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CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 5  |  Page : 588 Table of Contents     

Off Pump Coronary Artery Bypass Grafting in Rheumatoid Arthritis - A Case Report


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 Acceptance07-Jul-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Ranjith B Karthekeyan
Department of cardiothoracic Anesthesiology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai-400116
India
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Source of Support: None, Conflict of Interest: None


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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 2019 Dec 12];52:588. Available from: http://www.ijaweb.org/text.asp?2008/52/5/588/60682


   Introduction Top


The association of coronary artery disease and acute coronary syndromes with rheumatoid arthritis has been well established [1] . 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 Top


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 Top


Rheumatoid arthritis is one of the recognized risk factors for the development of coronary artery disease [1] . 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 [1] . The increased CD4 + CD28 null T cells found in rheumatoid arthritis have been directly related to the development of coronary artery disease. [2] The increased arterial stiffness and in­creased circulating prothrombotic factors may also contribute to the risk of cardiovascular morbidity [3] .Also they have more advanced coronary atherosclerosis, with an increased likelihood of triple vessel disease on first angiogram [1] . 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 [1] . 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 [1] . RA patients have shown to have ultrasonic marker of early atherosclerosis consis­tent with an increased risk for atherosclerosis [4] . 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 [5] . Cricoarytenoid arthri­tis is common in patients with rheumatoid arthritis and the diagnosis can be difficult [6] . 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 [7] .

Rheumatoid arthritis is associated with interstitial lung disease that can be subclinical [8],[9] . 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 Top

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.  Back to cited text no. 1      
2.Liuzzo G, Giubilato G, Pinnelli M. T cells and cytokines in atherogenesis. Lupus 2005;14:732-5.  Back to cited text no. 2      
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.  Back to cited text no. 3      
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.  Back to cited text no. 4      
5.Quoss A, Buurman C. Anesthesiological considerations in rheumatic diseases. Anaesthesiol Reanim 2000;26:116-­21.  Back to cited text no. 5      
6.Takakura K, Hirakawa S, Kudo K et al. Cricoarytenoid arthritis diagnosed after tracheostomy in a rheumatoid arthritis patient. Masui 2005 ;54:690-3.  Back to cited text no. 6      
7.Shannon TM, Gale ME. Noncardiac manifestations of rheumatoid arthritis in the thorax. J Thorac Imaging 1992 ;7:19-29.  Back to cited text no. 7      
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.  Back to cited text no. 8      
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.  Back to cited text no. 9      


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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