Impact of cardiopulmonary complications of lung cancer surgery on long-term outcomes

Thrombus formation at the stump of the pulmonary vein after lobectomy: a prospective multi-institutional study

PURPOSE

Recent reports suggest that postoperative cerebral infarction following lung cancer surgery is caused by thrombus formation at the stump of the pulmonary vein and that the risk is highest after left upper lobectomy (LUL). Thrombosis at the stump of the pulmonary vein and the incidence of cerebral infarction was investigated prospectively in patients who underwent lobectomy for lung cancer.

METHODS

Lung cancer patients undergoing planned pulmonary lobectomy were enrolled. The endpoint was to confirm if there is a higher incidence of thrombus formation (primary) and a higher incidence of cerebral infarction (secondary) in patients undergoing LUL. We planned to accrue 600 patients. An interim analysis was scheduled for just after the data center received the final clinical review form of the 300th patient.

RESULTS

The interim analysis revealed a significant difference in the primary endpoint. In the final analysis, thrombus was identified in 16 of 88 LUL patients (20.5%), and in 4 of 247 patients who underwent other types of lobectomy (1.6%) (p < 0.05). Cerebral infarction was identified in 1 of the LUL patients (1.3%) and in 9 of the other patients (3.6%) (p = 0.318).

CONCLUSIONS

Thrombus frequently forms at the stump of the left superior pulmonary vein after LUL. However, our study did not identify a relationship between thrombosis and cerebral infarction.

Recognition of Strokes in the ICU: A Narrative Review

Despite the remarkable progress in acute treatment for stroke, in-hospital stroke is still devastating. The mortality and neurological sequelae are worse in patients with in-hospital stroke than in those with community-onset stroke. The leading cause of this tragic situation is the delay in emergent treatment. To achieve better outcomes, early stroke recognition and immediate treatment are crucial. In general, in-hospital stroke is initially witnessed by non-neurologists, but it is sometimes challenging for non-neurologists to diagnose a patient's state as a stroke and respond quickly. Therefore, understanding the risk and characteristics of in-hospital stroke would be helpful for early recognition. First, we need to know "the epicenter of in-hospital stroke". Critically ill patients and patients who undergo surgery or procedures are admitted to the intensive care unit, and they are potentially at high risk for stroke. Moreover, since they are often sedated and intubated, evaluating their neurological status concisely is difficult. The limited evidence demonstrated that the intensive care unit is the most common place for in-hospital strokes. This paper presents a review of the literature and clarifies the causes and risks of stroke in the intensive care unit.

Prediction of postoperative cardiopulmonary complications after lung resection in a Chinese population: A machine learning-based study

Background

Approximately 20% of patients with lung cancer would experience postoperative cardiopulmonary complications after anatomic lung resection. Current prediction models for postoperative complications were not suitable for Chinese patients. This study aimed to develop and validate novel prediction models based on machine learning algorithms in a Chinese population.

Methods

Patients with lung cancer receiving anatomic lung resection and no neoadjuvant therapies from September 1, 2018 to August 31, 2019 were enrolled. The dataset was split into two cohorts at a 7:3 ratio. The logistic regression, random forest, and extreme gradient boosting were applied to construct models in the derivation cohort with 5-fold cross validation. The validation cohort accessed the model performance. The area under the curves measured the model discrimination, while the Spiegelhalter z test evaluated the model calibration.

Results

A total of 1085 patients were included, and 760 were assigned to the derivation cohort. 8.4% and 8.0% of patients experienced postoperative cardiopulmonary complications in the two cohorts. All baseline characteristics were balanced. The values of the area under the curve were 0.728, 0.721, and 0.767 for the logistic, random forest and extreme gradient boosting models, respectively. No significant differences existed among them. They all showed good calibration (p > 0.05). The logistic model consisted of male, arrhythmia, cerebrovascular disease, the percentage of predicted postoperative forced expiratory volume in one second, and the ratio of forced expiratory volume in one second to forced vital capacity. The last two variables, the percentage of forced vital capacity and age ranked in the top five important variables for novel machine learning models. A nomogram was plotted for the logistic model.

Conclusion

Three models were developed and validated for predicting postoperative cardiopulmonary complications among Chinese patients with lung cancer. They all exerted good discrimination and calibration. The percentage of predicted postoperative forced expiratory volume in one second and the ratio of forced expiratory volume in one second to forced vital capacity might be the most important variables. Further validation in different scenarios is still warranted.

