Life-Threatening Postpneumonectomy Syndrome Complicated with Right Aortic Arch after Left Pneumonectomy.
Karasaki Takahiro,Tanaka Makoto
Case reports in surgery
A 54-year-old man with right aortic arch underwent left lower lobectomy and lingular segmentectomy, followed by complete pneumonectomy, for refractory nontuberculous mycobacterial infection. Three months after the pneumonectomy, he developed acute respiratory distress. Computed tomography showed an excessive mediastinal shift with an extremely narrowed bronchus intermedius and right lower bronchus compressed between the right pulmonary artery and the right descending aorta. Soon after the nearly obstructed bronchus intermedius was observed by bronchoscopy, he began to exhibit frequent hypoxic attacks, perhaps due to mucosal edema. Emergent surgical repositioning of the mediastinum and decompression of the bronchus was indicated. After complete adhesiolysis of the left thoracic cavity was performed, to maintain the proper mediastinal position, considering the emergent setting, an open wound thoracostomy was created and piles of gauze were inserted, mildly compressing the heart and the mediastinum to the right side. Thoracoplasty was performed three months later, and he was eventually discharged without any dressings needed. Mediastinal repositioning under thoracostomy should be avoided in elective cases because of its extremely high invasiveness. However, in the case of life-threatening postpneumonectomy syndrome in an emergent setting, mediastinal repositioning under thoracostomy may be an option to save life, which every thoracic surgeon could attempt.
Risk of mortality from cardiovascular and respiratory causes in patients with chronic obstructive pulmonary disease submitted to follow-up after lung resection for non-small cell lung cancer.
Volpino P,Cangemi R,Fiori E,Cangemi B,De Cesare A,Corsi N,Di Cello T,Cangemi V
The Journal of cardiovascular surgery
AIM:Considerable controversy surrounds mortality from non-neoplastic diseases during the postoperative follow-up of patients with non-small cell lung cancer (NSCLC) and chronic obstructive pulmonary disease (COPD). This study investigated the incidence of mortality from cardiovascular and respiratory (CVR) causes in patients with COPD submitted to follow-up after lung resection for NSCLC, and identified preoperative and postoperative risk factors. METHODS:A total of 398 patients with mild or moderate COPD were followed up in our department after lung resection for NSCLC (median follow-up 61 months). Statistical analysis of the data was carried out to determine the incidence and the prognostic factors of postoperative death from CVR causes. RESULTS:Of the 398 resected patients, 186 survived without tumor recurrence; 24/186 (12.9%) died of CVR causes (acute respiratory failure, pneumonia, pulmonary embolism, acute pulmonary edema, acute myocardial ischemia or stroke). These 24 patients had a higher frequency of pre-existing coronary artery disease or heart failure (P=0.0003), predicted postoperative FEV1 <1000 mL (P=0.0008), exertional dyspnea (P=0.0000), and 30-day operative cardiopulmonary complications (P=0.001). Protective features were young age (<40 years), early stage disease, and minor resection (lobectomy). Independently significant adverse prognostic factors were stage III-IV disease (cumulative CVR death rate 47% at 5-10 years; P=0.028 vs. stage I-II) and completion pneumonectomy or partial resection of the other lung for a second primary tumor (cumulative CVR death rate 50% and 57%, respectively, at 5-10 years; P=0.0016 vs. all other resections). Older age and tumor histology were significant risk factors only in patients with advanced stage disease. CONCLUSION:The findings suggest that postoperative CVR death may be expected in patients with COPD and advanced stage NSCLC or in those undergoing completion pneumonectomy or partial resection of the other lung for a second primary tumor. Other risk factors are previous coronary artery disease and/or heart failure, exertional dyspnea and predicted postoperative FEV1 <1000 mL.
Takotsubo Cardiomyopathy Developed After Two-stage Surgery for Double Primary Lung Cancer.
