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LETTER TO THE EDITOR
Year : 2023 | Volume
: 9
| Issue : 1 | Page : 95-98
Concerns of non-hodgkin's lymphoma in open-heart surgery for rheumatic heart disease: A case report and review of literature
Anish Gupta1, Anshuman Darbari1, Uttam Kumar Nath2, RS Abisho1
1 Department of CTVS, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Medical Oncology and Haematology, AIIMS, Rishikesh, Uttarakhand, India
Correspondence Address:
Anish Gupta
Department of CTVS, AIIMS, Rishikesh - 249 203, Uttarakhand
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jpcs.jpcs_79_22
There are concerns regarding safe conduct of open-heart surgery in a patient with hematological malignancy, both in intraoperative and postoperative management of the patient. There is a paucity of literature regarding this problem and limited data have been published regarding the conduct of coronary artery bypass surgery on pump in a patient with hematological malignancies. We describe our experience in a patient with rheumatic heart disease with non-Hodgkin's lymphoma requiring mitral valve replacement.
Keywords: Mitral valve replacement, non-Hodgkin's lymphoma, open-heart surgery
Non-Hodgkin lymphoma (NHL) patients can have co existing rheumatic heart disease (RHD) or can have worsening of RHD symptoms during the course of their NHL treatment with radiotherapy or chemotherapy. These patients may require open heart surgery for their valvular problems in the form of valve repair or replacement, here we present one such case who was diagnosed with NHL and required mitral valve replacement (MVR) and we have discussed the perioperative concerns, challenges and management during open heart surgery.
Case ReportA 43-year-old male was diagnosed with rheumatic heart disease with moderate mitral stenosis and was on medical follow-up. He developed a painless swelling in the right submandibular region without any associated fever or bone pain. There was associated splenomegaly but no other swelling elsewhere in the body. He was anemic (hemoglobin – 8.2 g/dl) and had a history of bleeding per rectum. His total leukocyte count and platelet counts were normal. His coagulation profile (prothrombin time and partial thromboplastin time) was normal, but lactate dehydrogenase levels were raised (~600 U/L). His peripheral smear consisted of mild anisocytosis showing microcytic hypochromic red cells and adequate platelets.
A fine-needle aspiration cytology was done, which showed atypical lymphoid proliferation and raised suspicion of lymphoma. He underwent an excisional biopsy of the swelling and high-grade B-cell non-Hodgkin's lymphoma (NHL) was diagnosed [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f. On immunohistochemistry, bcl-6 and CD-20 were focally and diffusely positive, respectively. Ki-67 labeling index was high (90%), MUM-1 was focally positive, and S-100 was negative. CD-3 was positive in scattered T-cells, shown below [Table 1].
Figure 1: (a) H and E section ×200, shows diffuse infiltration by large atypical cells, (b) Section shows diffuse CD-20-positive cells, (c) Section shows cells positive for Bcl-6 (30%), (d) Section shows cells positive for MUM-1 (70%), (e) Section shows cells with Ki-67 labeling index (60%–70%), (f) Section shows background T-cells positive with CD-3
Table 1: Immunohistochemistry result of Lymph Node biopsy of our patientHowever, during his treatment, he developed a worsening of dyspnea, and repeat echocardiography showed severe mitral stenosis with severe pulmonary artery hypertension with normal ejection fraction [Figure 2]a and [Figure 2]b. The mitral valve area was 0.7 cm2 by planimetry and was associated with moderate mitral regurgitation and severe subvalvular disease and evidence of calcification in leaflets (Wilkins score 12). There was moderate tricuspid regurgitation with right ventricular systolic pressure of 80 mmHg and trace aortic regurgitation and mild pulmonary regurgitation. There was a clot seen in the left atrial appendage, transesophageal echo was not done, but computed tomography (CT) coronary angiography was done, which revealed normal coronaries. The patient was in normal sinus rhythm and chest X-ray showed the presence of cardiomegaly with signs of the left atrial enlargement. Positron emission tomography-CT (PET-CT) was done, which revealed fluorodeoxyglucose-avid bilateral lung changes and mediastinal lymphadenopathy, probably infective origin and no hypermetabolic focus of residual disease was found. The patient was planned to be kept under hematological follow-up for any recurrence and need for future chemotherapy. The patient was not a candidate for percutaneous balloon mitral valvotomy because of calcified leaflets, associated moderate regurgitation, and sub valvar disease, therefore was planned for mitral valve replacement (MVR).