Endovascular recanalization of acute ischemic stroke patients exhibiting large vessel occlusion after pulmonary lobectomy: case series

Objective

We analyzed the outcomes of patients suffering acute ischemic stroke (AIS) with large vessel occlusion (LVO) soon after pulmonary lobectomy.

Methods

We retrospectively reviewed the clinical records of patients who underwent pulmonary lobectomy to treat primary lung cancer. We retrieved clinical characteristics and the incidence of AIS with LVO. The clinical courses of patients who experienced AIS were reviewed.

Results

In 10 (0.3%) of 3406 patients, AIS with LVO developed soon (within 3 days) after pulmonary lobectomy. The lung resection site was on the left in eight patients (80%). All patients underwent thrombectomy and achieved complete recanalization (Thrombolysis in Cerebral Infarction [TICI] 3). The average time between symptom onset and recanalization was 165.5 min. Nine (90%) patients exhibited favorable outcomes (modified Rankin scale [mRS] score ≤ 2) at the 3-month follow-up.

Conclusion

Endovascular therapy effectively treats AIS with LVO that develops after lung surgery, and direct aspiration is a promising strategy. A large, multicenter study is warranted to further confirm these findings.

Postoperative cerebral infarction risk is related to lobectomy site in lung cancer: a retrospective cohort study of nationwide data in Japan

OBJECTIVES

To determine the incidence of cerebral infarction after lobectomy at different sites using inpatient data from a diagnosis procedure combination database.

DESIGN

Retrospective cohort study.

SETTING

Data were retrieved from the Japanese diagnosis procedure combination inpatient database for patients who underwent lobectomies for lung cancer between April 2018 and March 2020.

PARTICIPANTS

The analysis included 37 352 patients from 556 institutions who underwent lobectomies for lung cancer.

MAIN OUTCOMES AND MEASURES

The occurrence of cerebral infarction after lobectomy during hospitalisation was estimated using multilevel logistic regression models adjusted for sex, age, body mass index, smoking history, activity of daily living, surgical approach (thoracotomy or video-assisted), clinical cancer stage, comorbidities and hospital-level factors to describe the association between cerebral infarction and different lobectomy sites.

RESULTS

Overall cerebral infarction after lobectomy occurred in 99 patients (0.27%): 29 with left upper lobectomy (0.39%), 19 with left lower lobectomy (0.34%), 32 with right upper lobectomy (0.24%), 6 with right middle lobectomy (0.21%) and 13 with right lower lobectomy (0.16%). The multilevel multivariate logistic regression analysis revealed high ORs for the left upper lobectomy and left lower lobectomy groups. In both univariate and multivariate analyses, left upper lobectomy had the highest OR for the occurrence of cerebral infarction compared with lobectomies at other sites.

CONCLUSIONS AND RELEVANCE

Left upper lobectomy had the highest OR for the occurrence of cerebral infarction after lung cancer lobectomy during hospitalisation. There is an urgent need to investigate the specific mechanisms underlying postoperative cerebral infarction after left upper lobectomy and to establish preventive measures such as altering surgical methods, using radiological examinations for early detection and better use of anticoagulants.

Hemodynamic features underlying pulmonary vein stump thrombus formation after left upper lobectomy: four-dimensional flow magnetic resonance imaging study

BACKGROUND

We previously reported that to-and-fro blood movement near the pulmonary vein stump was particularly prominent after left upper lobectomy compared with other lobectomy, which may be the cause of the high susceptibility of pulmonary vein thrombus after left upper lobectomy. The aim of the present study was to compare the hemodynamics in patients who developed pulmonary vein thrombus after left upper lobectomy with those in patients who did not develop pulmonary vein thrombus using four-dimensional flow magnetic resonance imaging (4D MRI).

METHODS

This was a retrospective evaluation of a prospectively collected clinical and radiological database of 37 patients who underwent 4D MRI 7 days after left upper lobectomy for lung cancer (n=37). We obtained two parameters by 4D MRI: the grade of to-and-fro blood movement and the flow energy loss around the pulmonary vein stump. The length of the pulmonary vein stump, a known risk factor for pulmonary vein thrombus, was also measured.

