A Case of Mitral Stenosis with Bronchiectasis: Which Surgery First – Thoracic or Cardiac

It has been reported from literature that patients with pulmonary hypertension have poor postoperative outcomes[1] ending up in complications like heart failure and delayed extubation.[2] We present a case of 46-year-old male, with a case of severe mitral stenosis [Figure 2] with bronchiectasis of the right lower lobe. He had a history of valvular heart disease for the past 10 years, medically managed, gradually progressed to severe mitral stenosis, currently had breathlessness of New York heart association class III (NYHA III). The patient also had a history of cardioembolic stroke 2 years back causing hemifacial weakness on warfarin and clonazepam. Along with the history of breathlessness, he developed complaints of cough with copious expectoration for the past 1 year with respiratory complaints more over the cardiac complaints. On evaluation, echocardiography revealed mitral valve area of 1 cm2 measured by planimetry, no left atrial (LA) clots, calcified leaflets with dilated left atrium 66 mm, right ventricular systolic pressure of 40 mmHg, and mean valvular pressure gradient of 20 mmHg. transoesophageal echo (TEE) was not done for the patient. CT chest imaging revealed right lower lobe bronchiectasis changes [Figure 1]. His pulmonary function tests revealed moderate obstruction with Forced expiratory volume in 1 second (FEV1) <80% of the predicted value. The preoperative anticoagulation was bridged with injection heparin. Also, the Revised cardiac risk index (RCRI) score of the patient was 2 and the effort tolerance was equivalent to four Metabolic equivalents of task (METs). Now the question was whether to proceed with cardiac surgery or thoracic surgery first. Our patient had undergone a staged procedure of right lower lobectomy followed by mitral valve replacement.Figure 1: (a) The chest X-ray of the patient with right lower lobe dilated bronchi (b) The CT chest of the patient showing a honeycomb appearanceFigure 2: Transesophageal echo image mid esophageal long axis view with thickened and stenotic mitral valveThe decision to right lower lobectomy over mitral valve replacement in the initial stage was based on the literature evidence. Prior studies show that patients with moderate and severe obstructive lung disease are at risk of cardiac surgery with a sharp increase in perioperative mortality.[3] Also, if the cardiac surgery is done first in a patient with bronchiectasis, there is a high risk of hemorrhage in the cavity (after a full Cardio pulmonary bypass (CPB) dose of heparinization), further compromising the lung function. The intraoperative challenge that was faced during the procedure of lobectomy was precipitous desaturation. The probable attribution was perfusion to the side of thoracotomy without ventilation resulting in shunt and raised pulmonary artery pressures.[4] The preexisting pulmonary hypertension in our patient due to cardiac disease was likely to be worsened due to one lung ventilation. The technique of one lung ventilation was done with left-sided double lumen tube 37 fr. The intermittent episodes of desaturation were overcome by intermittent Continuous positive airway pressure (CPAP) along with the recruitment of the nonventilated lung. With these measures in the intraoperative period, the partial pressure of oxygen (Pa02) was maintained. After the procedure, the patient was extubated on post operative day 1 (POD-1). The patient had undergone a staged procedure of right lower lobectomy followed by mitral valve replacement after a period of 4 weeks, which was done uneventfully. So, we conclude that in a patient with compromised lung function for cardiac surgery, performing the thoracic surgery first has a lower risk of perioperative mortality following the cardiac surgery. There are few studies that stated that concomitant open heart surgery and lung resection can be performed.[5,6] Cheng S et al. performed a systematic review and meta-analysis of the perioperative outcomes of combined heart surgery and lung tumor resection and concluded only off-pump Coronary artery bypass grafting (CABG) may reduce the complication rate compared with on-pump CABG even though the combined procedure had a lower mortality rate.[7] Lower lobectomies always pose a technical challenge and also mitral valve replacement requires Cardiopulmonary bypass (CPB). Hence, in our case, we planned a staged procedure. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.