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Christos E. Tourmousoglou, Efstratios Apostolakis, Dimitrios Dougenis, Simultaneous occurrence of coronary artery disease and lung cancer: what is the best surgical treatment strategy?, Interactive CardioVascular and Thoracic Surgery, Volume 19, Issue 4, October 2014, Pages 673–681, https://doi.org/10.1093/icvts/ivu218
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Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether combined surgical procedures in one or two stages are the best surgical treatment strategy in patients with simultaneous coronary artery disease and lung cancer. Altogether, 264 papers were found using the reported search; of which, 15 represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group, study type, outcomes and results of papers are tabulated. The outcomes of the reported studies provided interesting results. All the studies were retrospective. Ten papers reported the results of combined and staged operations. The operative mortality rate of combined procedures was 0–20.8% and of staged procedures was 0–10%. The reoperation rate for bleeding of combined procedures was 0–11% and of staged procedures was 0%. The survival rate of combined procedures at 1 year was 79–100%, at 5 years was 34.9–85% and at 7 years was 61%. The survival rate of staged procedures at 1 year was 72.7% and at 5 years was 53%. Five studies reported the results of off-pump coronary artery bypass grafting (OPCABG) and lung surgery versus on-pump and lung surgery. The operative mortality rate of OPCABG and lung surgery was 0–6.6%. The 2-year survival rate of OPCABG and lung surgery was 47% and the 5-year survival rate was 13–68%. The re-exploration rate for bleeding of OPCABG was 4%. Simultaneous lung surgery and CABG could be safely performed with adequate cancer-free survival in patients with Stage I or II lung cancer. Lung surgery is better performed before institution of cardiopulmonary bypass, avoiding the complications of such a technique. Long-term survival after combined treatment is mostly related to the predicted survival after lung resection. This depends on the T stage and mostly on the patient's nodal status. In certain high-risk groups (if the cardiac procedure is difficult or if the patient is unstable), separate staged procedures (CABG as the first and lung resection as the second procedure) might be the most prudent action (3–6 weeks apart). There is also another option: OPCABG and lung resection, which could be a safe and effective treatment when unstable coronary heart disease and lung cancer coexist.
INTRODUCTION
A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
THREE-PART QUESTION
In [patients with simultaneous coronary artery disease and lung cancer] are [the combined surgical procedures in one or two stages] the best surgical treatment strategy to optimize [event-free survival]?
CLINICAL SCENARIO
A patient presents with coronary artery disease and a coronary artery bypass grafting (CABG) surgery is scheduled. During his preoperative work-up with a chest X-ray, an asymptomatic pulmonary lesion is found. A CT biopsy and PET scan finds this to be a T2aN0M0 adenocarcinoma. You wonder whether you should perform the CABG and then the lobectomy or attempt the two operations at the same time.
SEARCH STRATEGY
An English language literature review was performed on Medline using the Ovid interface from 1980 to September 2013 [coronary artery disease.mp OR lung cancer.mp Or simultaneous.mp] AND [surgical treatment.mp].
SEARCH OUTCOME
Using the reported search, 264 papers were identified, of which, 15 papers provided the best evidence to answer the question. These papers are summarized in Table 1.
| Author, date, journal and country Study type (level of evidence) . | Patient group . | Outcomes . | Key results . | Comments . |
|---|---|---|---|---|
| Miller et al. (1994), Ann Thorac Surg, USA [2] Cohort study (level 2b) | 30 patients (23 M and 7 F) underwent pulmonary resection for primary lung cancer and a concomitant open heart operation (combined group). 93.3% of the combined group presented with cardiac symptoms During the same period, another 15 patients (14 M and 1 F) underwent an open cardiac procedure followed by pulmonary resection for lung cancer 1–11 months later (median 2 months); 86.7% of the staged group presented with cardiac symptoms | Combined group Median age CABG CABG and AVR Lobectomy Wedge resection Lung resection was done in the combined group: (i) before CPB (ii) after CPB (ii) during CPB Tumour grade 3 or 4 Post-surgical Stage I Stage II Stage IIIA Staged group (cardiac operation followed by lung operation 1–11 months later) Median age CABG CABG and AVR Lobectomy Pneumonectomy Tumour grade 3 or 4 Post-surgical Stage I Stage II Stage IIIA Operative mortality rate Reoperations for bleeding Median follow-up Survivors in the combined group (with no disease) Overall estimated 1- and 5-year survival for the combined group Survivors in the staged group (with no disease) Overall estimated 1- and 5-year survival for the staged group 5-year survival for Stage I patients | 68 years (range 50–79 years) 23/30 patients (76.6%) 1/30 patient 21/30 patients (70%) 7/30 patients (23.3%) 12/30 patients (40%) 13/30 patients (43.3%) 5/30 patients (16.6%) 19 patients (63.3%) 23/30 patients (76.6%) 5/30 patients (16.6%) 2/30 patients (6.6%) 15 patients 69 years 11/15 patients (73.3%) 1/15 patients 9/15 patients (60%) 5/15 patients (33.3%) 10/15 patients (66.6%) 6/15 patients (40%) 4/15 patients (26.6%) 5/15 patients (33.3%) 6.7% (2/30 patients) in the combined group versus 0% in the staged group 2/30 patients in the combined versus 0/15 patients in the staged group 44 months for the combined and 59 months for the staged group 8/28 patients (28.6%) 79.7 and 34.9%, respectively 7/15 patients (46.7%) 72.7 and 53%, respectively 100% in the staged group versus 36.5% in the combined group | Survival in the combined group was not affected by the post-surgical stage of the neoplasm, but survival in the staged group was affected significantly by the extent of disease No significant difference was observed between the two groups with regard to the pattern of recurrence or cause of death Given that survival in patients with post-surgical Stage I disease was significantly reduced in patients who had concomitant open heart operation, the authors believed that a combined pulmonary resection and open heart operation should be limited to patients with clinical Stage I disease who could not tolerate a second-staged procedure Otherwise, patients who had clinical Stage I disease should undergo a staged pulmonary resection |
| Brutel de la Riviere et al. (1995), Eur J Cardiothorac Surg, Netherlands [3] Cohort study (level 2b) | From 1979 to 1993, 79 patients underwent pulmonary resection for lung cancer and a concomitant cardiac operation with CPB There were 75 men and 4 women Mean age: 65 years (52–77) | CABG CABG and mitral valve repair CABG with AVR AVR Lobectomy Pneumonectomy Bilobectomy Sleeve lobectomy Segmental resection Postoperatively patients in Stage I Stage II Stage IIIA Hospital mortality Estimated mean survival (all patients, including hospital deaths) 2- and 5-year survival rates Late deaths because of lung cancer Re-exploration for bleeding | 69/79 patients (87.3%) 1/79 patient 2/69 patients 5/69 patients 60/69 patients (86.9%) 6/69 patients (8.6%) 5/69 patients 3/69 patients 4/69 patients 52/69 patients (65.8%) 18/69 patients (22.8%) 9 patients (11.4%) 6.3% 58 months 62 and 42%, respectively 64% 7/79 patients (8.8%) | Pulmonary resection for lung cancer in patients undergoing a concomitant cardiac operation could be performed safely with low operative morbidity and mortality and good long-term survival |
| Rao et al. (1996), Ann Thorac Surg, Canada [4] Cohort study (level 2b) | From 1982 to 1995, 30 patients underwent simultaneous cardiac operations and lung resections Patients who underwent single- or double-lung transplantation were excluded Mediastinoscopy was performed at the beginning of the operative procedure in 16 of the 18 patients who presented preoperatively with abnormal chest X-ray or with a known diagnosis of malignancy No N2 disease was found in any of these 16 patients | Follow-up Mean follow-up Pulmonary resection was performed Before CPB During CPB After reversal of heparin Cardiac procedure was completed before lung resection Mean age Pneumonectomy Lobectomy Wedge resection CABG AVR or MVR Pulmonary malignant lesion N2 disease at thoracotomy despite negative mediastinoscopy results Aortic cross-clamp average time CPB average time Operative deaths Reoperation for bleeding Perioperative MI Late deaths Length of stay postoperative Overall actuarial survival at 1, 5 and 7 years | 100% 22 months (range 1–100 months) 4/30 patients (13.3%) 19/30 patients (63.3%) 7/30 patients (23.3%) 23/30 patients (76.6%) 61 ± 13 years 3 patients (10%) 14 patients (47%) 12 patients (40%) 24/30 patients (80%) 6/30 patients (20%) 21/30 patients (70%) 2/30 patients (6.6%) 54 ± 21 min 109 ± 34 min 2/30 patients (6.6%) 1/30 patients (3.3%) 0% 3/30 patients (1%) 12.1 ± 7.6 days (median 10 days) 85 ± 7%, 85 ± 7%, 61 ± 21%, respectively | In this study, it did not appear that CPB had a detrimental effect on the 5-year survival 63% of patients in this study underwent resection during CPB and only 1 patient suffered from a bleeding complication If the patient remained stable after discontinuation of CPB, they proceeded with the pulmonary resection If the cardiac procedure was difficult or the patient was unstable, the lung resection could be delayed The combined procedure was feasible and safe in carefully selected patients In certain high-risk groups, separate staged procedures might be the most prudent action |
