Cardiovascular Complications Following Thoracic Surgery

Preoperative frailty screening in elderly patients with non-small cell lung cancer surgery: an essential step for a good surgical outcome

INTRODUCTION

Non-small cell lung cancer (NSCLC) is a disease commonly diagnosed in the elderly, often in advanced stages. However, elderly patients with lung cancer can benefit from surgery, provided that postoperative risks are assessed appropriately before surgery. Frailty is a measure of age-related impaired functional status and a predictor of mortality and morbidity. However, its importance as a preoperative marker is not well defined.

AREAS COVERED

This systematic review discusses the importance of preoperative frailty screening in elderly patients with NSCLC. A literature search was performed on the MEDLINE database in June 2023, and relevant studies on frailty or preoperative assessment of NSCLC which were published between 2000 and 2023 were retained and discussed in this review.

EXPERT OPINION

Among the types of existing methods used to assess frailty those on the geriatric assessment seem to be the most appropriate; however, they are unable to fully capture the 'surgical' frailty; thus, other instruments should be developed and validated in NSCLC.

Study protocol for an observational cohort evaluating incidence and clinical relevance of perioperative elevation of high-sensitivity troponin I and N-terminal pro-brain natriuretic peptide in patients undergoing lung resection

INTRODUCTION

Myocardial injury after non-cardiac surgery has been defined as myocardial injury due to ischaemia, with or without additional symptoms or ECG changes occurring during or within 30 days after non-cardiac surgery and mainly diagnosed based on elevated postoperative cardiac troponin (cTn) values. In patients undergoing thoracic surgery for lung resection, only postoperative cTn elevations are seemingly not enough as an independent predictor of cardiovascular complications. After lung resection, troponin elevations may be regulated by mechanisms other than myocardial ischaemia. The combination of perioperative natriuretic peptide measurement together with high-sensitivity cTns may help to identify changes in ventricular function during thoracic surgery. Integrating both cardiac biomarkers may improve the predictive value for cardiovascular complications after lung resection. We designed our cohort study to evaluate perioperative elevation of both high-sensitivity troponin I (hs-TnI) and N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients undergoing lung resection and to establish a risk score for major cardiovascular postoperative complications.

METHODS AND ANALYSIS

We will conduct a prospective, multicentre, observational cohort study, including 345 patients undergoing elective thoracic surgery for lung resection. Cardiac biomarkers such as hs-TnI and NT-proBNP will be measured preoperatively and at postoperatively on days 1 and 2. We will calculate a risk score for major cardiovascular postoperative complications based on both biomarkers' perioperative changes. All patients will be followed up for 30 days after surgery.

ETHICS AND DISSEMINATION

All participating centres were approved by the Ethics Research Committee. Written informed consent is required for all patients before inclusion. Results will be disseminated through publication in peer-reviewed journals and presentations at national or international conference meetings.

TRIAL REGISTRATION NUMBER

NCT04749212.

"Fit for Surgery? What's New in Preoperative Assessment of the High-Risk Patient Undergoing Pulmonary Resection"

Advances in perioperative assessment and diagnostics, together with developments in anesthetic and surgical techniques, have considerably expanded the pool of patients who may be suitable for pulmonary resection. Thoracic surgical patients frequently are perceived to be at high perioperative risk due to advanced age, level of comorbidity, and the risks associated with pulmonary resection, which predispose them to a significantly increased risk of perioperative complications, increased healthcare resource use, and costs. The definition of what is considered "fit for surgery" in thoracic surgery continually is being challenged. However, no internationally standardized definition of prohibitive risk exists. Perioperative assessment traditionally concentrates on the "three-legged stool" of pulmonary mechanical function, parenchymal function, and cardiopulmonary reserve. However, no single criterion should exclude a patient from surgery, and there are other perioperative factors in addition to the tripartite assessment that need to be considered in order to more accurately assess functional capacity and predict individual perioperative risk. In this review, the authors aim to address some of the more erudite concepts that are important in preoperative risk assessment of the patient at potentially prohibitive risk undergoing pulmonary resection for malignancy.