RESULTS

According to a scatterplot of the grade of to-and-fro blood movement versus the flow energy loss, patients with pulmonary vein thrombus (n=15) were concentrated in an area which appears to be a 'dangerous' hemodynamic condition. There were few patients without pulmonary vein thrombus in this 'dangerous' area, except for one who unfortunately developed delayed pulmonary vein thrombus and cerebral infarction. We proposed a formula using the 4D MRI-derived parameters based on a stepwise multiple regression analysis that was more closely associated with the development of pulmonary vein thrombus than the length of the pulmonary vein stump (area under the receiver operating characteristics curve: 0.918 vs. 0.705, P=0.0500).

CONCLUSIONS

We proposed the existence of a 'dangerous' hemodynamic condition responsible for pulmonary vein thrombus formation. 4D MRI before the development of pulmonary vein thrombus may help identify patients requiring preventive therapy against pulmonary vein thrombus and subsequent thromboembolic complications.

Four-dimensional flow magnetic resonance imaging study to explain high prevalence of pulmonary vein stump thrombus after left upper lobectomy

Background

Pulmonary vein (PV) stump thrombus, a known source of cerebral infarction, develops almost exclusively after left upper lobectomy; however, the mechanism remains unclear. We therefore evaluated the hemodynamics in the left atrium with four-dimensional flow magnetic resonance imaging (4D-flow MRI), which enables the simultaneous depiction of blood flow at three locations and the evaluation of hemodynamics.

Methods

4D-flow MRI was basically performed 7 days after lobectomy for cancer arising in the right upper lobe (n=11), right lower lobe (n=8), left upper lobe (n=13), or left lower lobe (n=8). We evaluated dynamic blood movement from the ipsilateral remaining PV, the resected PV stump, and the contralateral PVs into the left atrium using 4D-flow MRI.

Results

There were some characteristic blood flow patterns that seemed to either promote or prevent PV stump thrombus. Promotive flow patterns were significantly more frequent and preventive flow patterns were significantly less frequent in patients who had undergone left upper lobectomy than in those who had undergone other lobectomy. Accordingly, the degree of blood turbulence near the vein stump, as measured by the extent of change in the blood movement, was significantly higher in patients who had undergone left upper lobectomy than in patients who had undergone other lobectomy.

Conclusions

Our study revealed that left upper lobectomy likely causes blood turbulence near the vein stump through complicated blood streams in the left atrium, which can play a part in the development of vein stump thrombus. Further study to identify patients at high risk of vein stump thrombus is warranted.

Preoperative Electrocardiogram and Perioperative Methods for Predicting New-Onset Atrial Fibrillation During Lung Surgery

OBJECTIVE

To investigate if preoperative electrocardiogram scores and perioperative surgical methods could predict new-onset atrial fibrillation during lung surgery.

DESIGN

Retrospective observational case-control study.

SETTING

The First Affiliated Hospital of Nanjing Medical University, China.

PARTICIPANTS

Eighty adult patients (40 with new-onset atrial fibrillation, 40 without) who underwent lung surgery.

INTERVENTIONS

The authors compared and analyzed the relationship among preoperative electrocardiogram scores, clinical variables, and surgical variables with new-onset atrial fibrillation during lung surgery.

MEASUREMENTS AND MAIN RESULTS

Clinical data and demographics involving 80 adult patients (40 with new-onset atrial fibrillation, 40 without) who underwent lung surgery were retrieved from the Medical Records of the First Affiliated Hospital of Nanjing Medical University. Patients with prior atrial fibrillation were excluded. Preoperative electrocardiograms were collected from medical records and checked by two independent blinded researchers. Preoperative clinical variables (age, sex, body mass index, American Society of Anesthesiologists Class) were selected for a multivariate preoperative clinical model (model C). Perioperative surgical methods (thoracoscopy or open-chest surgery, lymph node dissection, left or right pneumonectomy, extent of pulmonary resection) were selected for a multivariate surgical methods model (model S). Five electrocardiogram variables (PR interval, P-wave duration, the longest interval measured between the onset of Q-wave and the J-point (QRS) duration, left atrial enlargement, and left ventricular hypertrophy) were included in a multivariate electrocardiogram model (model E). A combined clinical and electrocardiogram model (Model CE) and a combined univariate significant variables model (Model CSE) were formed. Left atrial enlargement, QRS duration, American Society of Anesthesiologists Class, and open-chest surgery were risk factors of new-onset atrial fibrillation. The result showed that the predictive ability of Model E was significantly higher than Models C and S. Model CSE showed the highest prediction of all models. Fifty percent of patients with one risk element will develop new-onset atrial fibrillation, and 100% of patients with two or more risk elements of Model CSE will develop new-onset atrial fibrillation.