| Voets et al. (1997), Eur J Cardiothorac Surg, Netherlands [5] Cohort study (level 2b) | From 1988 to 1995, 34 patients underwent pulmonary resection for Stages I–II primary bronchogenic carcinoma and open heart surgery (CABG almost always), either concomitantly (n = 24) or in a staged procedure (n = 10) In all staged procedures, cardiac surgery was done first and lung surgery was performed later The mean interval between staged procedures was 33.9 ± 34.7 days (12–120 days) In all concomitant procedures, except one, heart operations on CPB were followed by lung resection, either still on CPB (13 patients) or afterwards (11 patients) after reversing hypocoagulation, whereas in 10 patients, after closing the sternotomy, a posterolateral incision for the lung resection was performed | Overall perioperative mortality Perioperative mortality in staged versus concomitant procedures Overall median survival time | 6/34 patients (17.6%) 1/10 patient (10%) versus 5/24 patients (20.8%), (P = 0.64) 4.2 years | There was a slightly better survival in the group undergoing a staged procedure, but this was not statistically significant The authors said that there was a substantially higher perioperative mortality, although this difference was not statistically significant because of the small number of patients, but this difference should be taken into account and the staged approach be the preferred one The interval between operations should be individualized according to the clinical status of the patient to a period as short as 2 weeks No relationship between survival and age, histopathology or extent of tumour No relation was demonstrated between survival and timing of lung resection in relation to CPB in the concomitantly operated group |
| Danton et al. (1998), Eur J Cardiothorac Surg, UK [6] Cohort study (level 2b) | From 1990 to 1997, 13 patients underwent simultaneous pulmonary resection and cardiac surgery 11/13 patients (84.6%) had coronary disease, and 1 patient had CABG and MV stenosis Primary lung carcinoma was detected in 10/13 patients (77%) Lung resection was performed before heparinization and CPB in 12/13 patients (92%) 2 patients underwent CABG on the beating heart without CPB | Operative mortality MI perioperative Mean follow-up Late deaths Survival rate of patients with bronchogenic carcinoma Overall survival rate | 0% 1/13 patient (7.6%) 23.8 months (1–48 months) 5/13 patients (38.5%) 5/10 patients (50%) 61.5% (8/13 patients) | Simultaneous pulmonary resection and cardiac surgery can be safely performed with adequate cancer-free survival in patients with Stage I or II pulmonary neoplastic disease Poor long-term survival and early cancer recurrence were mainly determined by the primary tumour stage |
| Patane et al. (2002), Interact CardioVasc Thorac Surg, Italy [7] Cohort study (level 2b) | From 1991 to 1999, 11 patients underwent simultaneous lung resection and cardiac operation Lung resection was performed before heparinization and CPB Mean age: 56.8 ± 11.2 years | Follow-up Follow-up period Perioperative death rate Re-exploration for bleeding Lung cancer Deaths during follow-up | 100% 12–108 months (mean 41.2) 0% 0% 9/11 patients (82%) 3/11 patients (27%) | Simultaneous cardiac surgery and lung resection in this small number of patients were safely performed and not associated with increased early or late morbidity or mortality |
| Ciriaco et al. (2002), Eur J Cardiothorac Surg, Italy [8] Cohort study (level 2b) | From 1993 to 2001, 50 patients with concomitant coronary artery disease and lung cancer underwent lung resection 19 of 50 patients first underwent myocardial revascularization 6 of these 19 patients first underwent CABG and the remaining 13 of 19 patients underwent PTCA; then lung surgery was performed with a mean interval of 32 ± 9 days The remaining 31 of the 50 patients underwent lung surgery alone Mean age: 68 ± 5 years | Prior myocardial revascularization and lung surgery at a later time Overall morbidity Overall mortality Complications postoperatively Deaths operative Deaths operative among patients with prior CABG | 19 patients 28% 4% 4/19 patients (with prior CABG) 2/31 patients (with no prior CABG) 0% | The authors preferred to stage the 2 procedures 3–6 weeks apart to allow optimization of the anticoagulant therapy |
| Saxena and Tam (2004), Ann Thorac Surg, Australia [9] Cohort study (level 2b) | 6 patients underwent combined OPCABG and lung resection during a 4-year period Follow-up ranged from 9 months to 3 years | Mean age Hospital mortality Late deaths Lobectomy Recurrence rate for angina or malignancy upon follow-up | 67.6 years 0% 2/6 patients (33.3%) 4/6 patients (66.6%) 0% | The authors believed that combined OPCABG surgery and pulmonary resection could be performed safely in high-risk patients with minimal possibility of morbidity and mortality |
| Schoenmakers et al. (2007), Ann Thorac Surg, Netherlands [10] Cohort study (level 2b) | 43 patients underwent a concomitant procedure for lung cancer and CABG, with or without the use of CPB between 1994 and 2005 In 28 patients, CABG was performed with CPB after lung resection was carried out (on-pump) 15 patients had first CABG without CPB and lung resection thereafter (off-pump) | On-pump group Mean age Postoperatively patients in Stage I Stage II Stage III Off-pump group Mean age Postoperatively patients in Stage I Stage II Stage III MI preoperatively or postoperatively Hospital mortality rate Overall mean survival (years) Mean survival 2-year survival rate 5-year survival rate Cardiac causes of death Lung cancer causes of death | 28/43 patients (65%) 66 years 71% of patients 14% of patients 14% of patients 15/43 patients (35%) 71 years 53% 33% 7% 0% in both groups 2/28 (7%) in the on-pump versus 1/15 (6.6%) in the off-pump group 4.8 years 5.25 years in the on-pump versus 3 years in the off-pump group (P = 0.09) 18/28 patients (64%) in the on-pump versus 7/15 patients (47%) in off-pump group (P <0.01) 13/28 patients (46%) in the on-pump versus 2/15 patients (13%) in the off-pump group (P <0.01) 1/28 (3.5%) in the on-pump versus 2/15 (13%) in the off-pump group 13/28 (46.4%) in the on-pump versus 7/15 (46.6%) in the off-pump group | No significant difference in hospital survival was seen between the on-pump and the off-pump group Late survival in both groups was comparable, even if the 2- and 5-year survival rates were significantly better for the on-pump group No significant difference in the cause of death was seen between the two groups The authors concluded that there was no evidence that off-pump surgery was a better treatment strategy of patients with combined cardiac and lung pathology The authors also stated that the off-pump group included less patients, older and with more advanced lung cancer and so the off-pump procedure in combined cardiac and lung surgery should be evaluated more |
| Prokakis et al. (2008), Med Sci Monit, Greece [11] Cohort study (level 2b) | From 2004 to 2006, 5 patients underwent combined surgical treatment for heart and lung disease in one stage Lung surgery was performed first and heart surgery was done with CPB Mean age: 65 years (52–77 years) 1 patient had CABG and wedge resection, 3 patients had AVR and lobectomy and 1 patient had an ascending aortic replacement and wedge resection | Perioperative mortality Mean follow-up Survival rate at follow-up | 0% 19 months (range 6–30 months) 100% | A combined treatment is feasible and safely performed with good results in patients with Stage I and II disease The long-term outcome is determined by the primary tumour stage |
| Dyszkiewicz et al. (2008), Eur J Cardiothorac Surg, Poland [12] Cohort study (level 2b) | From 2001 to 2006, 25 patients with NSCLC and unstable angina were operated CABG (off-pump) was performed simultaneously with lung resection First OPCABG was performed, followed by the pulmonary resection Mean age: 63 ± 12 years (57–75) 13 (52%) of the patients had undergone either coronary angioplasty and/or stenting before the diagnosis of lung cancer Patients with positive N2 disease were excluded from the study | OPCABG followed by lung resection Lung resection followed by OPCABG Duration of follow-up Perioperative death rate New MI perioperative Re-exploration for bleeding Deaths during follow-up | 23/25 patients (92%) 2/25 patients (8%) 8 months–5 years 0% 0% 1/25 patients (4%) 8/25 patients (32%) | The only statistically significant factor having an impact on survival was cancer recurrence (P <0.01) The operated patients had a 50% chance of 3-year survival A limitation of the study was that it was retrospective and there was a relatively small number of patients In the one-stage approach, CABG was performed off-pump and the risks of cancer spread, intraoperative haemorrhage, SIRS or pulmonary oedema were markedly lower Simultaneous off-pump and lung resection procedures require different surgical skills and are a safe and effective treatment when unstable CHD and lung cancer coexist The authors said that an important aspect of this procedure was to perform the coronary anastomosis before the lung resection. However, in selected cases, it might be necessary to perform a 1- or 2-vessel bypass followed by the pulmonary resection and finally the remaining coronary anastomosis |
| Cathenis et al. (2009), Acta Chir Belg, Belgium [13] Cohort study (level 2b) | From 2000 to 2008, 27 patients underwent pulmonary and cardiac surgery concomitantly Mean age: 68 years CABG was performed in 22/27 patients (82%) | Lung cancer Stage IA Stage IB Stage IIB Stage IIIB In-hospital mortality Re-exploration for bleeding Mean follow-up Median survival for all patients | 8/27 (31%) 11/27 (42%) 5/27 (19%) 2/27 (8%) 0% 3/27 patients (11%) 30.7 months 46 months | Simultaneous procedures for cardiac disease and pulmonary lesions could be performed without life-threatening morbidity and no in-hospital mortality |
| Hosoba et al. (2012), Ann Thorac Cardiovasc Surg, Japan [14] Cohort study (level 2b) | From 2008 to 2011, 11 patients underwent cardiac surgery simultaneously with pulmonary resection Mean age: 71 ± 13 years Cardiac procedures included OPCABG (n = 4), AVR (n = 3), mitral valve repair (n = 2), total arch replacement (n = 1) and descending aortic replacement (n = 1) | Operative mortality rate Hospital death rate MI perioperative or postoperative Mean follow-up Death rate postoperatively Local recurrences Mean cancer-free period 2-year cancer-free rate | 0% 0% 0% 19 ± 11 months 2/11 patients (18%) 2 patients 17 ± 10 months 79% | The operated patients had 80% chance of 2-year survival The shortcomings of the authors' strategy were that its cost, stress and pain were double if the lesion required subsequent lobectomy The authors said that a second-stage operation can be used to perform a complete radical nodal dissection through a lateral thoracotomy OPCABG is a reasonable choice for isolated coronary bypass grafting with concomitant lung resection |
