Combined operation for myasthenia gravis and coronary artery disease.

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

Autoimmune myasthenia gravis after coronary artery bypass surgery

We report a rare case of spontaneous dissection of an anomalous systemic artery supplying a normal basal segment of the right lung during pregnancy, leading to recurrent hemoptysis. This article aims to discuss the clinical presentation, diagnostic curiosity, management using a minimally invasive technique (video-assisted thoracoscopic lobectomy), and finally the histopathologic findings.     

Anesthetic management for a patient with myasthenia gravis undergoing coronary artery bypass graft

PURPOSE: Report the clinical management of a patient having Myasthenia Gravis (MG), undergoing cardiopulmonary bypass (CPB). CLINICAL FEATURES: A 71-yr-old man having MG (Osserman IIB), was admitted for coronary artery bypass graft (CABG) under CPB. Optimization of the patient was achieved preoperatively. Thymectomy was done following midsternotomy. Continuous monitoring of the neuromuscular transmission (NMT) was maintained throughout the perioperative period. The hemodilutional effect of CPB was counteracted by the hypothermia resulting in maintenance of cisatracurium requirements at the same levels as the prebypass period. Extubation of the trachea was done after ensuring adequate recovery of the NMT and respiratory function. Oral myasthenic therapy was resumed following extubation. CONCLUSION: A myasthenic patient can safely undergo CPB provided adequate preoperative optimization is achieved. Continuous monitoring of the NMT must be throughout the perioperative period. Thymectomy is recommended in the myasthenic patient since it may improve the outcome. Extubation of the trachea is to be done after ensuring adequate NMT and respiratory function.     

Combined cervicothoracic approach in thymectomy for myasthenia gravis

Thymectomy was performed for myasthenia gravis on 30 patients, using a new approach with a collar incision which gave full exposure of the retrothyroid space and was directly connected to a median sternotomy. The thymus was removed en bloc without pleural incision. There was no perioperative mortality and the only complications were transient respiratory insufficiency in two cases. The postoperative hospital stay was 3-9 (mean 5.8) days. The effect of thymectomy was evaluated after 2-8 years at the Department of Neurology, when changes in symptoms (stages I-IV) or medication (need for cholinesterase inhibitors) were registered. The total clinical improvement rate was 97%, with 3% of the patients improved three stages, 33% two stages and 60% one stage compared with the preoperative classification. Twenty patients (67%) were asymptomatic at follow-up and six (20%) also required no medication. The medication need was reduced in 70% of cases (mean reduction 42%). Our cervicothoracic approach resulted in the same rate of improvement as in studies using more extensive transsternal procedures, but the morbidity was lower, with no complications requiring prolonged hospital stay. The morbidity was also less than after only transcervical procedures aiming to perform total thymectomy--a prerequisite for maximal and lasting benefit from surgery. Moreover, as this cervicothoracic approach is simple and safe, it can be recommended as an option in the surgical management of myasthenia gravis.     

Combined surgery for coronary artery disease and pheochromocytoma

PURPOSE: To report a case of severe coronary artery disease complicating pheochromocytoma, managed with combined coronary artery bypass grafting (CABG) and adrenalectomy. CLINICAL FEATURES: A 55-yr-old woman presented with poorly controlled hypertension and investigation revealed an active pheochromocytoma of her left adrenal gland. During medical preparation for adrenalectomy, she developed an acute myocardial infarct complicated with unstable angina. This required urgent CABG, and combined surgery for the triple vessels coronary artery disease and the pheochromocytoma was planned. We explain the details of medical preparation before surgery and the anesthetic considerations during the surgical procedure. Postoperative recovery was normal and no complication occurred. Even if the pheochromocytoma was malignant, her urinary catecholamines two months after the surgery were normal and remain normal after more than two years of follow-up. CONCLUSION: We report a patient who underwent combined CABG and adrenalectomy for pheochromocytoma. The CABG was done first, followed by the adrenalectomy with invasive monitoring. The procedure was well tolerated with cure of the two underlying conditions. So we propose that combined procedure should be considered in this clinical setting.     

Combined carotid and coronary artery disease

Stroke is a devastating complication of coronary artery bypass surgery. It increases the mortality and morbidity of the operation, and prolongs the length of hospital stay. Functional disability from the stroke may dramatically reduce the quality of life post-operatively, and some patients will require permanent institutional care. Although there are many causes of stroke extra-cerebral carotid stenosis is the most important predictor of stroke for patients undergoing coronary artery bypass grafting (CABG). If patients are identified before coronary intervention, they may benefit from treatment of their carotid disease. Carotid endarterectomy can be performed before or simultaneously with coronary artery bypass. However, carotid angioplasty with stenting and cerebral protection may offer a superior method to conventional surgery in this high-risk group of patients.     

Castleman's disease associated with myasthenia gravis

Castleman's disease presents as a peculiar type of lymph node hyperplasia. Traditionally, the disease has been classified on clinical grounds (solitary or multicentric) and by histologic appearance (hyaline vascular pattern, plasma cell predominance, or mixed lesions). It is now increasingly clear that there are different etiologies for each of these different subtypes. Reported associations include POEMS syndrome (polyneuropathy, organomegally, endocrinopathy, monoclonal gammopathy, and skin changes), paraneoplastic pemphigus, Hodgkin's disease, and follicular dendritic cell sarcoma. We present a case of Castleman's disease associated with myasthenia gravis, the third reported case in the literature. We discuss Castleman's disease and review the literature.     

