Introduction

Widespreadly performing cardiac operations and their successfull results, caused to carry out these operations in the patients with high risk and comorbidities, or for treated patients. Decreased lymphatic flow can occur because of neoplasms, previous surgery, and inflammation (elephantiasis). The word elephantiasis is a vivid and accurate term for the syndrome it describes: the gross (visible) enlargement of the arms, legs, or genitals to elephantoid size. There is an abnormal accumulation of watery fluid in the tissues (edema) causing severe swelling. The skin usually develops a thickened, pebbly appearance and may become ulcerated and darkened(₁,₂). Elephantiasis is associated in the public mind with “The Elephant Man”, the carnival stage name of Joseph Merrick. Merrick was a carnival side show in the late 1890s, and although Merrick wasn't afflicted with elephantiasis, his skin's similarity to an elephant's resulted in the name. Among the case presentations that represent coronary artery by pass surgery associated with elephantiasis, there is no any case presentation in the recent literature.

Case Presentation

Our case was a 61-year-old female. She had elephantiasis in her right lower extremity going on for 15 years and had undergone an unsuccessful reconstructive surgical intervention previously (Figure 1).

Figure 1

Figure 1: Preoperative view of our patient with massive right leg elephantiasis.

She was suffering from chest pain for 3 months. After the investigations related with this symptom the diagnosis of coronary artery disease was put and surgical approach was indicated. Therefore she was admitted to our clinic. Her coronary angiography revealed subsequent and long stenotic lesions in left anterior descending artery (Figure 2).

Figure 2

Figure 2: Coronary angiography of our case revealing lesions in left anterior descending artery.

Her transthoracic echocardiography showed mild aortic, tricuspid and mitral insufficiencies and pulmonary arterial pressure was measured as 40 mmHg. Left ventricular ejection fraction was 60%.Blood pressure values were in the normal range. The patient had no significant changes in standard biochemical findings on admission. She was a nonsmoker. The cholesterol and triglyceride levels were within the high range. Color Doppler ultrasound showed that venous circulation in her left lower extremity was normal.

She was operated under endotracheal general anesthesia and in supine position.Following a median sternotomy,pericardium was opened longitudinally. After heparinization, extra-corporeal circulation is established between the venae cavae and the ascending aorta. A cross clamp was placed on aorta and by antegrade intermittant isothermic blood cardioplegia from aortic root,cardiac arrest was established.Hypothermia was moderate (28°c). Aortoconary bypass was established by using the proximal segment of the left great saphenous vein prepared as a graft. In order to avoid volume overload during cardiopulmonary bypass, prime solution was held within the minimal limits, adding 300 milliliters of whole blood regarding the hematocrit level. She did not require inotropic support during weaning from cardiopulmonary bypass and early postoperative period. The volume of blood transfused was one unit. The quantity of mediastinal drainage was 300 cc.She was extubated after an intubation of 7 hours and stayed in the intensive care for 2 days. The hospital stay was 6 days(Figure 3).

Figure 3

Figure 3: View of our case during the uneventful postoperative period.

The functional capacity of our patient improved dramatically and she was in NYHA functional class I.We found no postoperative cardiac symptom in our patient during late follow-up and she was followed at our outpatient clinic without additional problem.

Discussion

The extreme enlargement of the limbs characterized by elephantiasis, is the result of obstruction of the lymphatic system, which results in the accumulation of a fluid called lymph in the affected areas (₂,₃). Obstruction of these vessels results in the massive swelling and gross enlargement characteristic of elephantiasis. This blockage causes fluids to collect in the tissues, which can lead to great swelling, called “lymphedema.” Other terms for elephantiasis are Barbados leg, morbus herculeus, mal de Cayenne, elephant leg and myelolymphangioma.

Lymphatic(primary) filariasis, which is the most common form of elephantiasis, is caused by a parasitic disease resulting from a bite from an infected mosquito.Nonfilarial(secondary) elephantiasis, the second type of elephantiasis, is non-parasitic. Secondary lymphedema is a disorder of the lymphatic system resulting from infection(₁,₂). The lymphatic blockage can be due to recurrent attacks of a bacterial infection which causes inflammation of the lymphatic vessels (streptococcal lymphangitis). The disease is difficult to be detected early.

Elephantiasis can be very uncomfortable and reduces the sufferer's ability to lead a normal life.There is a severe handicap leading to physical limitations and social stigmatization(₁,₄). Surgical treatments are usually only effective on scrotal elephantiasis and hydrocele(₅). However, surgery is generally ineffective at correcting elephantiasis of the limbs(₁,₂,₅,₆). Surgery can be performed to reduce elephantiasis by removing excess fatty and fibrous tissue, draining the swelled area, and removing the dead worms.

Resolution of the cardiac problem of the patients with limited functional capacity would increase the quality of life and life expectancy by simplifying even the palliative therapies of the permanent coexisting disorders. This expectancy shows the obligation of the immediate surgical therapy for the cases whose lives are under threat of a cardiovascular pathology that could be corrected surgically and a coexisting chronic disorder. Surgically correctable cardiac disorders of these people could be treated by performing open heart surgery safely with acceptable morbidity and low mortality rates. They would experience relief in cardiac symptoms and increase in quality of life with a rise in duration of survival.

Correspondence to

Doç. Dr. Ufuk YETKIN 1379 Sok. No: 9,Burç Apt. D: 13 35220, Alsancak – IZMIR / TURKEY Tel: +90 505 3124906 Fax: +90 232 2434848 e-mail: ufuk_yetkin@yahoo.fr