| Ma et al. (2012), Zhonghua Yi Xue Za Zhi, China [15] Cohort study (level 2b) | From 2003 to 2011, 22 patients underwent combined OPCABG and lung cancer surgery Mean age: 65 ± 4 years First OPCAB was performed and then lung resection | Perioperative death rate Perioperative new MI NSCLC Follow-up period Deaths during follow-up of 4 years | 0% 0% 18/22 patients (82%) 10–60 months 4/22 patients (18%), because of cancer recurrence | The combined procedure of OPCABG and pulmonary resection was a safe and effective treatment option |
| Zhang et al. (2012), Thorac Cardiovasc Surg, Germany [16] Cohort study (level 2b) | 33 patients with incidental solitary pulmonary nodules underwent cardiac and lung surgery, either simultaneously (n = 30) or sequentially (n = 3) | Primary NSCLC 5-year survival of patients with malignant pulmonary nodules 5-year survival of patients with benign pulmonary nodules | 14/33 patients (42.4%) 43.6% 85.6% | Malignant pulmonary nodules were larger in size and nodules with diameter larger than 10 mm had a higher incidence of malignancy 5-year survival of patients with malignant pulmonary nodules was lower than that of patients with benign nodules |
| Author, date, journal and country Study type (level of evidence) . | Patient group . | Outcomes . | Key results . | Comments . |
|---|---|---|---|---|
| Miller et al. (1994), Ann Thorac Surg, USA [2] Cohort study (level 2b) | 30 patients (23 M and 7 F) underwent pulmonary resection for primary lung cancer and a concomitant open heart operation (combined group). 93.3% of the combined group presented with cardiac symptoms During the same period, another 15 patients (14 M and 1 F) underwent an open cardiac procedure followed by pulmonary resection for lung cancer 1–11 months later (median 2 months); 86.7% of the staged group presented with cardiac symptoms | Combined group Median age CABG CABG and AVR Lobectomy Wedge resection Lung resection was done in the combined group: (i) before CPB (ii) after CPB (ii) during CPB Tumour grade 3 or 4 Post-surgical Stage I Stage II Stage IIIA Staged group (cardiac operation followed by lung operation 1–11 months later) Median age CABG CABG and AVR Lobectomy Pneumonectomy Tumour grade 3 or 4 Post-surgical Stage I Stage II Stage IIIA Operative mortality rate Reoperations for bleeding Median follow-up Survivors in the combined group (with no disease) Overall estimated 1- and 5-year survival for the combined group Survivors in the staged group (with no disease) Overall estimated 1- and 5-year survival for the staged group 5-year survival for Stage I patients | 68 years (range 50–79 years) 23/30 patients (76.6%) 1/30 patient 21/30 patients (70%) 7/30 patients (23.3%) 12/30 patients (40%) 13/30 patients (43.3%) 5/30 patients (16.6%) 19 patients (63.3%) 23/30 patients (76.6%) 5/30 patients (16.6%) 2/30 patients (6.6%) 15 patients 69 years 11/15 patients (73.3%) 1/15 patients 9/15 patients (60%) 5/15 patients (33.3%) 10/15 patients (66.6%) 6/15 patients (40%) 4/15 patients (26.6%) 5/15 patients (33.3%) 6.7% (2/30 patients) in the combined group versus 0% in the staged group 2/30 patients in the combined versus 0/15 patients in the staged group 44 months for the combined and 59 months for the staged group 8/28 patients (28.6%) 79.7 and 34.9%, respectively 7/15 patients (46.7%) 72.7 and 53%, respectively 100% in the staged group versus 36.5% in the combined group | Survival in the combined group was not affected by the post-surgical stage of the neoplasm, but survival in the staged group was affected significantly by the extent of disease No significant difference was observed between the two groups with regard to the pattern of recurrence or cause of death Given that survival in patients with post-surgical Stage I disease was significantly reduced in patients who had concomitant open heart operation, the authors believed that a combined pulmonary resection and open heart operation should be limited to patients with clinical Stage I disease who could not tolerate a second-staged procedure Otherwise, patients who had clinical Stage I disease should undergo a staged pulmonary resection |
| Brutel de la Riviere et al. (1995), Eur J Cardiothorac Surg, Netherlands [3] Cohort study (level 2b) | From 1979 to 1993, 79 patients underwent pulmonary resection for lung cancer and a concomitant cardiac operation with CPB There were 75 men and 4 women Mean age: 65 years (52–77) | CABG CABG and mitral valve repair CABG with AVR AVR Lobectomy Pneumonectomy Bilobectomy Sleeve lobectomy Segmental resection Postoperatively patients in Stage I Stage II Stage IIIA Hospital mortality Estimated mean survival (all patients, including hospital deaths) 2- and 5-year survival rates Late deaths because of lung cancer Re-exploration for bleeding | 69/79 patients (87.3%) 1/79 patient 2/69 patients 5/69 patients 60/69 patients (86.9%) 6/69 patients (8.6%) 5/69 patients 3/69 patients 4/69 patients 52/69 patients (65.8%) 18/69 patients (22.8%) 9 patients (11.4%) 6.3% 58 months 62 and 42%, respectively 64% 7/79 patients (8.8%) | Pulmonary resection for lung cancer in patients undergoing a concomitant cardiac operation could be performed safely with low operative morbidity and mortality and good long-term survival |
| Rao et al. (1996), Ann Thorac Surg, Canada [4] Cohort study (level 2b) | From 1982 to 1995, 30 patients underwent simultaneous cardiac operations and lung resections Patients who underwent single- or double-lung transplantation were excluded Mediastinoscopy was performed at the beginning of the operative procedure in 16 of the 18 patients who presented preoperatively with abnormal chest X-ray or with a known diagnosis of malignancy No N2 disease was found in any of these 16 patients | Follow-up Mean follow-up Pulmonary resection was performed Before CPB During CPB After reversal of heparin Cardiac procedure was completed before lung resection Mean age Pneumonectomy Lobectomy Wedge resection CABG AVR or MVR Pulmonary malignant lesion N2 disease at thoracotomy despite negative mediastinoscopy results Aortic cross-clamp average time CPB average time Operative deaths Reoperation for bleeding Perioperative MI Late deaths Length of stay postoperative Overall actuarial survival at 1, 5 and 7 years | 100% 22 months (range 1–100 months) 4/30 patients (13.3%) 19/30 patients (63.3%) 7/30 patients (23.3%) 23/30 patients (76.6%) 61 ± 13 years 3 patients (10%) 14 patients (47%) 12 patients (40%) 24/30 patients (80%) 6/30 patients (20%) 21/30 patients (70%) 2/30 patients (6.6%) 54 ± 21 min 109 ± 34 min 2/30 patients (6.6%) 1/30 patients (3.3%) 0% 3/30 patients (1%) 12.1 ± 7.6 days (median 10 days) 85 ± 7%, 85 ± 7%, 61 ± 21%, respectively | In this study, it did not appear that CPB had a detrimental effect on the 5-year survival 63% of patients in this study underwent resection during CPB and only 1 patient suffered from a bleeding complication If the patient remained stable after discontinuation of CPB, they proceeded with the pulmonary resection If the cardiac procedure was difficult or the patient was unstable, the lung resection could be delayed The combined procedure was feasible and safe in carefully selected patients In certain high-risk groups, separate staged procedures might be the most prudent action |
| Voets et al. (1997), Eur J Cardiothorac Surg, Netherlands [5] Cohort study (level 2b) | From 1988 to 1995, 34 patients underwent pulmonary resection for Stages I–II primary bronchogenic carcinoma and open heart surgery (CABG almost always), either concomitantly (n = 24) or in a staged procedure (n = 10) In all staged procedures, cardiac surgery was done first and lung surgery was performed later The mean interval between staged procedures was 33.9 ± 34.7 days (12–120 days) In all concomitant procedures, except one, heart operations on CPB were followed by lung resection, either still on CPB (13 patients) or afterwards (11 patients) after reversing hypocoagulation, whereas in 10 patients, after closing the sternotomy, a posterolateral incision for the lung resection was performed | Overall perioperative mortality Perioperative mortality in staged versus concomitant procedures Overall median survival time | 6/34 patients (17.6%) 1/10 patient (10%) versus 5/24 patients (20.8%), (P = 0.64) 4.2 years | There was a slightly better survival in the group undergoing a staged procedure, but this was not statistically significant The authors said that there was a substantially higher perioperative mortality, although this difference was not statistically significant because of the small number of patients, but this difference should be taken into account and the staged approach be the preferred one The interval between operations should be individualized according to the clinical status of the patient to a period as short as 2 weeks No relationship between survival and age, histopathology or extent of tumour No relation was demonstrated between survival and timing of lung resection in relation to CPB in the concomitantly operated group |
| Danton et al. (1998), Eur J Cardiothorac Surg, UK [6] Cohort study (level 2b) | From 1990 to 1997, 13 patients underwent simultaneous pulmonary resection and cardiac surgery 11/13 patients (84.6%) had coronary disease, and 1 patient had CABG and MV stenosis Primary lung carcinoma was detected in 10/13 patients (77%) Lung resection was performed before heparinization and CPB in 12/13 patients (92%) 2 patients underwent CABG on the beating heart without CPB | Operative mortality MI perioperative Mean follow-up Late deaths Survival rate of patients with bronchogenic carcinoma Overall survival rate | 0% 1/13 patient (7.6%) 23.8 months (1–48 months) 5/13 patients (38.5%) 5/10 patients (50%) 61.5% (8/13 patients) | Simultaneous pulmonary resection and cardiac surgery can be safely performed with adequate cancer-free survival in patients with Stage I or II pulmonary neoplastic disease Poor long-term survival and early cancer recurrence were mainly determined by the primary tumour stage |
