was performed in 2 (8.3%) cases. Among 20 isolated CABG operations, 7 (35%) were carried out without the use of CPB.

Length of hospital stay data was available in 32 cases and averaged 12 days (range: 4-57 days). Postoperative complications were experienced after 11 (26.1%) operations. The most common complication was atrial fibrillation (n=5, 11.9%), followed by respiratory failure requiring re-intubation (n=4, 9.5%), pneumothorax (n=2, 4.7%), pneumonia (n=2, 4.7%), and bleeding requiring re-exploration (n=2, 4.7%). Two (5.2%) patients did not survive to discharge.

Previous pneumonectomy adds two major risks to cardiac operations: (1) there is an increased risk of postoperative pulmonary complications due to reduced lung capacity; (2) heart and great vessels are displaced and rotated, making surgical exposure more difficult.

Six months after pneumonectomy, FVC decreases by 36% and FEV1 by 34%. These parameters do not significantly improve beyond 6 months[2]. Considering that the pulmonary function may deteriorate significantly after cardiac surgery even in patients who have normal preoperative respiratory function, previous pneumonectomy poses a great risk of postoperative pulmonary complications[35]. Hulzebos et al.[36] found preoperative inspiratory muscle training to be effective in preventing postoperative pulmonary complications in high-risk patients undergoing elective CABG surgery. Conventional measures such as avoidance of phrenic nerve injury and fluid overload, early extubation, early mobilization, and postoperative chest physiotherapy should be utilized. Central venous line should be placed on the side of the pneumonectomy to avoid pneumothorax.

Considerable anatomical changes occur in long-term survivors after pneumonectomy. Smulders et al.[1] evaluated the function and position of the heart using dynamic magnetic resonance imaging (MRI) in 15 patients who underwent pneumonectomy at least 5 years ago. They reported that although varying degrees of mediastinal shift occur in all patients, right-sided pneumonectomy is mostly associated with a lateral shift and only a minor rotation, whereas left-sided pneumonectomy leads to a greater degree of rotation[1]. Whether the patient had a left or right pneumonectomy, it affects the choice of surgical approach. For instance, in the case of a previous left pneumonectomy, it may be easier to bypass left-sided coronary arteries through a left thoracotomy, rather than a median sternotomy, and mitral and tricuspid valves may be inaccessible from the usual right thoracotomy. Stoller et al.[19] reported difficult exposure of the mitral valve through a median sternotomy in a patient who underwent a left pneumonectomy 9 years ago. However, we found it relatively easy to perform a mitral valve surgery in a similar setting. Because long-term anatomical changes after pneumonectomy vary considerably among patients, preoperative CT and/or MRI should be performed to assess the exact locations of cardiac structures and cannulation sites[37]. Decision of surgical approach should only be made after carefully examining the extent of the shift and the rotation of the cardiac structures.

Another subject that needs addressing is the concomitant pectus excavatum. Schmidt et al.[38] advocate simultaneous correction of the pectus excavatum in patients requiring cardiac surgery. We resected deformed cartilages prior to sternotomy to improve surgical exposure as previously reported by Sacco-Casamassima et al.[39].

Cardiac operations on patients with previous pneumonectomy can be performed with a favourable outcome. Thorough preoperative evaluation with imaging studies to assess cardiac position and function and intensive respiratory physiotherapy are essential.

Authors’ roles & responsibilities
IK Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; final approval of the version to be published
ACT Substantial contributions to the conception or design of the work; final approval of the version to be published
KO Substantial contributions to the conception or design of the work; final approval of the version to be published
YO Substantial contributions to the conception or design of the work; final approval of the version to be published
AB Substantial contributions to the conception or design of the work; final approval of the version to be published
MY Substantial contributions to the conception or design of the work; final approval of the version to be published

This study was carried out at Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey.

No financial support.

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