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The Safety and Feasibility of Gastrointestinal Cancer Surgery with the Aid of Balloon Aortic Valvuloplasty in Patients with Severe Aortic Stenosis

Yusuke Sakamoto, MD, Takahisa Fujikawa, MD, FACS, Yuichiro Kawamura, MD, Kenji Ando, MD

Yusuke Sakamoto, Takahisa Fujikawa, Yuichiro Kawamura, Department of Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka 802-8555, Japan
Kenji Ando, Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Fukuoka 802-8555, Japan

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Takahisa Fujikawa, MD, PhD, FACS, Department of Surgery, 3-2-1 Asano, Kokurakita-Ku, Kitakyushu, Fukuoka 802-8555, Japan.
Email: fujikawa-t@kokurakinen.or.jp
Telephone: +81-93-511-2000
Fax: +81-93-511-3240

Received: May 26, 2018
Revised: July 27, 2018
Accepted: July 29, 2018
Published online: August 21, 2018

ABSTRACT

AIM: Patients with severe aortic stenosis (AS) have been considered to be high-risk patients for noncardiac surgery. We evaluated the safety and feasibility of gastrointestinal (GI) cancer surgery after performing balloon aortic valvuloplasty (BAV) in patients with severe AS.

METHODS: A total of 16 patients who diagnosed with GI cancer and simultaneously met the criteria for AS intervention were included in this study. In our hospital, indications for AS intervention are as follows: (1) peak aortic valve velocity of > 4 m/sec and presence of exertional dyspnea; or (2) peak aortic valve velocity of > 5 m/sec. Our policy defined that cancer patients who meet these criteria undergo BAV in order to reduce the risk of noncardiac surgery for the treatment of cancer. We evaluated the outcomes of BAV and GI cancer surgery.

RESULTS: The echocardiographic data of AS was significantly improved after BAV. After BAV, mitral regurgitation occurred in 1 patient and transcatheter aortic valve implantation was required before GI cancer surgery in 1 patient. However, all enrolled patients proceeded to GI cancer surgery, which was performed uneventfully.

CONCLUSION: We demonstrated the safety and feasibility of GI cancer surgery after performing BAV in patients with severe AS. GI cancer surgery can be performed even in high-risk severe AS patients.

Key words: Balloon aortic valvuloplasty; Gastrointestinal cancer surgery; Noncardiac surgery; Severe aortic stenosis

© 2017 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Sakamoto Y, Fujikawa T, Kawamura Y, Ando K. The Safety and Feasibility of Gastrointestinal Cancer Surgery with the Aid of Balloon Aortic Valvuloplasty in Patients with Severe Aortic Stenosis. Journal of Gastroenterology and Hepatology Research 2018; 7(4): 2644-2648 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/2351

INTRODUCTION

Patients with severe aortic stenosis (AS) have been considered to be extremely high-risk patients for noncardiac surgery[1,2]. According to the 2014 American College of Cardiology/American Heart Association guidelines, elective noncardiac surgery in patients who have indications for aortic valve replacement should be deferred[3]. These guidelines also suggest that asymptomatic patients with severe AS who have no evidence of left ventricular dysfunction can undergo moderate-risk noncardiac surgery. Preoperative balloon aortic valvuloplasty (BAV) is considered to be one of the options to enable patients with severe AS to undergo noncardiac surgery, but the effcectiveness of BAV remains controversial[4].

 Under these complex conditions, we have performed gastrointestinal (GI) cancer surgery after performing BAV as a preoperative therapy in patients with severe AS. We evaluated the safety and feasibility of GI cancer surgery after performing BAV in patients with severe AS.

PATIENTS AND METHODS

From January 2007 to December 2017, a total of 23 patients underwent surgery after BAV in our department. Among them, 16 patients had diagnosed with GI cancer were included in this study. Patients undergoing emergency operations or with benign diseases were excluded in this study. They were included in a retrospective registry.

 In our hospital, indications for the intervention for AS are as follows: (1) peak aortic valve velocity (Vmax) of > 4 m/sec and presence of exertional dyspnea; or (2) Vmax of > 5 m/sec. In principle, cancer patients who meet these criteria undergo BAV in order to reduce the risk of noncardiac surgery for the treatment of cancer. All patients in this study met these criteria for AS intervention and underwent BAV. The reasons for undergoing BAV instead of definitive AS interventions are: (1) artificial cardiac valve implantation via aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI) requires antiplatelet therapy, which may increase the risk of bleeding from known cancer or noncardiac surgery; and (2) the artificial cardiopulmonary systems used in AVR may also increase the risk of massive bleeding from known cancer.