| Patane et al. (2002), Interact CardioVasc Thorac Surg, Italy [7] Cohort study (level 2b) | From 1991 to 1999, 11 patients underwent simultaneous lung resection and cardiac operation Lung resection was performed before heparinization and CPB Mean age: 56.8 ± 11.2 years | Follow-up Follow-up period Perioperative death rate Re-exploration for bleeding Lung cancer Deaths during follow-up | 100% 12–108 months (mean 41.2) 0% 0% 9/11 patients (82%) 3/11 patients (27%) | Simultaneous cardiac surgery and lung resection in this small number of patients were safely performed and not associated with increased early or late morbidity or mortality |
| Ciriaco et al. (2002), Eur J Cardiothorac Surg, Italy [8] Cohort study (level 2b) | From 1993 to 2001, 50 patients with concomitant coronary artery disease and lung cancer underwent lung resection 19 of 50 patients first underwent myocardial revascularization 6 of these 19 patients first underwent CABG and the remaining 13 of 19 patients underwent PTCA; then lung surgery was performed with a mean interval of 32 ± 9 days The remaining 31 of the 50 patients underwent lung surgery alone Mean age: 68 ± 5 years | Prior myocardial revascularization and lung surgery at a later time Overall morbidity Overall mortality Complications postoperatively Deaths operative Deaths operative among patients with prior CABG | 19 patients 28% 4% 4/19 patients (with prior CABG) 2/31 patients (with no prior CABG) 0% | The authors preferred to stage the 2 procedures 3–6 weeks apart to allow optimization of the anticoagulant therapy |
| Saxena and Tam (2004), Ann Thorac Surg, Australia [9] Cohort study (level 2b) | 6 patients underwent combined OPCABG and lung resection during a 4-year period Follow-up ranged from 9 months to 3 years | Mean age Hospital mortality Late deaths Lobectomy Recurrence rate for angina or malignancy upon follow-up | 67.6 years 0% 2/6 patients (33.3%) 4/6 patients (66.6%) 0% | The authors believed that combined OPCABG surgery and pulmonary resection could be performed safely in high-risk patients with minimal possibility of morbidity and mortality |
| Schoenmakers et al. (2007), Ann Thorac Surg, Netherlands [10] Cohort study (level 2b) | 43 patients underwent a concomitant procedure for lung cancer and CABG, with or without the use of CPB between 1994 and 2005 In 28 patients, CABG was performed with CPB after lung resection was carried out (on-pump) 15 patients had first CABG without CPB and lung resection thereafter (off-pump) | On-pump group Mean age Postoperatively patients in Stage I Stage II Stage III Off-pump group Mean age Postoperatively patients in Stage I Stage II Stage III MI preoperatively or postoperatively Hospital mortality rate Overall mean survival (years) Mean survival 2-year survival rate 5-year survival rate Cardiac causes of death Lung cancer causes of death | 28/43 patients (65%) 66 years 71% of patients 14% of patients 14% of patients 15/43 patients (35%) 71 years 53% 33% 7% 0% in both groups 2/28 (7%) in the on-pump versus 1/15 (6.6%) in the off-pump group 4.8 years 5.25 years in the on-pump versus 3 years in the off-pump group (P = 0.09) 18/28 patients (64%) in the on-pump versus 7/15 patients (47%) in off-pump group (P <0.01) 13/28 patients (46%) in the on-pump versus 2/15 patients (13%) in the off-pump group (P <0.01) 1/28 (3.5%) in the on-pump versus 2/15 (13%) in the off-pump group 13/28 (46.4%) in the on-pump versus 7/15 (46.6%) in the off-pump group | No significant difference in hospital survival was seen between the on-pump and the off-pump group Late survival in both groups was comparable, even if the 2- and 5-year survival rates were significantly better for the on-pump group No significant difference in the cause of death was seen between the two groups The authors concluded that there was no evidence that off-pump surgery was a better treatment strategy of patients with combined cardiac and lung pathology The authors also stated that the off-pump group included less patients, older and with more advanced lung cancer and so the off-pump procedure in combined cardiac and lung surgery should be evaluated more |
| Prokakis et al. (2008), Med Sci Monit, Greece [11] Cohort study (level 2b) | From 2004 to 2006, 5 patients underwent combined surgical treatment for heart and lung disease in one stage Lung surgery was performed first and heart surgery was done with CPB Mean age: 65 years (52–77 years) 1 patient had CABG and wedge resection, 3 patients had AVR and lobectomy and 1 patient had an ascending aortic replacement and wedge resection | Perioperative mortality Mean follow-up Survival rate at follow-up | 0% 19 months (range 6–30 months) 100% | A combined treatment is feasible and safely performed with good results in patients with Stage I and II disease The long-term outcome is determined by the primary tumour stage |
| Dyszkiewicz et al. (2008), Eur J Cardiothorac Surg, Poland [12] Cohort study (level 2b) | From 2001 to 2006, 25 patients with NSCLC and unstable angina were operated CABG (off-pump) was performed simultaneously with lung resection First OPCABG was performed, followed by the pulmonary resection Mean age: 63 ± 12 years (57–75) 13 (52%) of the patients had undergone either coronary angioplasty and/or stenting before the diagnosis of lung cancer Patients with positive N2 disease were excluded from the study | OPCABG followed by lung resection Lung resection followed by OPCABG Duration of follow-up Perioperative death rate New MI perioperative Re-exploration for bleeding Deaths during follow-up | 23/25 patients (92%) 2/25 patients (8%) 8 months–5 years 0% 0% 1/25 patients (4%) 8/25 patients (32%) | The only statistically significant factor having an impact on survival was cancer recurrence (P <0.01) The operated patients had a 50% chance of 3-year survival A limitation of the study was that it was retrospective and there was a relatively small number of patients In the one-stage approach, CABG was performed off-pump and the risks of cancer spread, intraoperative haemorrhage, SIRS or pulmonary oedema were markedly lower Simultaneous off-pump and lung resection procedures require different surgical skills and are a safe and effective treatment when unstable CHD and lung cancer coexist The authors said that an important aspect of this procedure was to perform the coronary anastomosis before the lung resection. However, in selected cases, it might be necessary to perform a 1- or 2-vessel bypass followed by the pulmonary resection and finally the remaining coronary anastomosis |
| Cathenis et al. (2009), Acta Chir Belg, Belgium [13] Cohort study (level 2b) | From 2000 to 2008, 27 patients underwent pulmonary and cardiac surgery concomitantly Mean age: 68 years CABG was performed in 22/27 patients (82%) | Lung cancer Stage IA Stage IB Stage IIB Stage IIIB In-hospital mortality Re-exploration for bleeding Mean follow-up Median survival for all patients | 8/27 (31%) 11/27 (42%) 5/27 (19%) 2/27 (8%) 0% 3/27 patients (11%) 30.7 months 46 months | Simultaneous procedures for cardiac disease and pulmonary lesions could be performed without life-threatening morbidity and no in-hospital mortality |
| Hosoba et al. (2012), Ann Thorac Cardiovasc Surg, Japan [14] Cohort study (level 2b) | From 2008 to 2011, 11 patients underwent cardiac surgery simultaneously with pulmonary resection Mean age: 71 ± 13 years Cardiac procedures included OPCABG (n = 4), AVR (n = 3), mitral valve repair (n = 2), total arch replacement (n = 1) and descending aortic replacement (n = 1) | Operative mortality rate Hospital death rate MI perioperative or postoperative Mean follow-up Death rate postoperatively Local recurrences Mean cancer-free period 2-year cancer-free rate | 0% 0% 0% 19 ± 11 months 2/11 patients (18%) 2 patients 17 ± 10 months 79% | The operated patients had 80% chance of 2-year survival The shortcomings of the authors' strategy were that its cost, stress and pain were double if the lesion required subsequent lobectomy The authors said that a second-stage operation can be used to perform a complete radical nodal dissection through a lateral thoracotomy OPCABG is a reasonable choice for isolated coronary bypass grafting with concomitant lung resection |
| Ma et al. (2012), Zhonghua Yi Xue Za Zhi, China [15] Cohort study (level 2b) | From 2003 to 2011, 22 patients underwent combined OPCABG and lung cancer surgery Mean age: 65 ± 4 years First OPCAB was performed and then lung resection | Perioperative death rate Perioperative new MI NSCLC Follow-up period Deaths during follow-up of 4 years | 0% 0% 18/22 patients (82%) 10–60 months 4/22 patients (18%), because of cancer recurrence | The combined procedure of OPCABG and pulmonary resection was a safe and effective treatment option |
| Zhang et al. (2012), Thorac Cardiovasc Surg, Germany [16] Cohort study (level 2b) | 33 patients with incidental solitary pulmonary nodules underwent cardiac and lung surgery, either simultaneously (n = 30) or sequentially (n = 3) | Primary NSCLC 5-year survival of patients with malignant pulmonary nodules 5-year survival of patients with benign pulmonary nodules | 14/33 patients (42.4%) 43.6% 85.6% | Malignant pulmonary nodules were larger in size and nodules with diameter larger than 10 mm had a higher incidence of malignancy 5-year survival of patients with malignant pulmonary nodules was lower than that of patients with benign nodules |
CPB: cardiopulmonary bypass; CHD: coronary heart disease; AVR: aortic valve replacement; PTCA: percutaneous transluminal coronary angioplasty; MI: myocardial infarction; SIRS: systemic inflammatory response syndrome; NSCLC: non-small-cell lung cancer; OPCABG: off-pump coronary artery bypass grafting; MVR: mitral valve replacement; MV: mitral valve.
