Fatal myocardial infarction after lung resection in a patient with prophylactic preoperative coronary stenting †

Abstract

In this report we present the case of a 77-yr-old man who underwent resection of the upper lobe of the left lung for a carcinoma, six weeks after percutaneous transluminal coronary angioplasty (PTCA) with stenting of the left anterior descending (LAD) and circumflex coronary arteries. Antiplatelet therapy with clopidogrel was interrupted two weeks before surgery to allow for epidural catheter placement and to minimize haemorrhage. The surgical procedure was uneventful. In the immediate postoperative period, however, the patient suffered severe myocardial ischaemia. Emergency coronary angiography showed complete thrombotic occlusion of the LAD stent. In spite of successful recanalization, reinfarction occurred and the patient died in cardiogenic shock. Prophylactic preoperative coronary stenting may put the patient at risk of stent thrombosis if surgery cannot be postponed for three months. In such cases, other strategies such as perioperative beta-blockade for preoperative cardiac management should be considered.

The early and late results of combined off-pump coronary artery bypass grafting and pulmonary resection in patients with concomitant lung cancer and unstable coronary heart disease☆☆☆

“…Moreover, there is the important issue of the side-effects of antiplatelet therapy if cardiologic intervention precedes pulmonary resection. Recent publications regarding the early complications of surgical treatment involving coronary stenting report a significant risk of major intraoperative cardiac ischemia, including the risk of myocardial infarction, six weeks after the stenting [8,9]. Some authors even suggest that this risk may persist for as long as 3 months [10].…”

“…However, such delays are unacceptable once lung cancer has been diagnosed. Another approach to this problem could be a simple preoperative coronaroplasty with subsequent stenting after the lung resection [9]. However, a better option appears to be a two-stage approach with surgical myocardial revascularization as the first stage and lung resection as the second, 1 month later.…”

Perioperative in-stent thrombosis after lung resection performed within 3 months of coronary stenting☆

“…We had one perioperative death related to in-stent thrombosis after uncomplicated lobectomy for NSCLC following coronary artery stenting, despite 4 weeks of aspirin and clopidogrel medication after stenting and the administration of heparin plus aspirin in the perioperative setting [2]. This retrospective multi-institutional trial was performed to assess the incidence of perioperative in-stent thrombosis associated with myocardial infarction in patients undergoing major lung resection within 3 months of coronary stenting.…”

Noncardiac surgery in patients with coronary artery stent: what should the anesthesiologist know?

“…For example, the four to six weeks' delay recommended by the ACC/AHA was recently questioned following a case of fatal MI due to stent thrombosis in a patient who underwent lung resection six weeks after the prophylactic implantation of a coronary stent. 12 In their report, the authors strongly argued that complete stent re-endothelialization takes up to three months. 13 Consequently, they recommended a waiting period of three months between stent implantation and elective surgery, as previously suggested by Chassot et al 14 This discrepancy between the waiting period recommended by Chassot et al and the ACC/AHA guidelines is only one of the controversies that Canadian anesthesiology departments would face if they established their own policy.…”

“…Par exemple, le délai de quatre à six semaines demandé par l'ACC/AHA a été récemment contesté à la suite d'un cas d'IM fatal causé par une thrombose prothé-tique chez un patient opéré pour la résection d'un poumon six semaines après l'implantation prophylactique d'une endoprothèse coronaire. 12 Les auteurs soutiennent fermement que la réendothélialisation complète de la prothèse peut prendre jusqu'à trois mois. 13 Par conséquent, ils recommandent un délai de trois mois entre la mise en place de l'endoprothèse et la chirurgie élective, comme le suggéraient déjà Chassot et coll.…”