Anesthetic implications in coronary artery
bypass grafting after left pneumonectomy.
Case report

Background:

 After pneumonectomy thoracic space contracts by shift of mediastinum, elevation of diaphragm and crowding of ribs on the side of pneumonectomy. These changes can make surgical access to mediastinal structures through the median sternotomy. Establishment of cardiopulmonary bypass (CBP) can be challenging and will affect pulmonary function.

Case report: 
A 72 years old man with left pneumonectomy 9 yrs before (carcinoma). 
Preoprative: room air PaO2 76 mmhg, PaCO2 40 mmHg, pH 7.46. FEV1 1.20 l (33% predicted) FVC 1.80 (38% prd) FEV1/FVC 0,66 (80% prd). Hemodynamics: distal left main trunk disease and multivessel disease, apical akinesis, and anterobasal anterolateral hypokinesia with moderate to severe depression of LVEF (EF 35%).
He was scheduled to CABG x3 trhough left anterior thoracotomy, initially offpump, but considering his respiratory and cardiological situation an arterial and venous cannulation were placed in order to emergent CBP. (Left femoral artery, right internal jugular and left femoral veins as standard of Heartport surgery).
Surgery was done off pump (OPCABG) without incedences and a CABG x3 was performed with saphenous vein sequential to left subclavian artery. Inotropic support was required with dobutamine (4 mcgr/kg/min) and was transferred to Critical Care Unit. Extubation was performed 6h later.  After 3 days the patient was discharged.

Discussion:
Pneumonectomy incurs marked anatomical changes in the thorax. This may necessitate deviations from standard protocols regarding open heart surgery.
Prior pneumonectomy poses several special challenges and considerations in the approach to cardiac surgery, especially regarding exposure, line placement for CBP, attention to avoiding diaphragmatic dysfunction, and choice of bypassing conduit if CABG is to be performed.
If OPCABG is to be performed, we do not need to access the central venous system for the preparation of cardiopulmonary bypass, and we can determine the operative strategy as we preferentially consider the accessibility to target coronary vessels.

Learning points: Coronary artery bypass graft surgery (CABG) is a challenge in patients with prior pneumonectomy, because of the decreased pulmonary function and anatomical shift of the heart

Anaesthetic implications in coronary artery bypass grafting after left pneumonectomy. Case report