|Year : 2008 | Volume
| Issue : 5 | Page : 588
Off Pump Coronary Artery Bypass Grafting in Rheumatoid Arthritis - A Case Report
Ranjith B Karthekeyan1, NS Karthikeyan2, MG Rakesh2, KG Suresh Rao2, Mahesh Vakamudi3, KR Balakrishnan4
1 Assistant Professor, Dept of Cardiac Anesthesiology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, India
2 Resident, Dept of Cardiac Anesthesiology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, India
3 Prof and chief, Dept of Cardiac Anesthesiology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, India
4 Prof and Head, Dept of Anesthesiology and critical care, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, India
|Date of Acceptance||07-Jul-2008|
|Date of Web Publication||19-Mar-2010|
Ranjith B Karthekeyan
Department of cardiothoracic Anesthesiology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai-400116
There is a well known association of rheumatoid arthritis with coronary artery disease. We report a 59 year old male patient with rheumatoid arthritis who underwent off pump coronary artery bypass grafting(OPCAB). He had extensive arthritis and contractures involving all major joints. There was restriction of all movements in the neck though mouth opening was adequate. The cannulation of radial and femoral arteries was difficult because of the contractures in the wrist and hip joints. Intubation was difficult and was accomplished with intubating bougie. Post operatively the patient developed plate atelectasis. The various anaesthetic implications of rheumatoid arthritis in OPCAB and their effective management are discussed.
Keywords: Off pump CABG, Rheumatoid arthritis,Contractures,anesthesia,Extra-articular
|How to cite this article:|
Karthekeyan RB, Karthikeyan N S, Rakesh M G, Suresh Rao K G, Vakamudi M, Balakrishnan K R. Off Pump Coronary Artery Bypass Grafting in Rheumatoid Arthritis - A Case Report. Indian J Anaesth 2008;52:588
|How to cite this URL:|
Karthekeyan RB, Karthikeyan N S, Rakesh M G, Suresh Rao K G, Vakamudi M, Balakrishnan K R. Off Pump Coronary Artery Bypass Grafting in Rheumatoid Arthritis - A Case Report. Indian J Anaesth [serial online] 2008 [cited 2013 Jun 20];52:588. Available from: http://www.ijaweb.org/text.asp?2008/52/5/588/60682
| Introduction|| |
The association of coronary artery disease and acute coronary syndromes with rheumatoid arthritis has been well established  . The presence of articular and other extraarticular manifestations of rheumatoid arthritis can be a challenge for anaesthesiologist. We report a case of rheumatoid arthritis who underwent coronary artery bypass grafting.
| Case report|| |
A 59 year old male patient with a known history of coronary artery disease for the past five years, presented with severe chest discomfort to the emergency care unit. The patient had thirty year history of diabetes mellitus and hypertension. The patient had history of rheumatoid arthritis for past 10 years but he was not on any medication. He was using crutches for ambulation. On examination, heart rate was 100/min, blood pressure was106/71 mm of Hg and breath holding time was 25 seconds. He had severe contractures of all the major joints [Figure 1]. Movements were limited in the shoulder, elbow, wrist, hip, knee and ankle joints. Examination of the airway revealed severe limitation of neck extension to less than 20°, flexion to less than 20° and rotation to less than 30° [Figure 2]. Mouth opening was 6.5 cm. The patient also had buck teeth. The patient had pigeon chest deformity.
Electrocardiogram revealed lateral wall ischemia and a coronary angiogram revealed 80% lesion in the proximal left anterior descending artery, 80% lesion in the obtuse marginal artery and mild irregularities in the right coronary artery. Chest skiagram showed arthritic changes in both shoulder joints and increased bronchovascular markings. Echocardiogram showed dilated left atrium and left ventricle with hypokinetic inferior and lateral walls. Ejection fraction was 61 %.Patient developed acute contrast induced nephropathy following angiogram which was treated with potassium and salt restricted diet and Tab N-acetyl cysteine . Ten days later, the patient was taken for surgery after resolution of the acute renal failure. The patient was fasted for 6 hours preoperatively, received diazepam 10 mg, ranitidine 150 mg and allopurinol 300 mg per oral, the night before and on the day of surgery.