Kinoshita Fumihiko,Toyokawa Gouji,Tagawa Tetsuzo,Matsubara Taichi,Kozuma Yuka,Haratake Naoki,Takamori Shinkichi,Akamine Takaki,Hirai Fumihiko,Maehara Yoshihiko
Takotsubo cardiomyopathy (TC) is a syndrome characterized by transient local systolic dysfunction of the left ventricle with no evidence of coronary artery disease or acute plaque rupture. We present the case of 71-year-old woman who developed TC after two-stage surgery for double primary lung cancer. On computed tomography, lung nodules were identified in the left upper and right middle lobes. Based on the diagnosis of double primary lung cancer, we performed two-stage surgery (left upper lobectomy followed by right middle lobectomy). One day after the second surgery, respiratory failure developed. Electrocardiography showed ST segment elevation, serum troponin levels were elevated, and chest x-ray showed acute pulmonary edema. Cardiac catheterization showed no coronary artery disease and apical akinesia. Based on these findings, we diagnosed TC and the patient recovered with supportive treatment.
[Acute pulmonary thromboembolism complicating lung lobectomy; report of a case].
Kataoka D,Kadokura M,Nonaka M,Yamamoto S,Kawada T,Takaba T
Kyobu geka. The Japanese journal of thoracic surgery
Acute pulmonary thromboembolism is fatal if the diagnosis and treatments are delayed. Here we present a case of acute thromboembolism to the right and left pulmonary arteries after right lung lobar resection. A 52-year-old woman who admitted to our hospital with lung cancer was performed right upper lobectomy with mediastinal lymph node dissection (pT1N0M0, well differentiated adenocarcinoma). Two days after surgery, she complained sudden chest discomfort and dyspnea. The blood pressure and oxygen saturation were rapidly decreased. Because there was no lung edema or atelectasis in the chest portable roentgenogram and no ischemic change in the electrocardiogram, pulmonary thromboembolism was suspected and emergency chest computed tomography (CT) was performed. The CT showed left and right pulmonary arterial thromboembolism and immediate anti-coagulator therapy was started. Her condition was improved and chest CT, which was performed three days after the onset of the thromboembolism, showed decreased but still remained thrombus. The anti-coagulator therapy was continued and one month after the onset of the thromboembolism, thrombus was disappeared on chest CT. She is doing well 17 months after surgery. Early diagnosis and treatments are critical for the pulmonary thromboembolism.
Simultaneous surgery in patients with both cardiac and noncardiac diseases.
Yang Yang,Xiao Feng,Wang Jin,Song Bo,Li Xi-Hui,Li Jian,He Zhi-Song,Zhang Huan,Yin Ling
Patient preference and adherence
BACKGROUND:To investigate the possibility and feasibility of simultaneous cardiac and noncardiac surgery. METHODS:From August 2000 to March 2015, 64 patients suffering from cardiac and noncardiac diseases have been treated by simultaneous surgeries. RESULTS:Two patients died after operations in hospital; thus, the hospital mortality rate was 3.1%. One patient with coronary heart disease, acute myocardial infarction, and a recurrence of bladder cancer accepted emergency simultaneous coronary artery bypass grafting (CABG), bladder cystectomy, and ureterostomy. He died of acute cerebral infarction complicated with multiple organ failure on the 153rd day after operation. The other patient with chronic constrictive pericarditis and right lung cancer underwent pericardial stripping and right lung lower lobectomy, which resulted in multiple organ failure, and the patient died on the tenth day postoperatively. The remaining 62 patients recovered and were discharged. The total operative morbidity was 17.2%: postoperative hemorrhage (n, % [1, 1.6%]), pulmonary infection and hypoxemia (2, 3.1%), hemorrhage of upper digestive tract (1, 1.6%), incisional infection (3, 4.7%), subphrenic abscess (1, 1.6%), and postoperative acute renal failure and hemofiltration (3, 4.7%). Of the 62 patients discharged, 61 patients were followed up. Eleven patients died with 10 months to 10 years during the follow-up. The mean survival time is 116.2±12.4 months. The cumulative survival rate is 50.8%. CONCLUSION:Simultaneous surgeries in patients suffering from both cardiac and noncardiac benign or malignant diseases are safe and possible with satisfactory short-term and long-term survival.
Protective ventilation during anaesthesia reduces major postoperative complications after lung cancer surgery: A double-blind randomised controlled trial.