| Author, date, journal and country Study type (level of evidence) . | Patient group . | Outcomes . | Key results . | Comments . |
|---|---|---|---|---|
| Miller et al. (1994), Ann Thorac Surg, USA [2] Cohort study (level 2b) | 30 patients (23 M and 7 F) underwent pulmonary resection for primary lung cancer and a concomitant open heart operation (combined group). 93.3% of the combined group presented with cardiac symptoms During the same period, another 15 patients (14 M and 1 F) underwent an open cardiac procedure followed by pulmonary resection for lung cancer 1–11 months later (median 2 months); 86.7% of the staged group presented with cardiac symptoms | Combined group Median age CABG CABG and AVR Lobectomy Wedge resection Lung resection was done in the combined group: (i) before CPB (ii) after CPB (ii) during CPB Tumour grade 3 or 4 Post-surgical Stage I Stage II Stage IIIA Staged group (cardiac operation followed by lung operation 1–11 months later) Median age CABG CABG and AVR Lobectomy Pneumonectomy Tumour grade 3 or 4 Post-surgical Stage I Stage II Stage IIIA Operative mortality rate Reoperations for bleeding Median follow-up Survivors in the combined group (with no disease) Overall estimated 1- and 5-year survival for the combined group Survivors in the staged group (with no disease) Overall estimated 1- and 5-year survival for the staged group 5-year survival for Stage I patients | 68 years (range 50–79 years) 23/30 patients (76.6%) 1/30 patient 21/30 patients (70%) 7/30 patients (23.3%) 12/30 patients (40%) 13/30 patients (43.3%) 5/30 patients (16.6%) 19 patients (63.3%) 23/30 patients (76.6%) 5/30 patients (16.6%) 2/30 patients (6.6%) 15 patients 69 years 11/15 patients (73.3%) 1/15 patients 9/15 patients (60%) 5/15 patients (33.3%) 10/15 patients (66.6%) 6/15 patients (40%) 4/15 patients (26.6%) 5/15 patients (33.3%) 6.7% (2/30 patients) in the combined group versus 0% in the staged group 2/30 patients in the combined versus 0/15 patients in the staged group 44 months for the combined and 59 months for the staged group 8/28 patients (28.6%) 79.7 and 34.9%, respectively 7/15 patients (46.7%) 72.7 and 53%, respectively 100% in the staged group versus 36.5% in the combined group | Survival in the combined group was not affected by the post-surgical stage of the neoplasm, but survival in the staged group was affected significantly by the extent of disease No significant difference was observed between the two groups with regard to the pattern of recurrence or cause of death Given that survival in patients with post-surgical Stage I disease was significantly reduced in patients who had concomitant open heart operation, the authors believed that a combined pulmonary resection and open heart operation should be limited to patients with clinical Stage I disease who could not tolerate a second-staged procedure Otherwise, patients who had clinical Stage I disease should undergo a staged pulmonary resection |
| Brutel de la Riviere et al. (1995), Eur J Cardiothorac Surg, Netherlands [3] Cohort study (level 2b) | From 1979 to 1993, 79 patients underwent pulmonary resection for lung cancer and a concomitant cardiac operation with CPB There were 75 men and 4 women Mean age: 65 years (52–77) | CABG CABG and mitral valve repair CABG with AVR AVR Lobectomy Pneumonectomy Bilobectomy Sleeve lobectomy Segmental resection Postoperatively patients in Stage I Stage II Stage IIIA Hospital mortality Estimated mean survival (all patients, including hospital deaths) 2- and 5-year survival rates Late deaths because of lung cancer Re-exploration for bleeding | 69/79 patients (87.3%) 1/79 patient 2/69 patients 5/69 patients 60/69 patients (86.9%) 6/69 patients (8.6%) 5/69 patients 3/69 patients 4/69 patients 52/69 patients (65.8%) 18/69 patients (22.8%) 9 patients (11.4%) 6.3% 58 months 62 and 42%, respectively 64% 7/79 patients (8.8%) | Pulmonary resection for lung cancer in patients undergoing a concomitant cardiac operation could be performed safely with low operative morbidity and mortality and good long-term survival |
| Rao et al. (1996), Ann Thorac Surg, Canada [4] Cohort study (level 2b) | From 1982 to 1995, 30 patients underwent simultaneous cardiac operations and lung resections Patients who underwent single- or double-lung transplantation were excluded Mediastinoscopy was performed at the beginning of the operative procedure in 16 of the 18 patients who presented preoperatively with abnormal chest X-ray or with a known diagnosis of malignancy No N2 disease was found in any of these 16 patients | Follow-up Mean follow-up Pulmonary resection was performed Before CPB During CPB After reversal of heparin Cardiac procedure was completed before lung resection Mean age Pneumonectomy Lobectomy Wedge resection CABG AVR or MVR Pulmonary malignant lesion N2 disease at thoracotomy despite negative mediastinoscopy results Aortic cross-clamp average time CPB average time Operative deaths Reoperation for bleeding Perioperative MI Late deaths Length of stay postoperative Overall actuarial survival at 1, 5 and 7 years | 100% 22 months (range 1–100 months) 4/30 patients (13.3%) 19/30 patients (63.3%) 7/30 patients (23.3%) 23/30 patients (76.6%) 61 ± 13 years 3 patients (10%) 14 patients (47%) 12 patients (40%) 24/30 patients (80%) 6/30 patients (20%) 21/30 patients (70%) 2/30 patients (6.6%) 54 ± 21 min 109 ± 34 min 2/30 patients (6.6%) 1/30 patients (3.3%) 0% 3/30 patients (1%) 12.1 ± 7.6 days (median 10 days) 85 ± 7%, 85 ± 7%, 61 ± 21%, respectively | In this study, it did not appear that CPB had a detrimental effect on the 5-year survival 63% of patients in this study underwent resection during CPB and only 1 patient suffered from a bleeding complication If the patient remained stable after discontinuation of CPB, they proceeded with the pulmonary resection If the cardiac procedure was difficult or the patient was unstable, the lung resection could be delayed The combined procedure was feasible and safe in carefully selected patients In certain high-risk groups, separate staged procedures might be the most prudent action |
| Voets et al. (1997), Eur J Cardiothorac Surg, Netherlands [5] Cohort study (level 2b) | From 1988 to 1995, 34 patients underwent pulmonary resection for Stages I–II primary bronchogenic carcinoma and open heart surgery (CABG almost always), either concomitantly (n = 24) or in a staged procedure (n = 10) In all staged procedures, cardiac surgery was done first and lung surgery was performed later The mean interval between staged procedures was 33.9 ± 34.7 days (12–120 days) In all concomitant procedures, except one, heart operations on CPB were followed by lung resection, either still on CPB (13 patients) or afterwards (11 patients) after reversing hypocoagulation, whereas in 10 patients, after closing the sternotomy, a posterolateral incision for the lung resection was performed | Overall perioperative mortality Perioperative mortality in staged versus concomitant procedures Overall median survival time | 6/34 patients (17.6%) 1/10 patient (10%) versus 5/24 patients (20.8%), (P = 0.64) 4.2 years | There was a slightly better survival in the group undergoing a staged procedure, but this was not statistically significant The authors said that there was a substantially higher perioperative mortality, although this difference was not statistically significant because of the small number of patients, but this difference should be taken into account and the staged approach be the preferred one The interval between operations should be individualized according to the clinical status of the patient to a period as short as 2 weeks No relationship between survival and age, histopathology or extent of tumour No relation was demonstrated between survival and timing of lung resection in relation to CPB in the concomitantly operated group |
| Danton et al. (1998), Eur J Cardiothorac Surg, UK [6] Cohort study (level 2b) | From 1990 to 1997, 13 patients underwent simultaneous pulmonary resection and cardiac surgery 11/13 patients (84.6%) had coronary disease, and 1 patient had CABG and MV stenosis Primary lung carcinoma was detected in 10/13 patients (77%) Lung resection was performed before heparinization and CPB in 12/13 patients (92%) 2 patients underwent CABG on the beating heart without CPB | Operative mortality MI perioperative Mean follow-up Late deaths Survival rate of patients with bronchogenic carcinoma Overall survival rate | 0% 1/13 patient (7.6%) 23.8 months (1–48 months) 5/13 patients (38.5%) 5/10 patients (50%) 61.5% (8/13 patients) | Simultaneous pulmonary resection and cardiac surgery can be safely performed with adequate cancer-free survival in patients with Stage I or II pulmonary neoplastic disease Poor long-term survival and early cancer recurrence were mainly determined by the primary tumour stage |
| Patane et al. (2002), Interact CardioVasc Thorac Surg, Italy [7] Cohort study (level 2b) | From 1991 to 1999, 11 patients underwent simultaneous lung resection and cardiac operation Lung resection was performed before heparinization and CPB Mean age: 56.8 ± 11.2 years | Follow-up Follow-up period Perioperative death rate Re-exploration for bleeding Lung cancer Deaths during follow-up | 100% 12–108 months (mean 41.2) 0% 0% 9/11 patients (82%) 3/11 patients (27%) | Simultaneous cardiac surgery and lung resection in this small number of patients were safely performed and not associated with increased early or late morbidity or mortality |
| Ciriaco et al. (2002), Eur J Cardiothorac Surg, Italy [8] Cohort study (level 2b) | From 1993 to 2001, 50 patients with concomitant coronary artery disease and lung cancer underwent lung resection 19 of 50 patients first underwent myocardial revascularization 6 of these 19 patients first underwent CABG and the remaining 13 of 19 patients underwent PTCA; then lung surgery was performed with a mean interval of 32 ± 9 days The remaining 31 of the 50 patients underwent lung surgery alone Mean age: 68 ± 5 years | Prior myocardial revascularization and lung surgery at a later time Overall morbidity Overall mortality Complications postoperatively Deaths operative Deaths operative among patients with prior CABG | 19 patients 28% 4% 4/19 patients (with prior CABG) 2/31 patients (with no prior CABG) 0% | The authors preferred to stage the 2 procedures 3–6 weeks apart to allow optimization of the anticoagulant therapy |
| Saxena and Tam (2004), Ann Thorac Surg, Australia [9] Cohort study (level 2b) | 6 patients underwent combined OPCABG and lung resection during a 4-year period Follow-up ranged from 9 months to 3 years | Mean age Hospital mortality Late deaths Lobectomy Recurrence rate for angina or malignancy upon follow-up | 67.6 years 0% 2/6 patients (33.3%) 4/6 patients (66.6%) 0% | The authors believed that combined OPCABG surgery and pulmonary resection could be performed safely in high-risk patients with minimal possibility of morbidity and mortality |
| Schoenmakers et al. (2007), Ann Thorac Surg, Netherlands [10] Cohort study (level 2b) | 43 patients underwent a concomitant procedure for lung cancer and CABG, with or without the use of CPB between 1994 and 2005 In 28 patients, CABG was performed with CPB after lung resection was carried out (on-pump) 15 patients had first CABG without CPB and lung resection thereafter (off-pump) | On-pump group Mean age Postoperatively patients in Stage I Stage II Stage III Off-pump group Mean age Postoperatively patients in Stage I Stage II Stage III MI preoperatively or postoperatively Hospital mortality rate Overall mean survival (years) Mean survival 2-year survival rate 5-year survival rate Cardiac causes of death Lung cancer causes of death | 28/43 patients (65%) 66 years 71% of patients 14% of patients 14% of patients 15/43 patients (35%) 71 years 53% 33% 7% 0% in both groups 2/28 (7%) in the on-pump versus 1/15 (6.6%) in the off-pump group 4.8 years 5.25 years in the on-pump versus 3 years in the off-pump group (P = 0.09) 18/28 patients (64%) in the on-pump versus 7/15 patients (47%) in off-pump group (P <0.01) 13/28 patients (46%) in the on-pump versus 2/15 patients (13%) in the off-pump group (P <0.01) 1/28 (3.5%) in the on-pump versus 2/15 (13%) in the off-pump group 13/28 (46.4%) in the on-pump versus 7/15 (46.6%) in the off-pump group | No significant difference in hospital survival was seen between the on-pump and the off-pump group Late survival in both groups was comparable, even if the 2- and 5-year survival rates were significantly better for the on-pump group No significant difference in the cause of death was seen between the two groups The authors concluded that there was no evidence that off-pump surgery was a better treatment strategy of patients with combined cardiac and lung pathology The authors also stated that the off-pump group included less patients, older and with more advanced lung cancer and so the off-pump procedure in combined cardiac and lung surgery should be evaluated more |