CONCLUSIONS

Preoperative electrocardiogram markers can be used together with surgical methods as strong predictors to identify those patients at a high risk for new-onset atrial fibrillation during lung surgery.

Incidence, Management, Prevention and Outcome of Post-Operative Atrial Fibrillation in Thoracic Surgical Oncology

Atrial fibrillation (AF) is a common supraventricular arrhythmia, a recognized risk factor for ischemic stroke, as a potential driver for heart failure (HF). Cancer patients have an increased risk for AF, even not including any cancer-specific treatment, as surgery or chemotherapy. The mechanism is multifactorial, with inflammation and changes in autonomic tone as critical actors. Commonly, AF is a recurrent complication of the post-operative period in cancer surgery (especially thoracic). Recent papers confirmed a significant incidence of post-operative (non-cardiac surgery) AF (PAF), partially mitigated by the use of prophylactic (rate o rhythm control) treatments. A relevant difference, in terms of mean hospitalization time, emerges between patients developing PAF and those who do not, while long term impact remains a matter of debate, due to several potential confounding factors. Besides clinical predictors, structural (i.e., echocardiographic) and bio-humoral findings may help in risk prediction tasks. In this respect, pre-operative natriuretic peptides (NPs) concentrations are nowadays recognized as significant independent predictors of perioperative cardiovascular complications (including PAF), while elevated post-operative levels may further enhance risk stratification. The aim of the present paper is to trace the state of the art in terms of incidence, management, prevention, and outcome of PAF in the field of thoracic surgical oncology.

Cerebral Thromboembolism after Lobectomy for Lung Cancer: Pathological Diagnosis and Mechanism of Thrombus Formation

Lung cancer is the leading cause of cancer-related deaths worldwide. Although molecular therapies have emerged as efficacious strategies for the treatment of lung cancer, surgical resection is still recommended as a radical therapeutic option. Currently, lobectomy is regarded as the most reliable radical treatment of primary lung cancer. Among the various complications after lobectomy, cerebral thromboembolism requires attention as a life-threatening complication during the early postoperative period. It occurs in 0.2–1.2% of surgical cases of lung cancer and typically develops following left upper lobectomy with a long pulmonary vein stump (PVS). PVS-associated thrombosis is known to cause cerebral thromboembolism after such procedures; however, distinguishing this specific complication from that caused by postoperative atrial fibrillation is challenging. We summarize herein the diagnostic pathology of thrombus formation in accordance with its thrombogenic mechanism. We focus on the potential utility of the pathological assessment of thrombectomy specimens. The morphological information obtained from these specimens enables the presumption of thrombogenic etiology and provides useful clues to both select an appropriate pharmacotherapy and determine a follow-up treatment for cerebral thromboembolism.

Degree of pulmonary fissure completeness can predict postoperative cardiopulmonary complications and length of hospital stay in patients undergoing video-assisted thoracoscopic lobectomy for early-stage lung cancer

OBJECTIVES

To estimate the effects of pulmonary fissure completeness on postoperative cardiopulmonary complications (PCCs) and hospital stay in patients undergoing video-assisted thoracoscopic surgery lobectomy for early-stage non-small-cell lung cancer.

METHODS

We performed a single-centre retrospective analysis based on the prospectively maintained data of our institution during the study period. Demographic differences between the PCC group and the non-PCC group were initially examined. Then, the patients were classified into 3 groups according to their fissure sum averages (FSAs: 0 ≤ FSA ≤ 1, 1 < FSA ≤ 2, 2 < FSA ≤ 3) calculated by fissure development scores. The differences in PCC incidences and hospital stay between these 3 groups were further evaluated. Finally, FSA > 1 was determined as the cut-off to indicate the degree of pulmonary fissure completeness and involved into a multivariate logistic regression model to identify the predictors for PCCs.