Marret Emmanuel,Cinotti Raphael,Berard Laurence,Piriou Vincent,Jobard Jacques,Barrucand Benoit,Radu Dragos,Jaber Samir,Bonnet Francis,
European journal of anaesthesiology
BACKGROUND:Thoracic surgery for lung resection is associated with a high incidence of postoperative pulmonary complications. Controlled ventilation with a large tidal volume has been documented to be a risk factor for postoperative respiratory complications after major abdominal surgery, whereas the use of low tidal volumes and positive end-expiratory pressure (PEEP) has a protective effect. OBJECTIVE:To evaluate the effects of ventilation with low tidal volume and PEEP on major complications after thoracic surgery. DESIGN:A double-blind, randomised controlled study. SETTING:A multicentre trial from December 2008 to October 2011. PATIENTS:A total of 346 patients undergoing lobectomy or pneumonectomy for lung cancer. MAIN OUTCOME MEASURES:The primary outcome was the occurrence of major postoperative complications (pneumonia, acute lung injury, acute respiratory distress syndrome, pulmonary embolism, shock, myocardial infarction or death) within 30 days after surgery. INTERVENTIONS:Patients were randomly assigned to receive either lung-protective ventilation (LPV group) [tidal volume 5 ml kg ideal body weight + PEEP between 5 and 8 cmH2O] or nonprotective ventilation (control group) (tidal volume 10 ml kg ideal body weight without PEEP) during anaesthesia. RESULTS:The trial was stopped prematurely because of an insufficient inclusion rate. Major postoperative complications occurred in 23/172 patients in the LPV group (13.4%) vs. 38/171 (22.2%) in the control group (odds ratio 0.54, 95% confidence interval, 0.31 to 0.95, P = 0.03). The incidence of other complications (supraventricular cardiac arrhythmia, bronchial obstruction, pulmonary atelectasis, hypercapnia, bronchial fistula and persistent air leak) was also lower in the LPV group (37.2 vs. 49.4%, odds ratio 0.60, 95% confidence interval, 0.39 to 0.92, P = 0.02).The duration of hospital stay was shorter in the LPV group, 11 [interquartile range, 9 to 15] days vs. 12 [9 to 16] days, P = 0.048. CONCLUSION:Compared with high tidal volume and no PEEP, LPV combining low tidal volume and PEEP during anaesthesia for lung cancer surgery seems to improve postoperative outcomes. TRIALS REGISTRATION:ClinicalTrials.gov number: NCT00805077.
External validation of the recalibrated thoracic revised cardiac risk index for predicting the risk of major cardiac complications after lung resection.
Brunelli Alessandro,Cassivi Stephen D,Fibla Juan,Halgren Lisa A,Wigle Dennis A,Allen Mark S,Nichols Francis C,Shen K Robert,Deschamps Claude
The Annals of thoracic surgery
BACKGROUND:The recalibrated thoracic revised cardiac risk index (ThRCRI) has been recently proposed as a specific tool for cardiac risk stratification before lung resection. However, the ThRCRI has never been externally validated in a population other than the one from which it was derived. The objective of this study was to validate the ThRCRI in an external population of candidates having undergone major lung resections to assess its reliability for cardiac risk stratification across different samples. METHODS:We analyzed 2,621 patients undergoing lobectomy (2,431) or pneumonectomy (190) in a single center from 2000 to 2009. Patients were grouped into four classes of risk (A, B, C, and D) according to the recalibrated ThRCRI. The outcome variable measured was the occurrence of major cardiac complications (cardiac arrest, complete heart block, acute myocardial infarction, pulmonary edema, cardiac death during admission). Incidence of major cardiac events was assessed in the four risk class groupings to assess the discriminative ability of the index score. RESULTS:The incidence of major cardiac morbidity was 2.2% (59 cases). Patients were grouped into four risk classes according to their recalibrated ThRCRI. Incidence of major cardiac morbidity in risk classes A, B, C, and D were 0.9%, 4.2%, 8%, and 18%, respectively (p<0.0001). CONCLUSIONS:The recalibrated ThRCRI is a reliable instrument that can be used during preoperative workup to differentiate patients needing further cardiologic testing from those who can proceed without any further cardiac testing.
Comparison of serum cardiac specific biomarker release after non-cardiac thoracic surgery.