| Prokakis et al. (2008), Med Sci Monit, Greece [11] Cohort study (level 2b) | From 2004 to 2006, 5 patients underwent combined surgical treatment for heart and lung disease in one stage Lung surgery was performed first and heart surgery was done with CPB Mean age: 65 years (52–77 years) 1 patient had CABG and wedge resection, 3 patients had AVR and lobectomy and 1 patient had an ascending aortic replacement and wedge resection | Perioperative mortality Mean follow-up Survival rate at follow-up | 0% 19 months (range 6–30 months) 100% | A combined treatment is feasible and safely performed with good results in patients with Stage I and II disease The long-term outcome is determined by the primary tumour stage |
| Dyszkiewicz et al. (2008), Eur J Cardiothorac Surg, Poland [12] Cohort study (level 2b) | From 2001 to 2006, 25 patients with NSCLC and unstable angina were operated CABG (off-pump) was performed simultaneously with lung resection First OPCABG was performed, followed by the pulmonary resection Mean age: 63 ± 12 years (57–75) 13 (52%) of the patients had undergone either coronary angioplasty and/or stenting before the diagnosis of lung cancer Patients with positive N2 disease were excluded from the study | OPCABG followed by lung resection Lung resection followed by OPCABG Duration of follow-up Perioperative death rate New MI perioperative Re-exploration for bleeding Deaths during follow-up | 23/25 patients (92%) 2/25 patients (8%) 8 months–5 years 0% 0% 1/25 patients (4%) 8/25 patients (32%) | The only statistically significant factor having an impact on survival was cancer recurrence (P <0.01) The operated patients had a 50% chance of 3-year survival A limitation of the study was that it was retrospective and there was a relatively small number of patients In the one-stage approach, CABG was performed off-pump and the risks of cancer spread, intraoperative haemorrhage, SIRS or pulmonary oedema were markedly lower Simultaneous off-pump and lung resection procedures require different surgical skills and are a safe and effective treatment when unstable CHD and lung cancer coexist The authors said that an important aspect of this procedure was to perform the coronary anastomosis before the lung resection. However, in selected cases, it might be necessary to perform a 1- or 2-vessel bypass followed by the pulmonary resection and finally the remaining coronary anastomosis |
| Cathenis et al. (2009), Acta Chir Belg, Belgium [13] Cohort study (level 2b) | From 2000 to 2008, 27 patients underwent pulmonary and cardiac surgery concomitantly Mean age: 68 years CABG was performed in 22/27 patients (82%) | Lung cancer Stage IA Stage IB Stage IIB Stage IIIB In-hospital mortality Re-exploration for bleeding Mean follow-up Median survival for all patients | 8/27 (31%) 11/27 (42%) 5/27 (19%) 2/27 (8%) 0% 3/27 patients (11%) 30.7 months 46 months | Simultaneous procedures for cardiac disease and pulmonary lesions could be performed without life-threatening morbidity and no in-hospital mortality |
| Hosoba et al. (2012), Ann Thorac Cardiovasc Surg, Japan [14] Cohort study (level 2b) | From 2008 to 2011, 11 patients underwent cardiac surgery simultaneously with pulmonary resection Mean age: 71 ± 13 years Cardiac procedures included OPCABG (n = 4), AVR (n = 3), mitral valve repair (n = 2), total arch replacement (n = 1) and descending aortic replacement (n = 1) | Operative mortality rate Hospital death rate MI perioperative or postoperative Mean follow-up Death rate postoperatively Local recurrences Mean cancer-free period 2-year cancer-free rate | 0% 0% 0% 19 ± 11 months 2/11 patients (18%) 2 patients 17 ± 10 months 79% | The operated patients had 80% chance of 2-year survival The shortcomings of the authors' strategy were that its cost, stress and pain were double if the lesion required subsequent lobectomy The authors said that a second-stage operation can be used to perform a complete radical nodal dissection through a lateral thoracotomy OPCABG is a reasonable choice for isolated coronary bypass grafting with concomitant lung resection |
| Ma et al. (2012), Zhonghua Yi Xue Za Zhi, China [15] Cohort study (level 2b) | From 2003 to 2011, 22 patients underwent combined OPCABG and lung cancer surgery Mean age: 65 ± 4 years First OPCAB was performed and then lung resection | Perioperative death rate Perioperative new MI NSCLC Follow-up period Deaths during follow-up of 4 years | 0% 0% 18/22 patients (82%) 10–60 months 4/22 patients (18%), because of cancer recurrence | The combined procedure of OPCABG and pulmonary resection was a safe and effective treatment option |
| Zhang et al. (2012), Thorac Cardiovasc Surg, Germany [16] Cohort study (level 2b) | 33 patients with incidental solitary pulmonary nodules underwent cardiac and lung surgery, either simultaneously (n = 30) or sequentially (n = 3) | Primary NSCLC 5-year survival of patients with malignant pulmonary nodules 5-year survival of patients with benign pulmonary nodules | 14/33 patients (42.4%) 43.6% 85.6% | Malignant pulmonary nodules were larger in size and nodules with diameter larger than 10 mm had a higher incidence of malignancy 5-year survival of patients with malignant pulmonary nodules was lower than that of patients with benign nodules |
| Author, date, journal and country Study type (level of evidence) . | Patient group . | Outcomes . | Key results . | Comments . |
|---|---|---|---|---|
| Miller et al. (1994), Ann Thorac Surg, USA [2] Cohort study (level 2b) | 30 patients (23 M and 7 F) underwent pulmonary resection for primary lung cancer and a concomitant open heart operation (combined group). 93.3% of the combined group presented with cardiac symptoms During the same period, another 15 patients (14 M and 1 F) underwent an open cardiac procedure followed by pulmonary resection for lung cancer 1–11 months later (median 2 months); 86.7% of the staged group presented with cardiac symptoms | Combined group Median age CABG CABG and AVR Lobectomy Wedge resection Lung resection was done in the combined group: (i) before CPB (ii) after CPB (ii) during CPB Tumour grade 3 or 4 Post-surgical Stage I Stage II Stage IIIA Staged group (cardiac operation followed by lung operation 1–11 months later) Median age CABG CABG and AVR Lobectomy Pneumonectomy Tumour grade 3 or 4 Post-surgical Stage I Stage II Stage IIIA Operative mortality rate Reoperations for bleeding Median follow-up Survivors in the combined group (with no disease) Overall estimated 1- and 5-year survival for the combined group Survivors in the staged group (with no disease) Overall estimated 1- and 5-year survival for the staged group 5-year survival for Stage I patients | 68 years (range 50–79 years) 23/30 patients (76.6%) 1/30 patient 21/30 patients (70%) 7/30 patients (23.3%) 12/30 patients (40%) 13/30 patients (43.3%) 5/30 patients (16.6%) 19 patients (63.3%) 23/30 patients (76.6%) 5/30 patients (16.6%) 2/30 patients (6.6%) 15 patients 69 years 11/15 patients (73.3%) 1/15 patients 9/15 patients (60%) 5/15 patients (33.3%) 10/15 patients (66.6%) 6/15 patients (40%) 4/15 patients (26.6%) 5/15 patients (33.3%) 6.7% (2/30 patients) in the combined group versus 0% in the staged group 2/30 patients in the combined versus 0/15 patients in the staged group 44 months for the combined and 59 months for the staged group 8/28 patients (28.6%) 79.7 and 34.9%, respectively 7/15 patients (46.7%) 72.7 and 53%, respectively 100% in the staged group versus 36.5% in the combined group | Survival in the combined group was not affected by the post-surgical stage of the neoplasm, but survival in the staged group was affected significantly by the extent of disease No significant difference was observed between the two groups with regard to the pattern of recurrence or cause of death Given that survival in patients with post-surgical Stage I disease was significantly reduced in patients who had concomitant open heart operation, the authors believed that a combined pulmonary resection and open heart operation should be limited to patients with clinical Stage I disease who could not tolerate a second-staged procedure Otherwise, patients who had clinical Stage I disease should undergo a staged pulmonary resection |
| Brutel de la Riviere et al. (1995), Eur J Cardiothorac Surg, Netherlands [3] Cohort study (level 2b) | From 1979 to 1993, 79 patients underwent pulmonary resection for lung cancer and a concomitant cardiac operation with CPB There were 75 men and 4 women Mean age: 65 years (52–77) | CABG CABG and mitral valve repair CABG with AVR AVR Lobectomy Pneumonectomy Bilobectomy Sleeve lobectomy Segmental resection Postoperatively patients in Stage I Stage II Stage IIIA Hospital mortality Estimated mean survival (all patients, including hospital deaths) 2- and 5-year survival rates Late deaths because of lung cancer Re-exploration for bleeding | 69/79 patients (87.3%) 1/79 patient 2/69 patients 5/69 patients 60/69 patients (86.9%) 6/69 patients (8.6%) 5/69 patients 3/69 patients 4/69 patients 52/69 patients (65.8%) 18/69 patients (22.8%) 9 patients (11.4%) 6.3% 58 months 62 and 42%, respectively 64% 7/79 patients (8.8%) | Pulmonary resection for lung cancer in patients undergoing a concomitant cardiac operation could be performed safely with low operative morbidity and mortality and good long-term survival |
| Rao et al. (1996), Ann Thorac Surg, Canada [4] Cohort study (level 2b) | From 1982 to 1995, 30 patients underwent simultaneous cardiac operations and lung resections Patients who underwent single- or double-lung transplantation were excluded Mediastinoscopy was performed at the beginning of the operative procedure in 16 of the 18 patients who presented preoperatively with abnormal chest X-ray or with a known diagnosis of malignancy No N2 disease was found in any of these 16 patients | Follow-up Mean follow-up Pulmonary resection was performed Before CPB During CPB After reversal of heparin Cardiac procedure was completed before lung resection Mean age Pneumonectomy Lobectomy Wedge resection CABG AVR or MVR Pulmonary malignant lesion N2 disease at thoracotomy despite negative mediastinoscopy results Aortic cross-clamp average time CPB average time Operative deaths Reoperation for bleeding Perioperative MI Late deaths Length of stay postoperative Overall actuarial survival at 1, 5 and 7 years | 100% 22 months (range 1–100 months) 4/30 patients (13.3%) 19/30 patients (63.3%) 7/30 patients (23.3%) 23/30 patients (76.6%) 61 ± 13 years 3 patients (10%) 14 patients (47%) 12 patients (40%) 24/30 patients (80%) 6/30 patients (20%) 21/30 patients (70%) 2/30 patients (6.6%) 54 ± 21 min 109 ± 34 min 2/30 patients (6.6%) 1/30 patients (3.3%) 0% 3/30 patients (1%) 12.1 ± 7.6 days (median 10 days) 85 ± 7%, 85 ± 7%, 61 ± 21%, respectively | In this study, it did not appear that CPB had a detrimental effect on the 5-year survival 63% of patients in this study underwent resection during CPB and only 1 patient suffered from a bleeding complication If the patient remained stable after discontinuation of CPB, they proceeded with the pulmonary resection If the cardiac procedure was difficult or the patient was unstable, the lung resection could be delayed The combined procedure was feasible and safe in carefully selected patients In certain high-risk groups, separate staged procedures might be the most prudent action |