RESULTS

In total, 528 patients with Stage I to Stage II non-small-cell lung cancer were enrolled. There were 343 patients with 0 ≤ FSA ≤ 1, 105 patients with 1 < FSA ≤ 2 and 80 patients with 2 < FSA ≤ 3. Pulmonary complication rate in patients with 1 < FSA ≤ 2 (25.7% vs 14.3%; P = 0.006) and with 2 < FSA ≤ 3 (33.8% vs 14.3%; P < 0.001) was significantly higher than that in patients with 0 ≤ FSA ≤ 1. No difference was found in cardiovascular complication rate between these groups (P = 0.22). The Kaplan-Meier analysis showed that the length of hospital stay and the length of chest tube drainage in patients with 1 < FSA ≤ 2 and with 2 < FSA ≤ 3 were significantly longer than those in patients with 0 ≤ FSA ≤ 1. Incomplete pulmonary fissure (FSA > 1) was a strong independent predictor for PCCs (odds ratio = 2.12; P = 0.002) in the multivariate analysis.

CONCLUSIONS

The degree of pulmonary fissure completeness can predict the PCCs and the length of hospital stay following video-assisted thoracoscopic surgery lobectomy for early-stage non-small-cell lung cancer.

Elevated preoperative heart rate associated with increased risk of cardiopulmonary complications after resection for lung cancer

BACKGROUND

The study aimed to assess whether preoperative resting heart rate could be a risk factor for cardiopulmonary complications (CPCs) after lung cancer resection.

METHODS

Eligible consecutive patients who underwent resection surgery for non-small cell lung cancer (NSCLC) at Ningbo NO.2 Hospital between May, 2010 and July, 2015 were included. The demographic, clinical characteristics and laboratory parameters were compared in patients with or without CPCs within postoperative 30 days. The multivariate logistic regression analysis was used to analyze the association between CPCs and risk factors. Receiver operating characteristic (ROC) curve analysis was utilized for the predictive role of preoperative resting heart rate for CPCs.

RESULTS

One hundred eighty participants were enrolled into the final analysis and 42 of them had an established diagnosis of CPCs within postoperative 30 days. Elevated preoperative resting heart rate was an independent risk factor for postoperative CPCs (OR: 4.48, 95% CI: 1.17-18.42, P = 0.021) by the multivariate logistic regression analysis. ROC curve analysis indicated elevated resting heart rate as a predictor for CPCs with a cut-off value of 86 beats/min (AUC: 0.813, specificity: 80.95%, sensitivity: 72.46%, P < 0.001).

CONCLUSIONS

Elevated preoperative resting heart rate was associated with an increased risk of postoperative CPCs in patients after resection for lung cancer.

Estimated intraoperative blood loss correlates with postoperative cardiopulmonary complications and length of stay in patients undergoing video-assisted thoracoscopic lung cancer lobectomy: a retrospective cohort study

Background

The purpose of our study was to estimate the influence of estimated intraoperative blood loss (EIBL) on postoperative cardiopulmonary complications (PCCs) in patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy for non-small-cell lung cancer (NSCLC).

Methods

We conducted a single-center retrospective analysis on the clinical data of consecutive patients in our institution between April 2015 and February 2016. Demographic differences between PCC group and non-PCC group were initially assessed. Receiver operating characteristic (ROC) analysis was performed to determine the threshold value of EIBL for the prediction of PCCs. Demographic differences in the PCC rates and length of stay between two groups of patients divided by this cutoff were further evaluated. A multivariable logistic-regression model involving the clinicopathological parameters with P-value< 0.05 was finally established to identify independent risk factors for PCCs.

Results

A total of 429 patients with operable NSCLC were included and 80 of them developed PCCs (rate = 18.6%). The mean EIBL in PCC group was significantly higher than that in non-PCC group (133.3 ± 191.3 vs. 79.1 ± 107.1 mL; P < 0.001). The ROC analysis showed an EIBL of 100 mL as the threshold value at which the joint sensitivity (50.0%) and specificity (73.4%) was maximal. The PCC rate in patients with EIBL≥100 mL was significantly higher than that in patients with EIBL< 100 mL (30.1 vs. 13.5%; P < 0.001). Both the length of stay and chest tube duration were significantly prolonged in the patients with EIBL≥100 mL. Finally, EIBL≥100 mL was identified to be predictive of PCCs by multivariable logistic-regression analysis (odds ratio = 3.01; 95% confidence interval = 1.47–6.16; P = 0.003).

Conclusions

EIBL serves as a significant categorical predictor for cardiopulmonary complications following VATS lobectomy for NSCLC. Thoracic surgeons should minimize the EIBL and strive for the ‘bloodless’ goal to optimize surgical outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0360-0) contains supplementary material, which is available to authorized users.