Muley Thomas,Kurz Markus,Männle Clemens,Alekozai Adjmal,Winteroll Susanne,Dienemann Hendrik,Schmidt Werner,Pfannschmidt Joachim
BACKGROUND:The detection of postoperative myocardial infarction can be difficult in patients after lung surgery. The aim of this study was to verify the clinical significance of elevated Troponin I (cTnI), N-terminal pro-natriuretic peptide (NT-pro-BNP), lactate dehydrogenase (LDH), creatine kinase (CK), and CK-MB in the perioperative course. METHODS:Between 2007 and 2010, 64 patients (36 men, 28 women) were includeded in this prospective study and underwent thoracotomy and wedge lung resection (n = 20, group I), lobectomy/bilobectomy (n = 24, group II), and pneumonectomy (n = 20, group III). Peri-operative measurements were done for the serum markers: cTnI, NT-pro-BNP, LDH, CK, and CK-MB preoperatively and at 4 hours, 8 hours, and 24 hours postoperatively. Patients were followed over a 90-day period to evaluate postoperative cardiac mortality. RESULTS:No basal troponin I elevation (or CK-MB) was found prior to surgery. Elevation in concentrations of troponin I (> 0.32 ng/mL) occurring after the procedure were seen in 9 patients. However, there was neither association with 90-day survival, postoperative ECG changes, nor with elevated levels of the other cardiac serum markers. cTnI correlated significantly with intrapericardial procedures in 7 out of 20 patients (Spearman's rank correlation coefficient: 0.406; p < 0.0001). Additionally, of the 20 patients within the pneumonectomy group, 8 patients had postoperative elevated serum cTnI. The grouping of patients into groups I through III was significantly associated with cTnI elevation (Spearman's rank correlation coefficient: 0.455; p < 0.0001). CONCLUSIONS:Despite the excellent sensitivity of troponin I for detection of acute myocardial infarction the fact remains that troponin I elevations were common after intrapericardial procedures and pneumonectomies. Thus, to differentiate between cardiac ischemia provoked chest pain and wound pain related to thoracotomy remains most difficult. Patients with only marginally elevated cTnI concentrations after intrapericardial resections or pneumonectomy should remain in the intensive care unit and should be followed-up carefully by cardiologists.
Effects of intraoperative goal-directed fluid therapy and restrictive fluid therapy combined with enhanced recovery after surgery protocol on complications after thoracoscopic lobectomy in high-risk patients: study protocol for a prospective randomized controlled trial.
Guan Zheng,Gao Yanfeng,Qiao Qiao,Wang Qiang,Liu Jingjie
BACKGROUND:Acute kidney injury (AKI) is a common complication after thoracoscopic lobectomy in high-risk patients due to insufficient intraoperative infusion. Goal-directed fluid therapy (GDFT) is an individualized fluid infusion strategy; the fluid infusion strategy is adjusted according to the patient's fluid response. GDFT during operation can reduce the incidence of AKI after major surgery. Enhanced recovery after surgery (ERAS) protocol optimizes perioperative interventions to decrease the postoperative complications after surgery. In ERAS protocol of lobectomy, intraoperative restrictive fluid therapy is recommended. In this study, we will compare the effects of intraoperative GDFT with restrictive fluid therapy combined with an ERAS protocol on the incidence of AKI after thoracoscopic lobectomy in high-risk patients. METHODS/DESIGN:This is a prospective single-center single-blind randomized controlled trial. Two hundred seventy-six patients scheduled for thoracoscopic lobectomy are randomly allocated to receive either GDFT or restrictive fluid therapy combined with an ERAS protocol at a 1:1 ratio. The primary outcome is the incidence of AKI after operation. The secondary outcomes include (1) the incidence of renal replacement therapy, (2) the length of intensive care unit stay after operation, (3) the length of hospital stay after operation, and (4) the incidence of other complications including infection, acute lung injury, pneumonia, arrhythmia, heart failure, myocardial injury after noncardiac surgery, and cardiac infarction. DISCUSSION:This is the first study to compare intraoperative GDFT with restrictive fluid therapy combined with an ERAS protocol on the incidence of AKI after thoracoscopic lobectomy in high-risk patients. The hypothesis is that the restrictive fluid therapy is noninferior to GDFT in reducing the incidence of AKI, but restrictive fluid therapy is simpler to apply than GDFT. TRIAL REGISTRATION:ClinicalTrials.gov NCT04302467 . Registered on 26 February 2020.
A change of heart: acute cardiac dextroversion with cardiogenic shock after partial lung resection.