| Voets et al. (1997), Eur J Cardiothorac Surg, Netherlands [5] Cohort study (level 2b) | From 1988 to 1995, 34 patients underwent pulmonary resection for Stages I–II primary bronchogenic carcinoma and open heart surgery (CABG almost always), either concomitantly (n = 24) or in a staged procedure (n = 10) In all staged procedures, cardiac surgery was done first and lung surgery was performed later The mean interval between staged procedures was 33.9 ± 34.7 days (12–120 days) In all concomitant procedures, except one, heart operations on CPB were followed by lung resection, either still on CPB (13 patients) or afterwards (11 patients) after reversing hypocoagulation, whereas in 10 patients, after closing the sternotomy, a posterolateral incision for the lung resection was performed | Overall perioperative mortality Perioperative mortality in staged versus concomitant procedures Overall median survival time | 6/34 patients (17.6%) 1/10 patient (10%) versus 5/24 patients (20.8%), (P = 0.64) 4.2 years | There was a slightly better survival in the group undergoing a staged procedure, but this was not statistically significant The authors said that there was a substantially higher perioperative mortality, although this difference was not statistically significant because of the small number of patients, but this difference should be taken into account and the staged approach be the preferred one The interval between operations should be individualized according to the clinical status of the patient to a period as short as 2 weeks No relationship between survival and age, histopathology or extent of tumour No relation was demonstrated between survival and timing of lung resection in relation to CPB in the concomitantly operated group |
| Danton et al. (1998), Eur J Cardiothorac Surg, UK [6] Cohort study (level 2b) | From 1990 to 1997, 13 patients underwent simultaneous pulmonary resection and cardiac surgery 11/13 patients (84.6%) had coronary disease, and 1 patient had CABG and MV stenosis Primary lung carcinoma was detected in 10/13 patients (77%) Lung resection was performed before heparinization and CPB in 12/13 patients (92%) 2 patients underwent CABG on the beating heart without CPB | Operative mortality MI perioperative Mean follow-up Late deaths Survival rate of patients with bronchogenic carcinoma Overall survival rate | 0% 1/13 patient (7.6%) 23.8 months (1–48 months) 5/13 patients (38.5%) 5/10 patients (50%) 61.5% (8/13 patients) | Simultaneous pulmonary resection and cardiac surgery can be safely performed with adequate cancer-free survival in patients with Stage I or II pulmonary neoplastic disease Poor long-term survival and early cancer recurrence were mainly determined by the primary tumour stage |
| Patane et al. (2002), Interact CardioVasc Thorac Surg, Italy [7] Cohort study (level 2b) | From 1991 to 1999, 11 patients underwent simultaneous lung resection and cardiac operation Lung resection was performed before heparinization and CPB Mean age: 56.8 ± 11.2 years | Follow-up Follow-up period Perioperative death rate Re-exploration for bleeding Lung cancer Deaths during follow-up | 100% 12–108 months (mean 41.2) 0% 0% 9/11 patients (82%) 3/11 patients (27%) | Simultaneous cardiac surgery and lung resection in this small number of patients were safely performed and not associated with increased early or late morbidity or mortality |
| Ciriaco et al. (2002), Eur J Cardiothorac Surg, Italy [8] Cohort study (level 2b) | From 1993 to 2001, 50 patients with concomitant coronary artery disease and lung cancer underwent lung resection 19 of 50 patients first underwent myocardial revascularization 6 of these 19 patients first underwent CABG and the remaining 13 of 19 patients underwent PTCA; then lung surgery was performed with a mean interval of 32 ± 9 days The remaining 31 of the 50 patients underwent lung surgery alone Mean age: 68 ± 5 years | Prior myocardial revascularization and lung surgery at a later time Overall morbidity Overall mortality Complications postoperatively Deaths operative Deaths operative among patients with prior CABG | 19 patients 28% 4% 4/19 patients (with prior CABG) 2/31 patients (with no prior CABG) 0% | The authors preferred to stage the 2 procedures 3–6 weeks apart to allow optimization of the anticoagulant therapy |
| Saxena and Tam (2004), Ann Thorac Surg, Australia [9] Cohort study (level 2b) | 6 patients underwent combined OPCABG and lung resection during a 4-year period Follow-up ranged from 9 months to 3 years | Mean age Hospital mortality Late deaths Lobectomy Recurrence rate for angina or malignancy upon follow-up | 67.6 years 0% 2/6 patients (33.3%) 4/6 patients (66.6%) 0% | The authors believed that combined OPCABG surgery and pulmonary resection could be performed safely in high-risk patients with minimal possibility of morbidity and mortality |
| Schoenmakers et al. (2007), Ann Thorac Surg, Netherlands [10] Cohort study (level 2b) | 43 patients underwent a concomitant procedure for lung cancer and CABG, with or without the use of CPB between 1994 and 2005 In 28 patients, CABG was performed with CPB after lung resection was carried out (on-pump) 15 patients had first CABG without CPB and lung resection thereafter (off-pump) | On-pump group Mean age Postoperatively patients in Stage I Stage II Stage III Off-pump group Mean age Postoperatively patients in Stage I Stage II Stage III MI preoperatively or postoperatively Hospital mortality rate Overall mean survival (years) Mean survival 2-year survival rate 5-year survival rate Cardiac causes of death Lung cancer causes of death | 28/43 patients (65%) 66 years 71% of patients 14% of patients 14% of patients 15/43 patients (35%) 71 years 53% 33% 7% 0% in both groups 2/28 (7%) in the on-pump versus 1/15 (6.6%) in the off-pump group 4.8 years 5.25 years in the on-pump versus 3 years in the off-pump group (P = 0.09) 18/28 patients (64%) in the on-pump versus 7/15 patients (47%) in off-pump group (P <0.01) 13/28 patients (46%) in the on-pump versus 2/15 patients (13%) in the off-pump group (P <0.01) 1/28 (3.5%) in the on-pump versus 2/15 (13%) in the off-pump group 13/28 (46.4%) in the on-pump versus 7/15 (46.6%) in the off-pump group | No significant difference in hospital survival was seen between the on-pump and the off-pump group Late survival in both groups was comparable, even if the 2- and 5-year survival rates were significantly better for the on-pump group No significant difference in the cause of death was seen between the two groups The authors concluded that there was no evidence that off-pump surgery was a better treatment strategy of patients with combined cardiac and lung pathology The authors also stated that the off-pump group included less patients, older and with more advanced lung cancer and so the off-pump procedure in combined cardiac and lung surgery should be evaluated more |
| Prokakis et al. (2008), Med Sci Monit, Greece [11] Cohort study (level 2b) | From 2004 to 2006, 5 patients underwent combined surgical treatment for heart and lung disease in one stage Lung surgery was performed first and heart surgery was done with CPB Mean age: 65 years (52–77 years) 1 patient had CABG and wedge resection, 3 patients had AVR and lobectomy and 1 patient had an ascending aortic replacement and wedge resection | Perioperative mortality Mean follow-up Survival rate at follow-up | 0% 19 months (range 6–30 months) 100% | A combined treatment is feasible and safely performed with good results in patients with Stage I and II disease The long-term outcome is determined by the primary tumour stage |
| Dyszkiewicz et al. (2008), Eur J Cardiothorac Surg, Poland [12] Cohort study (level 2b) | From 2001 to 2006, 25 patients with NSCLC and unstable angina were operated CABG (off-pump) was performed simultaneously with lung resection First OPCABG was performed, followed by the pulmonary resection Mean age: 63 ± 12 years (57–75) 13 (52%) of the patients had undergone either coronary angioplasty and/or stenting before the diagnosis of lung cancer Patients with positive N2 disease were excluded from the study | OPCABG followed by lung resection Lung resection followed by OPCABG Duration of follow-up Perioperative death rate New MI perioperative Re-exploration for bleeding Deaths during follow-up | 23/25 patients (92%) 2/25 patients (8%) 8 months–5 years 0% 0% 1/25 patients (4%) 8/25 patients (32%) | The only statistically significant factor having an impact on survival was cancer recurrence (P <0.01) The operated patients had a 50% chance of 3-year survival A limitation of the study was that it was retrospective and there was a relatively small number of patients In the one-stage approach, CABG was performed off-pump and the risks of cancer spread, intraoperative haemorrhage, SIRS or pulmonary oedema were markedly lower Simultaneous off-pump and lung resection procedures require different surgical skills and are a safe and effective treatment when unstable CHD and lung cancer coexist The authors said that an important aspect of this procedure was to perform the coronary anastomosis before the lung resection. However, in selected cases, it might be necessary to perform a 1- or 2-vessel bypass followed by the pulmonary resection and finally the remaining coronary anastomosis |
| Cathenis et al. (2009), Acta Chir Belg, Belgium [13] Cohort study (level 2b) | From 2000 to 2008, 27 patients underwent pulmonary and cardiac surgery concomitantly Mean age: 68 years CABG was performed in 22/27 patients (82%) | Lung cancer Stage IA Stage IB Stage IIB Stage IIIB In-hospital mortality Re-exploration for bleeding Mean follow-up Median survival for all patients | 8/27 (31%) 11/27 (42%) 5/27 (19%) 2/27 (8%) 0% 3/27 patients (11%) 30.7 months 46 months | Simultaneous procedures for cardiac disease and pulmonary lesions could be performed without life-threatening morbidity and no in-hospital mortality |
| Hosoba et al. (2012), Ann Thorac Cardiovasc Surg, Japan [14] Cohort study (level 2b) | From 2008 to 2011, 11 patients underwent cardiac surgery simultaneously with pulmonary resection Mean age: 71 ± 13 years Cardiac procedures included OPCABG (n = 4), AVR (n = 3), mitral valve repair (n = 2), total arch replacement (n = 1) and descending aortic replacement (n = 1) | Operative mortality rate Hospital death rate MI perioperative or postoperative Mean follow-up Death rate postoperatively Local recurrences Mean cancer-free period 2-year cancer-free rate | 0% 0% 0% 19 ± 11 months 2/11 patients (18%) 2 patients 17 ± 10 months 79% | The operated patients had 80% chance of 2-year survival The shortcomings of the authors' strategy were that its cost, stress and pain were double if the lesion required subsequent lobectomy The authors said that a second-stage operation can be used to perform a complete radical nodal dissection through a lateral thoracotomy OPCABG is a reasonable choice for isolated coronary bypass grafting with concomitant lung resection |
| Ma et al. (2012), Zhonghua Yi Xue Za Zhi, China [15] Cohort study (level 2b) | From 2003 to 2011, 22 patients underwent combined OPCABG and lung cancer surgery Mean age: 65 ± 4 years First OPCAB was performed and then lung resection | Perioperative death rate Perioperative new MI NSCLC Follow-up period Deaths during follow-up of 4 years | 0% 0% 18/22 patients (82%) 10–60 months 4/22 patients (18%), because of cancer recurrence | The combined procedure of OPCABG and pulmonary resection was a safe and effective treatment option |
| Zhang et al. (2012), Thorac Cardiovasc Surg, Germany [16] Cohort study (level 2b) | 33 patients with incidental solitary pulmonary nodules underwent cardiac and lung surgery, either simultaneously (n = 30) or sequentially (n = 3) | Primary NSCLC 5-year survival of patients with malignant pulmonary nodules 5-year survival of patients with benign pulmonary nodules | 14/33 patients (42.4%) 43.6% 85.6% | Malignant pulmonary nodules were larger in size and nodules with diameter larger than 10 mm had a higher incidence of malignancy 5-year survival of patients with malignant pulmonary nodules was lower than that of patients with benign nodules |
CPB: cardiopulmonary bypass; CHD: coronary heart disease; AVR: aortic valve replacement; PTCA: percutaneous transluminal coronary angioplasty; MI: myocardial infarction; SIRS: systemic inflammatory response syndrome; NSCLC: non-small-cell lung cancer; OPCABG: off-pump coronary artery bypass grafting; MVR: mitral valve replacement; MV: mitral valve.
