How to manage a patient with aspergillosis (fungal infection) undergoing Coronary Artery Bypass Grafting (CABG)?

Management of Patients with Aspergillosis Undergoing CABG

Patients with aspergillosis undergoing CABG should receive appropriate antifungal therapy throughout the perioperative period, with voriconazole being the first-line agent, and surgery should not be delayed if medically necessary. 1

Preoperative Management

Antifungal Therapy

• First-line therapy: Voriconazole 6 mg/kg IV every 12 hours for the first 24 hours, then 4 mg/kg IV every 12 hours or 200 mg PO every 12 hours 2
• Alternative options if voriconazole is contraindicated:
  • Lipid formulation of amphotericin B (3-5 mg/kg/day IV)
  • Isavuconazole or posaconazole (for prophylaxis in high-risk patients) 3
  • Echinocandins (micafungin or caspofungin) only when azoles and polyenes are contraindicated 1

Preoperative Assessment

• Determine extent and severity of aspergillosis infection
• Evaluate response to current antifungal therapy
• Assess for multi-organ involvement (particularly CNS)
• Monitor inflammatory markers and Aspergillus galactomannan levels 1

Perioperative Considerations

Timing of Surgery

• Aspergillosis is not an absolute contraindication to CABG 1
• Decision to proceed should involve both infectious disease specialists and cardiothoracic surgeons
• Ideally, initiate antifungal therapy for at least 2 weeks before elective CABG if possible 4

Surgical Approach

• Consider minimally invasive techniques when appropriate to reduce surgical stress
• Video-assisted thoracic surgery (VATS) may be beneficial if pulmonary lesions require simultaneous resection 4
• Avoid spillage of fungal material during surgery to prevent dissemination 1

Intraoperative Management

• Continue antifungal therapy throughout surgery
• Consider washing the surgical field with antifungal agents if spillage occurs 1
• If pulmonary lesions are encountered during CABG:
  • For localized lesions, consider simultaneous resection 1
  • For complex aspergillomas, consider staged procedures 1

Postoperative Management

Antifungal Continuation

• Continue antifungal therapy postoperatively for a minimum of 6-12 weeks 1
• For invasive aspergillosis, treatment duration depends on:
  • Degree and duration of immunosuppression
  • Site of disease
  • Evidence of disease improvement 1

Monitoring

• Serial monitoring of serum galactomannan in appropriate patients to monitor disease progression and therapeutic response 1
• Regular chest imaging to assess for resolution or progression
• Monitor for drug interactions between antifungals and post-CABG medications 5

Drug Interactions

• Important: Azole antifungals may interact with medications commonly used post-CABG:
  • Sirolimus: Avoid combination with posaconazole; consider alternative antifungal 5
  • Monitor for interactions with statins, anticoagulants, and other cardiac medications
  • Therapeutic drug monitoring for voriconazole is recommended 1

Special Considerations

Hemoptysis Management

• For patients with aspergilloma and hemoptysis:
  • Oral tranexamic acid for mild cases
  • Bronchial artery embolization for severe cases prior to surgery 1
  • Consider surgical resection for persistent hemoptysis despite embolization 1

Immunosuppression Management

• Reduce immunosuppressive agents when feasible 1
• Consider colony-stimulating factors in neutropenic patients 1

Common Pitfalls to Avoid

1. Delaying necessary cardiac surgery: Aspergillosis is not an absolute contraindication to CABG 1
2. Discontinuing antifungal therapy perioperatively: Maintain therapeutic levels throughout
3. Failing to monitor for drug interactions: Particularly between azoles and post-CABG medications
4. Inadequate duration of therapy: Continue antifungals for at least 6-12 weeks after surgery 1
5. Missing concurrent aspergilloma: Evaluate for pulmonary lesions that may require simultaneous management

Follow-up After CABG

• Continue antifungal therapy for minimum recommended duration
• Regular monitoring of inflammatory markers and Aspergillus galactomannan
• Serial imaging to ensure resolution of infection
• Consider secondary prophylaxis in patients requiring subsequent immunosuppression 1