Karalapillai Dharshi,Larobina Marco,Stevenson Kushlani,Doolan Laurie
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine
Cardiac herniation and torsion are well described after intrapericardial pneumonectomy, but their occurrence after partial lung resection has been rarely discussed. This unusual case of acute right-sided cardiac dextroversion with torsion occurred in a 30-year-old man after radical right lower lobectomy, pericardial resection and a left lower-lobe wedge resection for locally recurrent and metastatic synovial sarcoma. We describe the management of this unusual cause of cardiogenic shock and review the current literature. Cardiac herniation and torsion are an uncommon cause of cardiogenic shock after lung resection and, if diagnosed late, are associated with significant mortality.
Influence of cardiomegaly on disordered breathing during exercise in chronic heart failure.
Olson Thomas P,Johnson Bruce D
European journal of heart failure
AIMS:Heart failure (HF) patients breathe with a rapid shallow pattern during exercise. This study examined the relationship between cardiac size and tachypnoeic breathing in HF patients during exercise. METHODS AND RESULTS:Thirty-seven HF patients [age = 55 ± 13 years, ejection fraction (EF) = 27 ± 10%, New York Heart Association (NYHA) class = 2.3 ± 1.2] and 42 controls (CTL) (age = 56 ± 14 years, EF = 63 ± 8%) were recruited. Participants underwent maximal exercise testing, pulmonary function testing, and chest radiography for calculation of total thoracic cavity volume (TTCV), diaphragm, heart, and lung volumes. Heart failure patients were divided into two groups: Group A = cardiac volume < median (n = 18) and Group B = cardiac volume ≥ median of the HF patients (n = 19). There was no difference between groups for TTCV (CTL = 8203 ± 1489 vs. Group A = 8694 ± 1249 vs. Group B = 8195 ± 1823 cm(3)). Cardiac volume was different between groups for both absolute (CTL = 630 ± 181 vs. Group A = 894 ± 186 vs. Group B = 1401 ± 382 cm(3), P< 0.001 for all comparisons) and %TTCV (CTL = 8 ± 2 vs. Group A = 10 ± 1 vs. Group A = 18 ± 5%, P< 0.001 for all comparisons). Similarly, total lung volume as a %TTCV was significantly different among the groups (CTL = 70 ± 4 vs. Group A = 65 ± 5 vs. Group A = 58 ± 7%, P< 0.01 for all comparisons). In HF patients, there was a trend (P = 0.10) towards an independent association between cardiac size and tidal volume (V(T)) at 75% of VO(2) peak whereas this relationship was statistically significant at VO(2) peak (P = 0.02) as patients with larger cardiac size had reduced V(T). CONCLUSION:This study demonstrates the close relationship between cardiac size and breathing pattern during exercise in HF patients. These results suggest cardiac size may pose a significant constraint on the lungs during exercise and may contribute to tachypnoeic breathing.
Right heart size and function significantly correlate in patients with pulmonary arterial hypertension - a cross-sectional study.
Fischer Lukas,Benjamin Nicola,Blank Norbert,Egenlauf Benjamin,Fischer Christine,Harutyunova Satenik,Koegler Maria,Lorenz Hanns-Martin,Marra Alberto M,Nagel Christian,Xanthouli Panagiota,Bossone Eduardo,Grünig Ekkehard
BACKGROUND:The objective of this study was to assess, whether right atrial (RA) and ventricular (RV) size is related to RV pump function at rest and during exercise in patients with pulmonary arterial hypertension (PAH). METHODS:We included 54 patients with invasively diagnosed PAH that had been stable on targeted medication. All patients underwent clinical assessments including right heart catheterization and echocardiography at rest and during exercise. RV output reserve was defined as increase of cardiac index (CI) from rest to peak exercise (∆CI). Patients were classified according to the median of RA and RV-area. RV pump function and further clinical parameters were compared between groups by student's t-test. Uni- and multivariate Pearson correlation analyses were performed. RESULTS:Patients with larger RA and/or RV-areas (above a median of 16 and 20cm, respectively) showed significantly lower ∆CI, higher mean pulmonary arterial pressure, pulmonary vascular resistance at rest and NT-proBNP levels. Furthermore, patients with higher RV-areas presented with a significantly lower RV stroke volume and pulmonary arterial compliance at peak exercise than patients with smaller RV-size. RV area was identified as the only independent predictor of RV output reserve. CONCLUSION:RV and RA areas represent valuable and easily accessible indicators of RV pump function at rest and during exercise. Cardiac output reserve should be considered as an important clinical parameter. Prospective studies are needed for further evaluation.