RESULTS
The search was wide. There were only 15 retrospective studies.
Miller et al. found that overall 1- and 5-year survival rates for the combined group were 79.7 and 34.9% and for the staged group were 72.7 and 53%, respectively. The 5-year survival rate for Stage I patients in the staged group was 100% and only 36.5% in the combined group.
Brutel de la Riviere et al. found that in combined procedures 2- and 5-year survival rates were 62 and 42%, respectively.
Rao et al. showed that, in combined lung surgery and cardiac operation, overall actuarial survival rates at 1, 5 and 7 years were 85 ± 7, 85 ± 7 and 61 ± 21%, respectively. Of the total, 63% of patients underwent pulmonary resection during CPB, which did not have a detrimental effect on 5-year survival. The operative death rate was 6.6% and the reoperation rate for bleeding was 3.3%.
Voets et al. found that the operative mortality rate was 20.8% in the concomitant group versus 10% in the staged group (but not statistically significant).
Danton et al. showed that there was no hospital mortality in performing simultaneous pulmonary resection and cardiac surgery. The overall survival rate was 61.5%. The survival rate of patients with bronchogenic carcinoma was 50%.
Patane et al. found that the perioperative mortality rate was 0% in patients treated with simultaneous lung surgery and cardiac surgery. The survival rate during follow-up was 73%.
Ciriaco et al. demonstrated that the overall morbidity and mortality rates were 28 and 4%, respectively. There were no deaths among patients who had prior CABG.
Saxena and Tam showed that the hospital mortality rate was 0% and the late death rate was 33.3% in patients who were operated with combined off-pump CABG (OPCABG) and pulmonary resection. No recurrence for angina or malignancy was detected during follow-up.
Schoenmakers et al. found that the hospital mortality rate was 7% in the on-pump versus 6.6% in the off-pump group. The mean survival was 5.25 years in the on-pump versus 3 years in the off-pump group. The 2-year survival rate was 64% in the on-pump versus 47% in the off-pump group, and the 5-year survival rate was 46% in the on-pump versus 13% in the off-pump group, respectively.
Prokakis et al. found that the hospital mortality rate was 0% in patients who underwent combined lung and heart surgery. The survival rate was 100%.
Dyszkiewicz et al. showed that the perioperative death rate and perioperative myocardial infarction (MI) rate were 0% in combined OPCABG and lung cancer surgery. The death rate was 32% during follow-up, mostly because of cancer relapse. No patient had an MI during follow-up.
Cathenis et al. found that the in-hospital mortality rate was 0% in patients who were operated simultaneously for cardiac disease and pulmonary lesions. The median survival was 46 months for these patients.
Hosoba et al. found that there was no operative or hospital death in patients treated simultaneously with cardiac surgery and pulmonary resection. The operated patients had an 80% chance of 2-year survival.
Ma et al. found that the perioperative death rate and the new MI rate were 0% in combined OPCABG and lung cancer surgery. The survival rate during follow-up was 82%.
Zhang et al. showed that the 5-year survival rate was only 43.6% in patients with simultaneous cardiac and lung surgery for malignant pulmonary nodules versus 85.6% in patients with benign pulmonary nodules.
CLINICAL BOTTOM LINE
Ten papers reported the results of combined and staged operations. The operative mortality rate of combined procedures was 0–20.8% and of staged procedures was 0–10%. The reoperation rate for bleeding of combined procedures was 0–11% and of staged procedures was 0%. The survival rate of combined procedures at 1 year was 79.–100%, at 5 years was 34.9–85% and at 7 years was 61%. The survival rate of staged procedures at 1 year was 72.7% and at 5 years was 53%. Five studies reported the results of OPCABG and lung surgery versus on-pump and lung surgery. The operative mortality rate of OPCABG and lung surgery was 0–6.6%. The 2-year survival rate of OPCABG and lung surgery was 47% and the 5-year survival rate was 13–68%. The re-exploration rate for bleeding of OPCABG was 4%. Simultaneous lung surgery and CABG could be safely performed with adequate cancer-free survival in patients with Stage I or II lung cancer. Lung surgery is better performed before CPB, avoiding the complications of the latter Long-term survival after combined treatment is mostly related to the predicted survival after lung resection. This depends on T stage and mostly on the patient's nodal status. In certain high-risk groups (if the cardiac procedure is difficult or if the patient is unstable), separate staged procedures (CABG as a first and lung resection as a second operation) might be the most prudent action (3–6 weeks apart). There is also another option (OPCABG and lung resection), which is a safe and effective treatment when unstable coronary heart disease and lung cancer coexist.
Conflict of interest: none declared.
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Topic:
Comments
We read with great interest the review by Tourmousoglou et al. [1] on the surgical management options of simultaneously occurring coronary artery disease (CAD) and lung cancer. The authors have nicely cited and assessed a large amount of literature reports dealing with the subject. We would like to highlight two issues regarding the management of this unusual occurrence. The first is the oncologic influence of cardiopulmonary bypass (CPB) due to its well-known immunosuppressive properties. Pinto et al. [2] performed a retrospective analysis of the risk of developing malignant disease in a patient cohort without a history of prior malignancy undergoing CABG, with (n= 35 795) and without (n= 12 214)the use of CPB. The former group demonstrated a higher risk of future development of lung cancer (adjusted RR= 1.36, 95% CI: 1.02-1.81, P= 0.034) and skin melanoma (adjusted RR= 1.66, 95% CI: 1.08-2.55, P= 0.022). Although the negative impact of CPB on the survival of cancer patients is unclear, the authors of the present best evidence topic have correctly stated that lung cancer resection should be preferably performed before the institution of CPB, whenever possible.
A second point worth mentioning is the option of percutaneous coronary revascularization with either balloon angioplasty or a bare metal stent. Although it has been reported that this prophylactic approach is safe and effective when applied before lung resection [3], dual antiplatelet therapy is required for 4-6 weeks, which significantly delays lung resection with the associated risk of disease progression. Thus, this approach has traditionally fallen out of favour for patients with CAD in need of undeferable non-cardiac surgery. Recently, stents using endothelial progenitor cell (EPC) capture technology have been introduced, demonstrating an enhanced speed of endothelization, necessitating dual antiplatelet therapy for only one week following implantation [4]. Subsequently, patients can undergo lung cancer surgery one week after clopidogrel discontinuation, on aspirin, with minimal risk of bleeding complications [5]. It remains to be seen if these EPC stents have comparable effectiveness with established coronary revascularization techniques. If so, in the near future, some patients with CAD and lung cancer might avoid the combined morbidity and mortality associated with two surgical procedures.
References
[1] Tourmousoglou CE, Apostolakis E, Dougenis D. Simultaneous occurrence of coronary artery disease and lung cancer: what is the best surgical treatment strategy? Interact CardioVasc Thorac Surg 2014;19:673-81
[2] Pinto CA, Marcella S, August DA, Holland B, Kostis JB, Demissie K. Cardiopulmonary bypass has a modest association with cancer progression: a retrospective cohort study. BMC Cancer 2013;3:519.
[3] Voltolini L, Rapicetta C, Luzzi L, Paladini P, Ghiribelli C, Scolletta S et al. Lung resection for non-small cell lung cancer after prophylactic coronary angioplasty and stenting: short- and long-term results. Minerva Chir 2012;67:77-85.
[4] Aoki J, Serruys PW, van Beusekom H, Ong AT, McFadden EP, Sianos G et al. Endothelial progenitor cell capture by stents coated with antibody against CD34: the HEALING-FIM (Healthy Endothelial Accelerated Lining Inhibits Neointimal Growth-First In Man) Registry. J Am Coll Cardiol 2005;45:1574- 9.
[5] Goldsmith IR, Smith D. Coronary revascularisation with Genous stent helps reduce the waiting time for lung resection. Eur J Cardiothorac Surg 2011;40:1248-9.
Conflict of interest:
none declared