An 80-year-old retired woman was referred to our cardiothoracic centre in February 2016 with an incidental finding of 1 cm lung nodule in the left midzone, after having presented to her local hospital with chest discomfort. Her past medical history included previous right nephrectomy for a nonmalignant lesion of the urethra, a previous transient ischaemic attack, polymyalgia rheumatica, hypothyroidism, hypertension, and osteoporosis. Positron emission tomography-computed tomography (PET-CT) showed a T1a N0 M0 left upper lobe cancer with small-cell lung carcinoma confirmed on CT-guided biopsy. The multidisciplinary team decision was for surgical management; therefore, she was admitted for elective lobectomy.
This was undertaken in March 2016 using a single-port VATS technique and included lymph node sampling. Sequential identification, dissection, and division of the pulmonary vessels and bronchi were performed as standard. The procedure was uncomplicated, and the patient was discharged 3 days later.
She then received adjuvant carboplatin/etoposide chemotherapy and was re-referred in December 2016 with a contralateral right lower lobe nodule found on surveillance CT. The patient underwent single-port VATS wedge resection of the nodule in February 2017, which was again uncomplicated. Interestingly, histopathological examination revealed the nodule to be an area of necrotising granulomatous inflammation with acid-fast bacilli, consistent with past tuberculosis, rather than a metastasis.
On postoperative day 1, the patient had a self-resolving episode of ventricular tachycardia following by bradycardia, with chest tightness on minimal exertion. Troponin T was performed which was <20 ng/L. She subsequently underwent a variety of cardiac investigations. Computed tomography coronary angiogram (CTCA) was performed the following day, which showed diffuse disease in all major epicardial vessels, with possible lesions in the left anterior descending (LAD) artery and right coronary artery (RCA), and a coronary calcification score of 1800. A 24-hour Holter investigation revealed bradycardia throughout with rare ventricular ectopics. A subsequent echocardiogram showed normal left ventricular size and function with an ejection fraction of 60-65%, and a myocardial perfusion scan showed an overall ischaemic burden of 7%. Finally, cardiac catheterisation on postoperative day 8 revealed 85% tubular stenosis of the distal left main stem (LMS) artery and minor irregularity in the dominant right coronary artery (RCA).
The patient was symptomatically managed on the ward, and the multidisciplinary team discussed the case. Bearing in mind the patient's comorbidities, a decision was made for Endo-ACAB, rather than conventional cardiac artery bypass grafting (CABG) or percutaneous coronary intervention (PCI), which took place 18 days after the initial thoracic surgery. 3 ports were utilised to harvest the left internal mammary artery (LIMA), and a submammary incision was performed in the 5th intercostal space to enable anastomosis to the LAD. She developed no further complications and was discharged 17 days later. She is awaiting cardiothoracic follow-up.