Cardiac function and position more than 5 years after pneumonectomy.
Smulders Sietske A,Holverda Sebastiaan,Vonk-Noordegraaf Anton,van den Bosch Harrie C M,Post Johannes C,Marcus J Tim,Smeenk Frank W J M,Postmus Pieter E
The Annals of thoracic surgery
BACKGROUND:Pneumonectomy not only reduces the pulmonary vascular bed but also changes the position of the heart and large vessels, which may affect the function of the heart. We investigated long-term effects of pneumonectomy on right ventricular (RV) and left ventricular (LV) function and whether this function is influenced by the side of pneumonectomy or the migration of the heart to its new position. METHODS:In 15 patients who underwent pneumonectomy and survived for more than 5 years, we evaluated by dynamic magnetic resonance imaging the function of the RV and LV and the position of the heart within the thorax. RESULTS:Long-term effect of pneumonectomy on the position of the heart is characterized by a lateral shift after right-sided pneumonectomy and rotation of the heart after left-sided pneumonectomy. Postoperatively, heart rate was high (p = 0.006) and stroke volume was low (p = 0.001), compared with the reference values, indicating impaired cardiac function. Patients after right-sided pneumonectomy had an abnormal low RV end-diastolic volume of 99 +/- 29 mL together with a normal LV function. No signs of RV hypertrophy were found. In left-sided pneumonectomy patients, RV volumes were normal whereas LV ejection fraction was abnormally low. CONCLUSIONS:The long-term effects of pneumonectomy on the position of the heart are characterized by a lateral shift in patients after right-sided pneumonectomy and rotation of the heart in patients after left-sided pneumonectomy. Overall, cardiac function in long-term survivors after pneumonectomy is compromised, and might be explained by the altered position of the heart.
Evaluation of cardiac size in chronic bronchitis and pulmonary emphysema.
Murphy M L,Boger J,Adamson J S,Rubin S
The accuracy of interobserver variability of roentgenographic analysis for cardiac size in patients dying with chronic bronchitis and pulmonary emphysema were correlated with pathologic data derived from special studies. Three trained observers were able to accurately and consistently diagnose chronic bronchitis and pulmonary emphysema and to detect cardiomegaly on the chest x-ray film. The best criteria for chronic bronchitis and pulmonary emphysema were those of overinflation; however, none of the roentgenographic criteria usually suggested for the specific diagnosis of right ventricular or left ventricular hypertrophy were found to be reliable. The inaccuracy and interobserver variability in the detection of enlargement of specific chambers make it evident that the usual criteria are not valid and that roentgenographic appraisal of cardiac size in these patients in limited to findings of normalcy or cardiomegaly.
Pulmonary function and respiratory muscle strength in chronic heart failure: comparison between ischaemic and idiopathic dilated cardiomyopathy.
Daganou M,Dimopoulou I,Alivizatos P A,Tzelepis G E
Heart (British Cardiac Society)
OBJECTIVE:To compare pulmonary function and respiratory muscle strength in patients with ischaemic and idiopathic dilated cardiomyopathy, well matched for indices of heart failure. METHODS:The study involved 30 patients with ischaemic cardiomyopathy and 30 with idiopathic dilated cardiomyopathy. The groups were well matched for age, weight, and clinical severity of cardiac dysfunction as assessed by ejection fraction and the New York Heart Association functional class. There were more smokers in the ischaemic group (p < 0.05), but indices of pulmonary function were comparable. RESULTS:Mean (SD) maximum static inspiratory pressure was lower in dilated cardiomyopathy than in ischaemic cardiomyopathy (73 (20) v 84 (22) cm H2O, p < 0.05), as was the maximum static expiratory pressure (90 (20) v 104 (21) cm H2O, p < 0.05). CONCLUSIONS:For a given degree of cardiac dysfunction, the respiratory muscles are weaker in patients with idiopathic dilated cardiomyopathy than in those with ischaemic cardiomyopathy.
The Relationship Between the Right Ventricle and its Load in Pulmonary Hypertension.