Preinduction monitoring included pulse oximeter, electrocardiogram, invasive radial artery blood pressure, pulmonary artery pressure and bispectral index. Radial artery cannulation and securing with a splint was difficult due to the flexion contracture of the wrist joint. Baseline blood pressure was 134/87 (54) mm of Hg, pulse rate 76/minute, pulmonary artery pressure 28/14 (18) mm of Hg and saturation 99%.
Patient was induced with midazolam, fentanyl and titrated dose of thiopentone. Neuromuscular blockade was achieved with vecuronium after checking ventilation with bag and mask. Laryngoscopy with 4 size Macintosh blade was attempted. Cormack Lehanegrade was IIIa. An intubating bougie was introduced into the trachea and an 8.5 mm cuffed oral endotracheal tube was rail roaded over the bougie. The endotracheal tube was secured after confirming bilateral equal air entry. Post induction monitors included end tidal carbon dioxide concentration, invasive femoral artery pressure, nasopharyngeal temperature and urine output monitoring. Maintenance of anaesthesia was with 50 % nitrous oxide in oxygen and sevoflurane 1%, fentany l50mcg and vecuronium2 mgs as required. Patient was on nitroglycerine infusion of 0.5-1ml/hr .
Intraoperative positioning was accomplished with pillows under the lower legs, as there was flexion contracture at the hip joints. Due to the same, cannulation of the femoral artery was difficult and was done with sheets under the hips. Off pump coronary artery bypass was planned. The surgeon had difficulty in harvesting the left internal mammary artery due to the pigeon chest.
Heart was positioned with coronary stabilizer (Octopus Tissue Stabilizer, Medtronic, Inc, Minneapolis, MN). Saphenous vein was grafted to obtuse marginal artery, with its proximal end anastomosed to the aorta.Left internal mammary artery was anatomosed to the left anterior descending artery. During left anterior descending grafting, there was a raise in pulmonary artery pressure and during obtuse marginal grafting there was a fall in arterial pressure. During grafting for obtuse marginal blood pressure decreased to 96/ 60 mm of Hg and pulmonary artery pressure was maintaining around the baseline value. The hemodynamics of the patients were maintained with 300 ml of Ringer lactate bolus, injection ephedrine 6 mg bolus and trendelenberg positioning. During grafting for left anterior descending artery pulmonary artery pressure increased to 30/18 mm of Hg which was treated nitroglycerine purge of 0.3ml. Blood pressure was maintaining around 130/76 mm of Hg.)
After the surgery, the patient was shifted to the post anaesthesia care unit and put on controlled ventilation. The patient was extubated after five hours of ventilation. Post operatively the patient developed plate atelectasis of the right mid zone [Figure 3]. With physiotherapy and nebulisation the patient's lungs improved. The patient was discharged from the post anaesthetic care unit on the 4 th post operative day.
| Discussion|| |
Rheumatoid arthritis is one of the recognized risk factors for the development of coronary artery disease  . Inflammatory mediators like C - reactive protein in rheumatoid arthritis, enhance atherogenesis by either direct endothelial injury or through sensitization of the T cell mediated cytotoxicity  . The increased CD4 + CD28 null T cells found in rheumatoid arthritis have been directly related to the development of coronary artery disease.  The increased arterial stiffness and increased circulating prothrombotic factors may also contribute to the risk of cardiovascular morbidity  .Also they have more advanced coronary atherosclerosis, with an increased likelihood of triple vessel disease on first angiogram  . Our patient had disease of all three major epicardial vessels with significant lesions in left anterior descending and obtuse marginal arteries.
The disease modifying agents used in rheumatoid arthritis have profound effect on the cardiovascular morbidity. Though steroids cause dyslipidemia, hyperglycemia and hypertension, they also decrease inflammation in rheumatoid arthritis. Methotrexate treated patients have decreased mortality, when compared to rheumatoid arthritis patients who have not received it  . Our patient though diagnosed to have rheumatoid arthritis before 10 years, had not taken any medications for the same. This could have contributed to the development of atherosclerosis and angina.
