Combined operation for myasthenia gravis and coronary artery disease

Abstract

A 57-year-old man with ocular myasthenia gravis was admitted to our hospital because of acute respiratory insufficiency associated with myasthenic crisis. He had a history of unstable angina indicated percutaneous coronary artery angioplasty. He was diagnosed with generalized nonthymomatous myasthenia gravis and a triple vessel coronary artery disease. We conducted a simultaneous surgical intervention, including extended thymectomy and coronary artery bypass grafting, using a standard cardiopulmonary bypass via median sternotomy. The patient had already been immunocompromised at surgery for having diabetes, and postoperative long-term steroid therapy. In this rare and special condition, a meticulous overall therapeutic strategy was needed in order to avoid myasthenic crisis and prepare for the worst case scenario of mediastinitis.

Myasthenia Gravis

“…It confirms previous findings (Asai et al, 2004;Hayashida et al, 2000) that such patients may safely undergo CPB for CABG with cisatracurium as a muscle relaxant.…”

“…Authors (Aps & O'Sullivan, 1987) describe a patient undergoing cardiac surgery under general anesthesia combined with incremental doses of atracurium extubated on the morning after surgery, yet soon reintubated, with fully successful extubation performed after further 24 hours. Others (Asai et al, 2004) report the 3-day mechanical ventilation after CABG in patients with MG, without anesthetic regimen described, unfortunately.…”

Coronary Artery Bypass Grafting in a Patient with Myasthenia Gravis

“…There have been very few reports describing perioperative anesthetic management in MG patients undergoing cardiac surgery [Hayashida 2000;Narin 2009;Ishimura 1998;Asai 2004;Haroun-Bizri 2003]. Some anesthesiologists prefer to avoid muscle relaxants, and use potent inhaled agents both for facilitating tracheal intubation and providing surgical relaxation, whereas some prefer a total intravenous anesthesia [Narin 2009].…”

“…A patient with MG who undergoes major surgery requires careful management during and after anesthesia because of unpredictable susceptibility to analgesia and muscle relaxants [Peacock 1989]. To date, however, there have been few reports that describe perioperative management in patients with MG undergoing cardiac surgery [Hayashida 2000;Narin 2009;Ishimura 1998;Asai 2004;Haroun-Bizri 2003]. In this paper, we present a successful coronary artery bypass grafting (CABG) in a patient with MG using cardiopulmonary bypass (CPB).…”

Simultaneous Operation for Multiple Valvular Disease and Myasthenia in a Woman

“…Very few cases have been reported in the reviewed literature of heart disease with MG. Most of the reported cases were combined operations of coronary artery bypass grafting and thymectomy in patients with ischaemic heart disease and myasthenia gravis [1][2][3][4]. To our knowledge, a simultaneous operation for rheumatic triple valve (mitralaortic-tricuspid) disease and MG is very unusual.…”