Vonk Noordegraaf Anton,Westerhof Berend E,Westerhof Nico
Journal of the American College of Cardiology
In pulmonary hypertension, the right ventricle adapts to the increasing vascular load by enhancing contractility ("coupling") to maintain flow. Ventriculoarterial coupling implies that stroke volume changes little while preserving ventricular efficiency. Ultimately, a phase develops where ventricular dilation occurs in an attempt to limit the reduction in stroke volume, with uncoupling and increased wall stress as a consequence. With pressure-volume analysis, we separately describe the changing properties of the pulmonary vascular system and the right ventricle, as well as their coupling, as important concepts for understanding the changes that occur in pulmonary hypertension. On the basis of the unique properties of the pulmonary circulation, we show how all relevant physiological parameters can be derived using an integrative approach. Because coupling is maintained by hypertrophy until the end stage of the disease, when progressive dilation begins, right ventricular volume is the essential parameter to measure in follow-up of patients with pulmonary hypertension.
The right ventricular response to lung resection.
McCall Philip J,Arthur Alex,Glass Adam,Corcoran David S,Kirk Alan,Macfie Alistair,Payne John,Johnson Martin,Kinsella John,Shelley Benjamin G
The Journal of thoracic and cardiovascular surgery
OBJECTIVES:Lung cancer is a leading cause of cancer death and in suitable cases the best chance of cure is offered by surgery. Lung resection is associated with significant postoperative cardiorespiratory morbidity, with dyspnea and reduced functional capacity as dominant features. These changes are poorly associated with deterioration in pulmonary function and a potential role of right ventricular (RV) dysfunction has been hypothesized. Cardiovascular magnetic resonance imaging is a reference method for noninvasive assessment of RV function and has not previously been applied to this population. METHODS:We used cardiovascular magnetic resonance imaging to assess the RV response to lung resection. Cardiovascular magnetic resonance imaging with volume and flow analysis was performed on 27 patients preoperatively, on postoperative day 2 and at 2 months. Left ventricular ejection fraction and RV ejection fraction, the ratio of stroke volume to end systolic volume, pulmonary artery acceleration time, and distensibility of main and branch pulmonary arteries were studied. RESULTS:Mean ± standard deviation RV ejection fraction deteriorated from 50.5% ± 6.9% preoperatively to 45.6% ± 4.5% on postoperative day 2 and remained depressed at 44.9% ± 7.7% by 2 months (P = .003). The ratio of stroke volume to end systolic volume deteriorated from median 1.0 (quartile 1, quartile 3: 0.9, 1.2) preoperatively to median 0.8 (quartile 1, quartile 3: 0.7, 1.0) on postoperative day 2 (P = .011). On postoperative day 2 there was a decrease in pulmonary artery acceleration time and operative pulmonary artery distensibility (P < .030 for both). There were no changes in left ventricular ejection fraction during the study period (P = .621). CONCLUSIONS:These findings suggest RV dysfunction occurs following lung resection and persists 2 months after surgery. The deterioration in the ratio of stroke volume to end systolic volume suggests a mismatch between afterload and contractility. There is an increase in indices of pulsatile afterload resulting from the operative pulmonary artery.
Cardiac dysrhythmia following pneumonectomy. Clinical correlates and prognostic significance.
Krowka M J,Pairolero P C,Trastek V F,Payne W S,Bernatz P E
Cardiac tachydysrhythmias occurred in 53 (22 percent) of 236 consecutive patients undergoing pneumonectomy. All patients had preoperative electrocardiograms which showed normal sinus rhythm. Patients did not receive digitalis before surgery. Atrial fibrillation was the most common dysrhythmia (64 percent; 34/53), followed by supraventricular tachycardia (23 percent; 12/53) and atrial flutter (13 percent; 7/53). No episodes of ventricular tachycardia were documented. Elevated concentrations of cardiac enzymes were associated with 12 (28 percent) of 43 tachydysrhythmias. Recurrent or persistent dysrhythmias were documented in 29 (55 percent) of 53 patients despite medical management or electrocardioversion (or both). Thirty-one percent (9/29) of these patients subsequently died during their hospitalization. There was no correlation between standard preoperative pulmonary function tests and the incidence of postoperative dysrhythmia. In addition, there was no correlation of dysrhythmia with postoperative diagnoses, surgical staging for lung cancer, postoperative arterial blood gas levels, or the fact that a completion pneumonectomy or chest wall resection was undertaken. An increased incidence of tachydysrhythmia was noted in patients undergoing intrapericardial dissections and those who developed postoperative interstitial or perihilar pulmonary edema. Twenty-five percent (13) of the patients experiencing tachydysrhythmias died within 30 days following their pneumonectomy. We conclude that tachydysrhythmias after pneumonectomy are associated with significant mortality, have poor correlation to preoperative pulmonary function, and occur more frequently following intrapericardial dissection and in patients who develop postoperative interstitial pulmonary edema or perihilar pulmonary edema.