 We evaluated the included 16 patients from medical records, including demographic characteristics, echocardiographic data, procedural results of BAV and GI cancer surgery, and clinical status after BAV and GI cancer surgery.

 The patients’ cardiac symptoms were evaluated using the New York Heart Association (NYHA) classification. Echocardiographic measurements were performed before and after BAV; patients who did not undergo GI cancer surgery immediately after BAV also underwent echocardiographic measurements before GI cancer surgery. The time of GI cancer surgery and the definitive intervention of AS after BAV were at each surgeon’s discretion.

 BAV was performed via the transfemoral retrograde approach. The balloon’s size was chosen based on the aortic annulus diameter assessed via preprocedural CT. An endocavitary electrode was placed in the right ventricle to obtain rapid pacing during ballooning.

 All GI cancer operations were performed as curative resection. The choice of laparoscopic or open surgery depended on each surgeon.

 Continuous values in the echocardiographic data were presented as a mean ± standard deviation. Continuous values in the other data were expressed as a median with range. Differences between continuous variables were assessed by Student’s t test. Statistical analysis was performed using JMP®11.0.0. P < 0.05 was considered statistically significant.

RESULTS

Baseline characteristics

The median age of enrolled patients was 85.5 years (64-94). All patients were symptomatic at baseline. Three patients were classified as NYHA class I, 10 patients as class II, and 3 patients as class III. Four patients had chronic heart failure. Five patients had some kinds of arrhythmia. Two patients had concomitant coronary artery disease. All patients diagnosed with GI cancer; gastric cancer in 6 patients, colon cancer in 9 patients and rectal cancer in 1 patient. The patients’ baseline characteristics are shown in Table 1.

Table 1 Baseline characteristics of 16 patients.
  Age (years)NYHA† Chronic heart failure Arrhythmia Coronary artery disease Type of cancer
patient 188nononenocecum cancer
patient 289yesnonenoascending colon cancer
patient 375yesAf‡yessigmoid colon cancer
patient 485yesnonogastric cancer
patient 580noAfnosigmoid colon cancer
patient 679nononocecum cancer
patient 787nononosigmoid colon cancer
patient 889nononogastric cancer
patient 964noAf+PVC§nogastric cancer
patient 1091nononogastric cancer
patient 1184nonoyesgastric cancer
patient 1294yesAfnodescending colon cancer
patient 1386nononoascending colon cancer
patient 1483nononogastric cancer
patient 1588nononorectal cancer
patient 1679noRBBB¶noascending colon cancer
NYHA†: New York Heart Association; Af‡: atrial fibrillation; PVC§: premature ventricular contraction; RBBB¶: right bundle branch block

Outcomes of BAV

The echocardiographic data before and after BAV are listed in Table 2. The aortic valve area (AVA) was improved after BAV (from 0.70 ± 0.23 to 0.80 ± 0.16 cm2; p = 0.0585). The peak aortic valve gradient was significantly reduced after BAV (from 92.90 ± 21.16 to 73.43 ± 22.14 mmHg, p = 0.0008). The mean aortic valve gradient was significantly reduced after BAV (from 53.37 ± 13.60 to 40.67 ± 12.60 mmHg, p = 0.0004). Vmax was also significantly reduced after BAV (from 4.79 ± 0.57 to 4.24 ± 0.64, p = 0.0009). Left ventricular ejection fraction slightly improved, but was not statistically significant (from 61.18 ± 9.75 to 63.59 ± 6.80; p = 0.085). All procedures were followed by GI cancer surgery.

Table 2 Echocardiographic data before and after BAV.
Variable Baseline After BAVP value
AVA† (cm2)0.70 ± 0.230.80 ± 0.160.0585
pAVG‡ (mmHg)92.90 ± 21.1673.43 ± 22.140.0008
mAVG‡ (mmHg)53.37 ± 13.6040.67 ± 12.600.0004
Vmax§ (m/sec)4.79 ± 0.574.24 ± 0.640.0009
LVEF¶ (%)61.18 ± 9.7563.59 ± 6.800.085
AVA†: aortic valve area; p/mAVG‡: peak/mean aortic valve gradient; Vmax§: peak aortic valve velocity LVEF¶: left ventricular ejection fraction

 Patient 9 had cardiac heart failure due to mitral regurgitation after BAV, which was treated by conservative treatment. In the rest of all cases, there were no complications after BAV, including death, myocardial infarction, cardiac tamponade, aortic regurgitation, severe arrhythmias, hemorrhage requiring transfusion, and vascular access site problems.

