Cancer in Heart Disease Patients
Cancer in Heart Disease Patients
The results of one-stage procedures in simultaneous disease are shown in Table 2. The columns show the number of patients, the use of ECC, the type of tumor, the hospital mortality and long-term survival. Short-term results of a one-stage procedure are comparable with those after cardiac surgery in patients with prior (and hence supposedly cured) solid tumors: mortality was between 0 and 7.1%, but the series were usually small and included mostly only pulmonary tumors. Postoperative infections and mortality were higher in patients with CLL, but there would be no effect of cardiac surgery on the course of CLL. In one series, cancer patients had more need for transfusion (80 vs 49%) or reintubation (8 vs 0%), pneumonia (15 vs 6%), sepsis (8 vs 2%), arrhythmias (42 vs 34%) and anticoagulation-related complications (7 vs 0%) compared with controls. Autonomic dysfunction and hypercoagulability by tumoral tissue factor and platelet activation could persist, even after removal of the tumor. An increased infection rate could be related to an increased need for transfusion. Long-term results and quality of life after a one-stage procedure were acceptable. A 5-year survival over 40% can be reached, but the cancer was responsible for most of the long-term mortality. The type and the stage of the tumor played a dominant role, with a drop in 1-year survival from 80 to 50% with advanced cancer. The series are too small to draw definitive conclusions. In this respect, the technical possibility to dissect pulmonary lymph nodes during a combined procedure, but without ECC, might be questioned with respect to the effect on survival. The same applies to the surgical exposure of the lower left lobe. With an ECC, it is possible to rotate the heart without compromising the circulation and the lower left lobe can be reached more easily, with better long-term survival as a result. In patients with aortic valve stenosis and decreased LVEF, the effect of a low contractile reserve was more significant for survival, but the presence of a prior tumor proved to be more clinically relevant.
Patient series with prior malignancy (or series that mix patients with simultaneous and prior malignancies) are shown in Table 3. These reports had varying study designs, which makes comparison of their results difficult. Hospital mortality varied between 2.4 and 13.0%, and was within the range of hospital mortality of patients with simultaneous disease. The extent of prior radiotherapy played a major role. Hospital complications of a series including patients with active malignancy, a malignancy in remission or without malignancy were comparable and ranged between 33 and 36%. Long-term survival seemed encouraging, with a 5-year survival between 42 and 89%. The interval between treatment of the prior malignancy and cardiac surgery played an important role in postoperative 5- and 10-year survival: the longer the interval, the better the survival. With an interval of 10 years, a normal gender- and age-matched survival had been reached. With shorter intervals or simultaneous disease, death due to metastasis increased. Few studies reported independent predictors of survival: a decreased LVEF, presence of chronic obstructive pulmonary disease, presence of cancer or an interval of less than 2 years between treatment of the malignancy have been identified as predictors. Symptomatic aortic valve stenosis needs separate consideration since this condition is very life-threatening in the short term. Aortic valve replacement (AVR) is the only life-prolonging and symptom-reducing treatment. Independent predictors of decreased survival after operation were decreased LVEF, concomitant three-vessel disease and presence of cancer. Compared with medical treatment, AVR significantly increased survival (and reached the survival of cancer patients without valve disease), irrespective of cancer status and presence of metastases. Death due to cardiovascular disease occurred only in patients medically treated for calcified aortic valve stenosis. Survival after AVR was only affected by the tumor after 2 years. Although these results point to symptomatic calcified aortic valve stenosis as the more lethal condition in the short term, the latter study shows weaknesses: the decision for surgery seems unclear and it seemed that several patients were unjustly denied AVR because they may have been symptomatic. Moreover, the question of whether operated patients were in better shape compared with unoperated ones remains unanswered.
Clinical Outcome of Cardiac Procedures in Patients With Current & Prior Malignancy
Outcome in Patients With Simultaneous Disease
The results of one-stage procedures in simultaneous disease are shown in Table 2. The columns show the number of patients, the use of ECC, the type of tumor, the hospital mortality and long-term survival. Short-term results of a one-stage procedure are comparable with those after cardiac surgery in patients with prior (and hence supposedly cured) solid tumors: mortality was between 0 and 7.1%, but the series were usually small and included mostly only pulmonary tumors. Postoperative infections and mortality were higher in patients with CLL, but there would be no effect of cardiac surgery on the course of CLL. In one series, cancer patients had more need for transfusion (80 vs 49%) or reintubation (8 vs 0%), pneumonia (15 vs 6%), sepsis (8 vs 2%), arrhythmias (42 vs 34%) and anticoagulation-related complications (7 vs 0%) compared with controls. Autonomic dysfunction and hypercoagulability by tumoral tissue factor and platelet activation could persist, even after removal of the tumor. An increased infection rate could be related to an increased need for transfusion. Long-term results and quality of life after a one-stage procedure were acceptable. A 5-year survival over 40% can be reached, but the cancer was responsible for most of the long-term mortality. The type and the stage of the tumor played a dominant role, with a drop in 1-year survival from 80 to 50% with advanced cancer. The series are too small to draw definitive conclusions. In this respect, the technical possibility to dissect pulmonary lymph nodes during a combined procedure, but without ECC, might be questioned with respect to the effect on survival. The same applies to the surgical exposure of the lower left lobe. With an ECC, it is possible to rotate the heart without compromising the circulation and the lower left lobe can be reached more easily, with better long-term survival as a result. In patients with aortic valve stenosis and decreased LVEF, the effect of a low contractile reserve was more significant for survival, but the presence of a prior tumor proved to be more clinically relevant.
Outcome in Patients With Mainly Prior Malignancy
Patient series with prior malignancy (or series that mix patients with simultaneous and prior malignancies) are shown in Table 3. These reports had varying study designs, which makes comparison of their results difficult. Hospital mortality varied between 2.4 and 13.0%, and was within the range of hospital mortality of patients with simultaneous disease. The extent of prior radiotherapy played a major role. Hospital complications of a series including patients with active malignancy, a malignancy in remission or without malignancy were comparable and ranged between 33 and 36%. Long-term survival seemed encouraging, with a 5-year survival between 42 and 89%. The interval between treatment of the prior malignancy and cardiac surgery played an important role in postoperative 5- and 10-year survival: the longer the interval, the better the survival. With an interval of 10 years, a normal gender- and age-matched survival had been reached. With shorter intervals or simultaneous disease, death due to metastasis increased. Few studies reported independent predictors of survival: a decreased LVEF, presence of chronic obstructive pulmonary disease, presence of cancer or an interval of less than 2 years between treatment of the malignancy have been identified as predictors. Symptomatic aortic valve stenosis needs separate consideration since this condition is very life-threatening in the short term. Aortic valve replacement (AVR) is the only life-prolonging and symptom-reducing treatment. Independent predictors of decreased survival after operation were decreased LVEF, concomitant three-vessel disease and presence of cancer. Compared with medical treatment, AVR significantly increased survival (and reached the survival of cancer patients without valve disease), irrespective of cancer status and presence of metastases. Death due to cardiovascular disease occurred only in patients medically treated for calcified aortic valve stenosis. Survival after AVR was only affected by the tumor after 2 years. Although these results point to symptomatic calcified aortic valve stenosis as the more lethal condition in the short term, the latter study shows weaknesses: the decision for surgery seems unclear and it seemed that several patients were unjustly denied AVR because they may have been symptomatic. Moreover, the question of whether operated patients were in better shape compared with unoperated ones remains unanswered.
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