Adjustments in cardiorespiratory function after pneumonectomy: results of the pneumonectomy project.
Deslauriers Jean,Ugalde Paula,Miro Santiago,Ferland Sylvie,Bergeron Sébastien,Lacasse Yves,Provencher Steve
The Journal of thoracic and cardiovascular surgery
OBJECTIVE:To assess lung function, gas exchange, exercise capacity, and right-sided heart hemodynamics, including pulmonary artery pressure, in patients long term after pneumonectomy. METHODS:Among 523 consecutive patients who underwent pneumonectomy for lung cancer between January 1992 and September 2001, 117 were alive in 2006 and 100 were included in the study. During a 1-day period, each patient had complete medical history, chest radiographs, pulmonary function studies, resting arterial blood gas analysis, 6-minute walk test, and Doppler echocardiography. RESULTS:Most patients (N = 73) had no or only minimal dyspnea. On the basis of predicted values, functional losses in forced expiratory volume in 1 second and forced vital capacity were 38% ± 18% and 31% ± 24%, respectively, and carbon monoxide diffusing capacity decreased by 31% ± 18%. There was a significant correlation between preoperative and postoperative forced expiratory volume in 1 second (P < .01), and more hyperinflation was associated with better lung function (P < .01 for forced expiratory volume in 1 second). Gas exchange was normal at rest (Pao(2) = 88 ± 10 mm Hg; Paco(2) = 42 ± 3 mm Hg), and exercise tolerance (6-minute walk) was also normal (83% ± 17% of predicted values). Thirty-two patients had some degree of pulmonary hypertension, but in most of those cases, it was mild to moderate (mean systolic pressure of 36 ± 9 mm Hg) and not associated with significant differences in lung function (P = .57 for forced expiratory volume in 1 second), gas exchange (P = .08), and exercise capacity (P = .66). CONCLUSIONS:These findings indicate that despite worsening of lung function by approximately 30% after pneumonectomy, most patients can adjust to living with only 1 lung. Pulmonary hypertension is uncommon and in most cases only mild to moderate.
Pulmonary function and adverse cardiovascular outcomes: Can cardiac function explain the link?
Burroughs Peña Melissa S,Dunning Allison,Schulte Phillip J,Durheim Michael T,Kussin Peter,Checkley William,Velazquez Eric J
BACKGROUND:The complex interaction between pulmonary function, cardiac function and adverse cardiovascular events has only been partially described. We sought to describe the association between pulmonary function with left heart structure and function, all-cause mortality and incident cardiovascular hospitalization. METHODS:This study is a retrospective analysis of patients evaluated in a single tertiary care medical center. We used multivariable linear regression analyses to examine the relationship between FVC and FEV1 with left ventricular ejection fraction (LVEF), left ventricular internal dimension in systole and diastole (LVIDS, LVIDD) and left atrial diameter, adjusting for baseline characteristics, right ventricular function and lung hyperinflation. We also used Cox proportional hazards models to examine the relationship between FVC and FEV1 with all-cause mortality and cardiac hospitalization. RESULTS:A total of 1807 patients were included in this analysis with a median age of 61 years and 50% were female. Decreased FVC and FEV1 were both associated with decreased LVEF. In individuals with FVC less than 2.75 L, decreased FVC was associated with increased all-cause mortality after adjusting for left and right heart echocardiographic variables (hazard ratio [HR] 0.49, 95% CI 0.29, 0.82, respectively). Decreased FVC was associated with increased cardiac hospitalization after adjusting for left heart size (HR 0.80, 95% CI 0.67, 0.96), even in patients with normal LVEF (HR 0.75, 95% CI 0.57, 0.97). CONCLUSION:In a tertiary care center reduced pulmonary function was associated with adverse cardiovascular events, a relationship that is not fully explained by left heart remodeling or right heart dysfunction.