Combined Cardiac Surgery and Total Thyroidectomy

Abstract

yperthyroid patients have hypertrophic hearts associated with reversible cardiomyopathy and can present with angina symptoms even in the absence of coronary artery disease. 1 Medical therapy for hyperthyroidism is currently the first choice of treatment in Japan and surgical treatment is rare except in certain patients. To the best of our knowledge, reports of combined cardiac surgery and thyroidectomy have rarely been published. 2 It is important to control the levels of thyroid hormone to prevent perioperative thyrothoxicosis in patients with hyperthyroidism. Case ReportA 65-year-old woman was admitted to hospital because of effort angina. She complained of palpitation and sweating for the 3 years prior to admission, and she had a history of rheumatoid arthritis and idiopathic thrombocytopenic purpura treated with prednisolone. There was also some history of cerebrovascular and ischemic heart disease in her family. A coronary angiogram and cardiac catheterization revealed ischemic heart disease and mild aortic stenosis. Laboratory studies revealed a hyperthyroid state: serum free triiodothyronine (FT3), free thyroxine (FT4), and thyroid-stimulating hormone (TSH) levels were, respectively, 8.39 pg/ml (normal range 2.47-4.34), 4.35 ng/dl (normal range 0.97-1.97), and less than 0.1 U/ml (normal range 0.4-5.0). Treatment for Graves' disease was initiated with methimazole combined with a -blocking agent. FT3 and FT4 levels then fell within the normal range. However, liver dysfunction had occurred within a few weeks due to the methimazole. Therefore, propylthiouracil was administered instead. However, the hepatoxicity still continued.Radioiodine instead of antithyroid drugs was administered. She was then discharged without any symptoms and in a euthyroid state. One year after the start of radioiodine administration, she experienced unstable angina with palpitation and sweating. FT3, FT4 and TSH levels were, respectively, 5.54 pg/ml, 2.37 ng/dl, and less than 0.1 U/ml. A second coronary angiogram revealed progressive ischemic heart disease with left main trunk disease and 2-vessel disease, and cardiac catheterization showed aortic stenosis with 34 mmHg of mean transvalvular pressure gradient and 0.7 cm 2 of estimated aortic valve area. Combined coronary artery bypass grafting (CABG), aortic valve replacement (AVR), and total thyroidectomy were recommended. In preparation for the surgery, a 50-mg daily dose of potassium iodine was initiated 17 days beforehand, in order to maintain thyroid function in the euthyroid or hypothyroid state. Thyroid hormone levels were gradually decreased to within the normal range by 10 days after the start of iodine administration, and then tended to increase again. Just before surgery, FT3, FT4, and TSH levels were, respectively, 3.88 pg/ml, 1.27 ng/dl, and less than 0.1 U/ml (Fig 1).During the induction of anesthesia, 20 mg of betametazone and a high dose of fentanyl were administered to prevent thyrotoxicosis and cardiac depression. Cardiac surgery through a median sternotomy was perfo...

Combining Thyroidectomy with Cardiac Surgery: Implications for the Endocrine Surgeon

“…[1][2][3][4][5][6] Patient age ranged from 55 to 79, with a mean age of 69 years. Five patients were males and four females.…”

“…18 Cumulative risk of the combined surgery seems to be less than a two stage procedure. 4 Amiodarone, the class III antiarrhythmic drug is associated with thyroid dysfunction. Due to its high iodine content, it can cause mild derangements, overt hypothyroidism or even thyrotoxicosis.…”

Incidental Detection of Internal Jugular Vein Thrombosis Secondary to Undiagnosed Benign Substernal Goiter

“…Because of the simultaneous presentation of serious coronary artery disease with non-ST elevation myocardial infarction and aortic valve stenosis combined with a giant intrathoracic goiter and IJVT, surgery was performed in one stage, starting with ligation of the thrombosed internal jugular vein in order to prevent per- and postoperative lung embolism [12]. Based upon the uneventful postoperative clinical course, the chosen surgical strategy seems to have been beneficial for the patient.…”

Indications for combined thyroidectomy and cardiac surgery

“…For the most part, these are isolated case reports [5][6][7][8][9]. However, two series of six and 14 patients have been published [10,11].…”

“…Pharmacologic agents include the synthetic antithyroid medications (propylthiouracil, methimazole), beta-blockers, Lugol's solution (potassium iodide), lithium, and glucocorticoids. Matsuyama et al reported a case of combined thyroid/cardiac surgery for unstable angina in a patient with Graves thyrotoxicosis [6].…”