Figure 2: (a) Preoperative echocardiogram showing left atrial appendage clot, (b) Preoperative echocardiogram showing severe mitral stenosisAs per the hematologist's opinion, two units of red blood cells were transfused the day before surgery and he underwent successful MVR with 31 #St. Jude medical mechanical prosthesis and subtotal chordal preservation with ligation of the left atrial appendage. Intraoperative and postoperative period was uneventful and the patient was extubated the same day after about 6 h. He needed two units of red blood cells, one each during intraoperative period and in the intensive care unit. The patient had an uneventful recovery and was discharged after about a week after surgery. The patient is on antiplatelets and warfarin therapy as anticoagulation with a target international normalized ratio of 2.5–3.5.
DiscussionThere are few concerns when it comes to a patient with hematological malignancy undergoing open-heart surgery on cardiopulmonary bypass (CPB).
Bleeding
It is one of the common complications after cardiac surgery, but its incidence is expected to increase due to lymphoma because these patients are anemic. The incidences of early postoperative reexploration and late intra-cranial bleeds have been found to be increased.
Infection
The incidence of infection is expected to increase after surgery in patients with NHL and has been shown in many case series, especially with chronic lymphocytic leukemia (CLL). It may be because the patients are immunocompromised, especially if they have undergone recent chemotherapy. CPB also depresses immune function early after surgery by various mechanisms on cellular and humoral immunity. Samuels et al.[1] have also described the addition of intravenous immunoglobulin to their antibiotic prophylaxis regimen for decreasing the incidence of postoperative infection and sepsis in such patients.
Finck et al.[2] have the largest study of patients with CLL undergoing coronary artery bypass grafting (CABG). Fink et al.[2] concluded that patients with CLL can undergo cardiac surgery with mortality rates comparable to patients without CLL, but with an increased risk of infection; and patients with CLL should be approached similarly to patients without CLL when the cardiac operation is considered.
Samuels et al.[1] have described their experience with CLL in 12 patients undergoing CABG, aortic valve replacement (AVR), and combined. They have found associated high mortality (17%) and morbidity (58%), mainly due to infection and sepsis, which was the most common complication. They also found a higher requirement of blood transfusion in these patients. They concluded that patients with CLL undergoing cardiac surgery have an increased hospital mortality and morbidity. The long-term outcome is variable and disappointing. As a result of these findings, careful preoperative analysis of the CLL status is necessary.
Guler et al.[3] recently published their experience of CABG in patients with hematological malignancies, six of these patients had NHL. They found an increased incidence of postoperative reexploration due to bleeding and three patients were lost in long-term follow-up due to intracranial bleeding.
Ghosh et al.[4] published a series of 13 patients with low-grade lymphocytic malignancies who underwent open heart surgeries, 5 of these patients had NHL and underwent either CABG or MVR. They concluded that an acceptable outcome may be anticipated after cardiac operations in patients with low-grade CLL and NHL in the early stages. However, the possibility of infection and progression of cardiac and lymph cytopathologic status in these patients should call for caution. It may be because white blood cell count generally increases after open-heart surgery, and CPB may stimulate a leukemoid reaction, which can lead to a relapse in an otherwise quiescent illness.
Sommer et al.[5] have an experience with 56 patients with hematological malignancies, 29 of which had NHL, who underwent CABG or valvular surgery. They concluded that although acceptable results can be achieved in such patients, but increased rate of mortality and vascular, pulmonary, and infectious complications is anticipated, especially in patients with preoperative chemotherapy or radiotherapy.
Žaliaduonytė et al.[6] have reviewed cardiovascular disorders developing after treatment of NHL. In a study of 6039 NHL patients followed for a median of 9 years after radiotherapy, cardiovascular complications were seen in 11.6%, the most common being coronary heart disease (19%), arrhythmia (16%), heart failure (12%), valvular heart disease (11%), and pericardial disease (5%). NHL patients receiving radiotherapy can develop valvular heart disease or worsen preexisting valve problems.[7] NHL patients receiving chemotherapy, especially anthracyclines, are at risk of precipitation of heart failure if they have preexisting heart disease.
We have seen that NHL patients are at increased risk of bleeding after cardiac surgery, but patients are anticoagulated after valve replacement which can exacerbate the risk of bleeding.
Radiation therapy has been associated with the development of valvular heart disease, especially at a dose of more than 30 Gy.[8],[9] We are unsure if the preexisting rheumatic heart disease was worsened by NHL in our patient, although he did not receive any chemotherapy or radiotherapy.
ConclusionPatients with NHL can undergo successful cardiac surgery on CPB, but there is an increased risk of bleeding and infectious complications, which can be avoided by careful preoperative and intraoperative planning with due consultation with hematologist throughout the treatment course and long-term follow-up is needed to detect any recurrence of malignancy.
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