The extra articular manifestations in rheumatoid arthritis have been shown to be associated with increased coronary artery disease. It is the strongest predictor of cardiovascular morbidity and mortality. Also rheumatoid arthritis patients are more prone for atherosclerosis as evidenced by increased carotid artery intima - media thickness  . RA patients have shown to have ultrasonic marker of early atherosclerosis consistent with an increased risk for atherosclerosis  . Our patient developed contrast induced acute renal failure after coronary angiogram. This may be due to the associated vascular disease in the kidneys due to the generalized atherosclerotic process and the associated diabetes mellitus.
The articular manifestations are a challenge to anaesthetic management. Possible reasons are the decreased range of motion of the cervical spine and the mandibular joint leading to a reduced opening of the mouth and reduced dorsal extension of the cervical spine. Furthermore, there is the problem of compression of the spinal cord in patients with subaxial instability of the cervical spine during laryngoscopy  . Cricoarytenoid arthritis is common in patients with rheumatoid arthritis and the diagnosis can be difficult  . The restricted neck motility due to arthritis of the cervical spines in our patient, made intubation of trachea difficult. Since the Cormack Lehane grading was IIIa, intubating bougie was used to intubate the trachea and then the endotracheal tube was railroaded over the bougie.
The fixed flexion deformity at the elbow and wrist joints made cannulation of the antecubital vein and the radial artery difficult. The flexion deformity at the knee and the hip joints required placement of pillows under the legs during positioning. Due to the same, the cannulation and securing of the right femoral artery cannula was difficult. Due to limited neck extension and arthritis of the thoracic joints, the surgeon found space for sternotomy limited  .
Rheumatoid arthritis is associated with interstitial lung disease that can be subclinical , . This could have contributed to the post operative pulmonary complication that had been present in our patient.
This case report brings out the various implications of rheumatoid arthritis in off pump coronary artery grafting including difficult airway, contractures of joints, positioning, harvesting of grafts and postoperative pulmonary complications. With careful planning, these challenges can be effectively managed.
| References|| |
|1.||Kenneth J Warrington, Peter D Kent, Robert L Frye. Rheumatoid arthritis is an independent risk factor for multi-vessel coronary artery disease: a case control study. Arthritis Research& Therapy 2005;7:R984 -R991. |
|2.||Liuzzo G, Giubilato G, Pinnelli M. T cells and cytokines in atherogenesis. Lupus 2005;14:732-5. |
|3.||Turesson C, Jarenros A, Jacobsson L. Increased incidence of cardiovascular disease in patients with rheumatoid arthritis: results from a community based study. Annals of the Rheumatic Diseases 2004; 63: 952 - 955. |
|4.||Park YB, Ahn CW, Choi HK et al. Atherosclerosis in rheumatoid arthritis: morphologic evidence obtained by carotid ultrasound. Arthritis Rheum 2002 ;46:1714-9. |
|5.||Quoss A, Buurman C. Anesthesiological considerations in rheumatic diseases. Anaesthesiol Reanim 2000;26:116-21. |
|6.||Takakura K, Hirakawa S, Kudo K et al. Cricoarytenoid arthritis diagnosed after tracheostomy in a rheumatoid arthritis patient. Masui 2005 ;54:690-3. |
|7.||Shannon TM, Gale ME. Noncardiac manifestations of rheumatoid arthritis in the thorax. J Thorac Imaging 1992 ;7:19-29. |
|8.||Bharadwaj A, Haroon N. Interstitial lung disease and neuropathy as predominant extra-articular manifestations in patients with rheumatoid arthritis: a prospective study. Med Sci Monit 2005;11:CR498-502. |
|9.||Carotti M, Salaffi F, Manganelli P et al. The subclinical involvement of the lung in rheumatoid arthritis: evaluation by high-resolution computed tomography. Reumatismo 2001;53:280-288. |
[Figure 1], [Figure 2], [Figure 3]