Outcomes of GI cancer surgery

The median duration between BAV and GI cancer surgery was 24.5 days (7-86). Patient 5 refused to undergo GI cancer surgery immediately after BAV and finally underwent laparoscopic sigmoidectomy 86 days after BAV. Among 16 patients, 8 patients underwent open surgery; left hemicolectomy in 1 patient, right hemicolectomy in 1 patient, sigmoidectomy in 1 patient, distal gastrectomy in 4 patients and total gastrectomy in 1 patient, and 8 patients underwent laparoscopic surgery; ileocecal resection in 2 patients, right hemicolectomy in 2 patients, sigmoidectomy in 2 patients, rectal lower anterior resection in 1 patient, distal gastrectomy in 1 patient. The median operation time was 232 min (99-344). The median anesthesia time was 323 min (158-449). The median blood loss was 75 g (20-1020). All patients underwent GI cancer surgery without major intraoperative complications including conversion to open surgery in laparoscopic surgery. All patients quickly recovered and transferred out of ICU on POD1. The median postoperative hospital stay was 13.5 days (7-26). While surgical sight infection was observed in 1 case, the postoperative course was uneventful in all cases. Perioperative data of GI cancer surgery are shown in Table 3.

Table 3 Outcomes of GI cancer surgery.
variables 
length between BAV and surgery (days)24.5 (7-86)
operative procedure (patients) 
open surgery8
laparoscopic surgery8
operation time (min)232 (99-344)
anesthesia time (min)323 (158-449)
blood loss (g)75 (20-1020)
postoperative hospital stay (days)13.5 (7-26)

Follow-up after BAV and GI cancer surgery

Eleven patients underwent definitive treatment: TAVI in 6 patients, AVR in 5 patients. The median time of definitive intervention after BAV was 103 days (17-462). After a median follow-up time of 502.5 days (41-1742) after GI cancer surgery, 1 patient had recurrence of cancer and died of recurrence. As for prognosis of AS treatment, 1 patient was in NYHAⅡ and 1 patient died of cardiac failure due to AS. Neither of these 2 patients underwent definitive treatment after BAV. No patients who received definitive treatment experienced cardiac symptom. Among 16 patients, 3 patients died: 1 patient related to AS, 1 patient related to recurrence of cancer, 1 patient related to acute panperitonitis. The clinical status of the patients after BAV and GI cancer are shown in Table 4.

Table 4 Follow-up after BAV and GI cancer surgery.
variable Type of definitive intervention of AS

Time of definitive intervention after

BAV (days)

Follow-up time

after surgery

(days)

Recurrence of cancer

The most recent

cardiac symptom

Survival Cause of death
patient 1TAVI267988nostableyes-
patient 2TAVI64684nostableyes-
patient 3AVR124585nostableyes-
patient 4none-588no NYHA Ⅱyes-
patient 5AVR287384nostableyes-
patient 6AVR55420nostableyes-
patient 7none-1445no NYHA Ⅳnoheart failure
patient 8none-41unknownunknownunknownunknown
patient 9none-42nostablenoacute panperitonitis
patient 10none-361yesstablenogastric cancer
patient 11TAVI4621742nostableyes-
patient 12TAVI1091100nostableyes-
patient 13TAVI17861nostableyes-
patient 14AVR82361nostableyes-
patient 15TAVI103173nostableyes 
patient 16AVR94113nostableyes 

DISCUSSION

We performed GI cancer surgery safely after BAV in high-risk severe AS patients. To the best of our knowledge, this is the first study to demonstrate the safety and feasibility of GI cancer surgery after performing BAV. This study is valuable in that we specified only GI cancer surgery, which tends to be invasive.

 Patients with severe AS have been considered to be high-risk patients for noncardiac surgery[1,2]. Predictors that are associated with adverse outcomes in patients with AS during noncardiac surgery are the following: severity of AS, high-risk surgery (vascular surgery), cardiac symptoms, concurrent mitral regurgitation, and coronary artery disease[5-8]. In this study, all patients were symptomatic and met the criteria for AS intervention. They were considered to be high-risk patients for noncardiac surgery, but they successfully underwent GI cancer surgery after BAV, which might involve a relatively invasive procedure.

 During perioperative management, tachycardia, systemic hypotention, and the hemodynamic effects of anesthesia as well as surgery should be avoided[9-14]. In addition, intravascular volume should be titrated at a level that ensures an adequate forward cardiac output. In this study, even after BAV to relieve the severity of AS, the risk of GI cancer surgery was considered to be so high that we performed careful intraoperative management.