Thymectomy for myasthenia gravis

Between 1951 and 1971 thymectomy was performed on 41 patients with myasthenia gravis. They were selected from a total group of 95 myasthenic patients receiving anticholinesterase therapy. The criteria for selecting patients for thymectomy and the assessment of their progress after operation are described. All the patients have been examined by us at intervals and the results of this follow-up are presented. The survey has shown that substantial improvement after thymectomy occurred in 21 patients (group A), seven of whom had complete remissions without medication for periods of up to 12 years after operation. Considerable benefit from the operation was also observed in seven patients (group B); although their response was less spectacular, in that their daily requirement of anticholinesterase drugs was not changed, their functional activities were significantly enhanced. The most favourable results were seen in female patients aged 15 to 40 years, six of whom had one or more successful pregnancies. Thymectomy did not improve the general condition or progress of six patients (group C). There were three deaths within 16 days of operation, and two patients died within one year. Eight patients survived for periods of 3 to 16 years; six of these died from causes other than directly from myasthenia, and two died at home without established cause.     

Thymectomy for myasthenia gravis

Thymectomy was performed on 249 patients with myasthenia gravis between 1957 and 1981. During a follow-up period that ranged from 2 months to 24 years (mean 7.5 years), the remission rate for the entire group was 51 percent, and an additional 36 percent had improvement (87 percent benefited). In those 51 patients with thymoma, the remission rate was 37 percent, with 68 percent of the patients benefiting from operations. The remaining 198 patients fared better after the operation: 54 percent had remission and a total of 91 percent benefited. The female patients within this group had a 94 percent probability of benefit from operation. We conclude that most patients with myasthenia gravis will benefit from thymectomy, and that the improvement persists over an extended period of time in a high percentage of patients.     

Thymectomy for myasthenia gravis

Opinion statement No Class I studies of the effectiveness of thymectomy for myasthenia gravis (MG) have been performed. Most Class II studies comparing outcomes in MG patients with and without thymectomy demonstrated higher MG remission and improvement rates in patients undergoing thymectomy. However, these Class II studies were also consistently confounded by important differences between MG patients in surgical and nonsurgical groups. Myasthenia gravis patients undergoing thymectomy were younger, more often women and were more likely to have severe myasthenia. The authors of this paper cannot determine from these Class II studies whether the observed association between thymectomy and improved MG outcomes was a result of a thymectomy benefit or was merely a result of the multiple differences in baseline characteristics between the surgical and nonsurgical groups. The authors concluded that the benefit of thymectomy in non-thymomatous autoimmune MG has not been conclusively established. Thus, for patients with non-thymomatous autoimmune myasthenia gravis, thymectomy should only be considered an option to increase the probability of remission or improvement. The quality standards subcommittee of the American Academy of Neurology recently adopted this position [1].     

Thymectomy for autoimmune myasthenia gravis

Thymectomy has been performed as surgical treatment for autoimmune myasthenia gravis (MG) since the mid-1900s. Although it has been performed for more than half a century, there has been no report objectively confirming the validity of this treatment. Many groups have reported that surgery is effective in treating patients with MG, but the indications and type of surgery differ in each case. In addition, there has been no comparative trial of the results of surgery and natural progression of the disease. To resolve this situation, it would be desirable to standardize the indications for surgery in MG patients and to establish the surgical approach, as is being attempted by the Myasthenia Gravis Foundation of America although the results have not yet been announced. With recent advances in video-assisted surgery, the number of institutions in which thoracoscopic surgery is performed has increased. However, it appears that improvement in MG symptoms is dependent on the extent of resection in thymectomy. With the cervical or thorascopic approach, the extent of resection appears to be less than that using the transsternal or cervical plus transsternal approach. Before establishing a standard surgical approach, the validity of thymectomy for the treatment of MG should be confirmed in a randomized, controlled trial.     

Thymectomy for myasthenia gravis.

A group of 71 patients with myasthenia gravis is reviewed. All were initially managed medically, and 18 underwent thymectomy. Twenty-three responded poorly to drug treatment, and seven died from respiratory failure. In contrast, thymectomy was beneficial in 16 of the 18 who were subjected to operation. Seven patients had significant postoperative respiratory complications, and nine required a tracheostomy. Thymectomy appears to be effective and safe and to be indicated in young patients with early disease, and in patients who do not respond to drug treatment. The transcervical approach to thymectomy was satisfactory on two occasions.     

Anaesthesia and myasthenia gravis

Myasthenia gravis is an autoimmune disease, resulting from the production of antibodies against the acetylcholine receptors of the endplate. These antibodies reduce the number of active receptors, brought about either by functional block of the receptors, by increased rate of receptor degradation, or by complement-mediated lysis. In myasthenic muscles, the miniature endplate potential amplitude is decreased, and a large proportion of the endplate potentials are subthreshold. Repetitive nerve stimulation results in a decremental response. The disease is frequently associated with morphological abnormalities of the thymus. In young patients, thymic hyperplasia is common while thymoma is more frequent in elderly patients. Medical treatment of myasthenia gravis aims at improving of neuromuscular transmission by anticholinesterases, suppressing the immune system by corticosteroids and immunosuppressents, or by decreasing the circulating antibodies by plasmapheresis. Adults with generalized myasthenia should have a transsternal thymectomy. A balanced technique of general anaesthesia which includes the use of muscle relaxants can be safely used, provided neuromuscular transmission is monitored. Myasthenic patients are sensitive to nondepolarizing relaxants but intermediate-acting nondepolarizing relaxants such as atracurium and vecuronium are eliminated rapidly, and can be titrated to achieve the required neuro-muscular block that can be completely reversed at the end of surgery. Postoperatively, ventilatory support may be required in high-risk patients. Also, medical treatment may be maintained, tapered or discontinued depending on the outcome of surgery. Thymectomy benefits nearly 96% of patients, 46% develop complete remission and 50% are asymptomatic or improve on therapy.