[Postoperative complications after major lung resection]

INTRODUCTION

The advent of the minimally invasive techniques has allowed an expansion of the indications for thoracic surgery, particularly in older patients and those with more comorbidities. However, the rate of postoperative complications has remained stable.

STATE OF THE ART

Postoperative complications are defined as any variation from the normal course. They occur in 30% but majority of them are minor. The 30-day mortality rate for lung resection varies range between 2 % and 3% in the literature. Complications can be classified as: (1) early (occurring in the first 24hours) including both "generic" surgical complications (especially postoperative bleeding) and complications more specific to lung surgery (Acute respiratory syndrome, atelectasis); (2) in-hospital complications and those occurring during the first 3 months; these are dominated by infectious events in particular pneumonia but also bronchial (bronchopleural fistula), pleural (pneumothorax, hydrothorax) or cardiac complications; (3) late complications are dominated by chronic pain, affecting 60% of patients having a thoracotomy at three months. Lobectomy is the most common lung resection. Pneumonectomy is a distinct procedure requiring a specific peri- and postoperative management. Right pneumonectomy is associated with a higher risk with a treatment related-mortality ranging between 7 and 10%.

CONCLUSION

Major lung resection has benefited from minimally invasive approaches and fast track to surgery. However, it is important to note the occurrence of new and specific complications related to those news surgical access.

The Outcome of Extracorporeal Life Support After General Thoracic Surgery: Timing of Application

BACKGROUND

Extracorporeal life support (ECLS) is widely used in refractory cardiac or pulmonary failure. Because complications of general thoracic surgery frequently involve the heart or lungs, ECLS can be a useful option. Therefore, we retrospectively reviewed our experience with ECLS after general thoracic surgery.

METHODS

There were 17,185 adult general thoracic surgery procedures between 2005 and 2013 at our institution, including resection of the lung (n = 10,434; 60.7%), esophagus (n = 1,847; 0.7%), and other procedures (n = 4,904; 28.5%). Twenty-nine patients (0.2%) were supported by ECLS postoperatively.

RESULTS

The median age was 64 years (range, 24 to 81). Primary operations were lobectomy (n = 13; 44.8%), pneumonectomy (n = 11; 37.9%), and bilobectomy (n = 5; 17.2%). The initial mode of ECLS was venovenous in 20 patients (69.0%) and venoarterial in 9 patients (31.0%). There were 10 patients (34.5%) who survived to decannulation and 7 patients (24.1%) who survived to discharge. Over the same period, the survival to decannulation rate and survival to discharge rate were 49.5% and 35.0%, respectively, among all ECLS patients (n = 759) at our institution. The hospital mortality of patients with surgery to ECLS time of longer than 2 days was 90.9%. Multivariate analysis revealed that a longer surgery to ECLS time was a risk factor for hospital mortality (odds ratio 1.720, 95% confidence interval: 1.039 to 2.849, p = 0.035).

CONCLUSIONS

ECLS after general thoracic surgery can be a viable rescue therapy option. Late presentation of complications or ECLS for late complications of general thoracic surgery may be predictors of death.

Effect of colchicine in prevention of pericardial effusion and atrial fibrillation: a meta-analysis

Randomized, controlled trials (RCTs) have assessed the effect of colchicine therapy in prevention of pericardial effusion (PE) and atrial fibrillation (AF). However, the effects are still inconclusive. PubMed, Cochrane Library, Google Scholar, and EMBASE database were searched. Primary outcome was the risk of PE and AF. Ten RCTs with 1981 patients and a mean follow-up of 12.6 months were included. Colchicine therapy was not associated with a significantly lower risk of post-operative PE (RR, 0.89; 95 % CI 0.70-1.13; p = 0.33, I (2) = 72.8 %) and AF (RR, 0.77; 95 % CI 0.52-1.13; p = 0.18, I (2) = 47.3 %). However, rates of pericarditis recurrence, symptoms persistence, and pericarditis-related hospitalization were significantly decreased with colchicine treatment. In addition, cardiac tamponade occurrence was similar between groups, and adverse events were significantly higher in the colchicine group. Colchicine may not significantly decrease the post-operative risk of PE and AF. However, only limited studies about patients undergoing cardiac surgery provide data about PE and AF.