 All GI cancer operations were performed as curative resections. The relatively long time operation was included; laparoscopic ileocecal resection took 344 minutes. In addition, the maximum blood loss was 1020 g. However, we did not experience any major intraoperative or postoperative complications. Concerning operative procedure, both open and laparoscopic surgeries were performed safely. This choice depended on each surgeon and was subject to biases, but it is noteworthy that laparoscopic surgery was chosen in more recent cases.

BAV may be useful as a preoperative therapy to noncardiac surgery. BAV is already considered a bridge to definitive treatment by AVR, TAVI or heart transplantation; palliative treatment for patients with contraindication for definitive treatment because of other severe comorbidities; or a preoperative therapy designed to temporally improve hemodynamic status during noncardiac surgery[15,16]. However, BAV has not been a standard treatment because of its incomplete relief of obstruction and high restenosis rate[4,17]. In recent studies[18-22], however, BAV has been reported to be acceptable in high-risk patients with AS (Table 5). BAV, as a preoperative therapy of noncardiac surgery, may be particularly beneficial for patients with severe AS because BAV can sufficiently improve hemodynamic status to lower the risk of noncardiac surgery[23]. In fact, patients after performing BAV successfully underwent noncardiac surgeries in these studies (Table 5), which included various types of surgeries. In our study, mitral regurgitation occurred in 1 patient and TAVI was required before GI cancer surgery because of insufficient effect of BAV in 1 patient, but all enrolled patients proceeded to GI cancer surgery, which was successfully performed. Our results were acceptable in terms of effects of BAV on echocardiographic date and outcomes of BAV and GI cancer operative procedures themselves. We believe that our study is valuable because we experienced a relatively greater number of cases of BAV as a preoperative therapy of GI cancer surgery, which tends to be a more-complex procedure and may be invasive.

Table 5 Recent studies of BAV in adult patients with severe AS.
 No. of patientsAVAAVA after BAVNo. of BAV as a bridge to noncardiac surgery

No, of BAV successfully

bridged to noncardiac surgery

Type of surgery
Hamid T et al[18]42NANA22OS1, OB1
Uchida T et al[19]50.56 ± 0.250.7 ± 0.2711GI1
Hui DS et al[20]620.69 ± 0.220.84 ± 0.271515unknown
Daniec M et al[21]1120.58 ± 0.180.82 ± 0.2499unknown
Calicchio F et al[22]150.52 ± 0.11.48 ± 0.41515TS5 HBP3 BS1 GI2 VS3 OS1
Our hospital160.70 ± 0.230.80 ± 0.161616GI16
Abbreviations: NA, not available; OS: orthopedic surgery; OB: obstetrics; GI: gastrointestinal surgery; TS: thoracic surgery; HBP: hepato-biliary-pancreatic surgery; BS: breast surgery; VS: vascular surgery.

 While AVR or TAVI is usually performed from 1 week to 6 months after BAV, the appropriate duration between BAV and noncardiac surgery has not been reported. In patient 5, who refused to undergo GI cancer surgery immediately after BAV, the severity of AS deteriorated 2 months after BAV. His AVA decreased from 0.75 cm2 1 day after BAV to 0.66 cm2 2 months after BAV, and he finally underwent laparoscopic sigmoidectomy about 3 months after BAV. We managed to perform this surgery without any complications. In general, restenosis after BAV occurs within 6 months in most patients[4]. On the other hand, the typical short-term adverse events are tamponade, aortic regurgitation, arrhythmias, hemorrhage of vascular site, and acute kidney injury, all of which occur within 3 days after BAV. Calicchio et al. reported that noncardiac surgery was successfully performed within 1 week after BAV[22]. Taking these reports and our limited experience into account, we suggest that noncardiac surgery should be performed within 1 week to 6 months after BAV.

 Finally, while patients who received definitive treatment didn’t experience cardiac symptom, 2 out of 5 patients who didn`t receive definitive treatment had cardiac symptom or cardiac failure after follow-up. BAV may be effective as a preoperative therapy of noncardiac surgery, but definitive treatment after noncardiac surgery is required if necessary.

 This study has several limitations. First, the size of this study was relatively small. Second, most of enrolled patients evaluated here were classified as NYHA Class ⅠorⅡ. Finally, in this study, emergency BAV or GI cancer surgery was excluded. Nevertheless, we believe that our findings will contribute to the optimization of the perioperative strategy for GI cancer surgery in patients with severe AS.

CONCLUSION

We demonstrated the safety and feasibility of BAV as a bridge to noncardiac surgery in patients with severe AS. Gastrointestinal cancer surgery can be performed even in these high-risk patients with the aid of BAV. In high-risk patients, it may be important not only to perform safely intraoperative management but to combine preoperative therapy with surgical treatment.

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Peer Reviewer: Kuo-Shyang Jeng

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