Cardiovascular Complications After Lung Surgery
Section snippets
Postoperative arrhythmias
Of the 600,000 Americans who undergo major cardiothoracic operations annually, more than 150,000 will have postoperative arrhythmias, of which atrial flutter/fibrillation (Fig. 1) is the most common [1], [2], [3]. Patients who have postoperative atrial fibrillation sustain substantial morbidity, such as hemodynamic compromise, a longer intensive care unit stay, increased postoperative mortality, an extended hospital stay, increased costs, and greater rates of hospital readmission after
Amiodarone
A prospective randomized trial comparing the administration of amiodarone, verapamil, and a placebo as prophylactic treatment for supraventricular dysrhythmias after pulmonary surgery was interrupted because adult respiratory distress syndrome (ARDS) developed in three pneumonectomy patients in the amiodarone-treated group [8]. Subsequently, a retrospective analysis of 553 pulmonary resections was performed. The overall incidence of ARDS was 11% in the patients treated with amiodarone and 1.8%
Myocardial ischemia/infarction
In a series of 598 patients undergoing thoracic surgery for lung cancer, transient ischemic electrocardiographic changes were documented in 23 patients (3.8%) and myocardial infraction (MI) in 7 (1.2%) [17]. Abnormal exercise testing and intraoperative hypotension were the strongest predictors for ischemic events [17]. Herrington and Shumway [18] reviewed the literature on MI in the postthoracotomy period. Mortality rates ranged from 2.1% to 21%; however, the incidence of perioperative MI
Heart failure
Four studies using thermodilution methods and one echocardiographic study have investigated the problem of postoperative right ventricular dysfunction (Fig. 2) [21], [22], [23], [24], [25]. Alterations in right ventricular contractile performance and changes in the right ventricular afterload are the presumed mechanisms of right ventricular dysfunction. Although right ventricular end-diastolic volume remains stable in the early postoperative hours, significant increases may be observed on the
Shunting
The development of an atrial right-to-left shunt through a persistent foramen ovale may occur and can be the cause of dyspnea or the so-called “platypnea-orthodeoxia syndrome.” Its incidence is low and seems to occur more frequently after right-sided pneumonectomy [29], [30]. The overall prevalence of permeable foramen ovale is estimated at 20% to 35% in the general population [31]. The contributing factors are anatomic changes such as mediastinal shift. This shift modifies the relationship
Thromboembolism
Only one prospective nonrandomized study [31] has determined the frequency and significance of thromboembolism after pulmonary resection. Thromboembolism may lead to serious cardiac complications such as sudden death, pulmonary hypertension, and heart failure. Seventy-seven patients were followed prospectively for 30 days or less postoperatively. The incidence of thromboembolic events was higher in patients with bronchogenic carcinoma than in patients with metastatic cancer or benign disease,
Cardiac herniation
Cardiac herniation is a rare but lethal complication of intrapericardial pneumonectomy. Bettman and Tannenbaum [36] in 1948 were the first to describe herniation of the heart through a pericardial defect following left intrapericardial pneumonectomy. Approximately 30 cases of cardiac herniation have been reported following left and right pneumonectomies, with a nearly 50% mortality rate [37], [38]. Patients with cardiac herniation typically have cardiovascular collapse and jugular venous
Summary
Cardiovascular complications following thoracic surgery remain a challenge to the physician, the hospital, and the health care system. These events add significantly to morbidity, mortality, and the cost of care of the general thoracic surgery patient. A proactive approach to identify patients at high risk for such complications is needed. In this manner, one may enhance prevention and treatment if problems occur. A thoughtful and complete preoperative risk assessment can identify patients who
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