Left ventricular stroke volume decreases due to surgical procedures of anatomical lung resection

OBJECTIVES

The influence of lung resection on cardiac function has been reported, and previous studies have mainly focused on right ventricular (RV) dysfunction. As few studies have analyzed changes in left ventricular hemodynamic variables caused by lung resection, we aimed to investigate the perioperative changes in left ventricular stroke volume (LVSV) caused by anatomical lung resection.

METHODS

We enrolled 61 patients who underwent anatomical lung resection and perioperative LVSV monitoring. The Flo Trac system was used for dynamic monitoring. We investigated changes in LVSV after lung resection and the factors that affected these changes. The operative procedures that contributed to these changes were also investigated.

RESULTS

LVSV decreased after anatomical lung resection in the majority of patients (n = 38, 62.2%). Operative procedures affecting this change were (a) taping the superior pulmonary vein (SPV; right: V1-3) before dorsal part procedure (e.g., major fissure division of right upper lobectomy, A1 + 2c, and A4 + 5 division of left upper lobectomy); (b) division of the SPV (right: V1-3, V4 + 5); (c) division of A6-10 (in lower lobectomy); and (d) finish division of all vessels.

CONCLUSIONS

LVSV decrease was caused by anatomical lung resection in the majority of patients owing to the intraoperative procedures described above.

Anesthetic and Intensive Care Approaches Following Radical Pneumonectomy: A Short Review of Patient Management and a Case Report

Around the world, lung cancer is the leading cause of cancer-related death and the most commonly diagnosed cancer. In the early stages, surgery is the preferable therapeutic strategy. We present the case of a male patient aged 49 years diagnosed with non-small cell lung cancer of the left lower lobe who was referred for a radical left pneumonectomy. After careful preoperative preparation, the surgery was proceeded with. During the surgery, the patient needed bronchoscopy for the aspiration of the trachea and bronchial tree; after the aspiration procedure, an intraoperative massive hemorrhage started, with shock and ventricular tachycardia. Nine days after surgery, the patient developed a pulmonary embolism and returned to the ICU. The patient benefited from transfusion, intrathoracic cardiac compressions, pulse index continuous cardiac output (PiCCO), renal replacement therapy (RRT), anticoagulation, and intensive care. After a complicated clinical course, the patient is discharged, and after more than 18 months, the patient comes regularly for follow-up consultation in good health.

Effects of preoperative mildly elevated pulmonary artery systolic pressure on the incidence of perioperative adverse events undergoing thoracoscopic lobectomy: an observational cohort study protocol

INTRODUCTION

Echocardiography provides a non-invasive estimation of pulmonary artery systolic pressure (PASP) and is the first diagnostic test for pulmonary hypertension. Recent studies have demonstrated that PASP of more than 30 mm Hg related to increased mortality and morbidity. However, perioperative risks and management for patients with mildly elevated PASP are not well established. This study aims to explore the association between mildly elevated PASP and perioperative adverse outcomes.

METHODS AND ANALYSIS

This will be a retrospective cohort study conducted at Shanghai Pulmonary Hospital in Shanghai, China. Eligible patients are adults (≥18 years) who performed preoperative echocardiography and followed thoracoscopic lobectomy. Our primary objective is to determine the effect of preoperative mildly elevated PASP on the incidence of hypotension during surgery. Whether mildly elevated PASP is related to other perioperative adverse events (including hypoxaemia, myocardial injury, new-onset atrial fibrillation, postoperative pulmonary complications, 30-day readmission and 30-day mortality) will be also analysed. An estimated 2300 patients will be included.

ETHICS AND DISSEMINATION

The study has been approved by the institutional review board of Shanghai Pulmonary Hospital (approval No: 2022LY1143). The research findings intend to be published in peer-reviewed scientific publications.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR2200066679).

Perioperative cardiovascular pathophysiology in patients undergoing lung resection surgery: a narrative review

Although thoracic surgery is understood to confer a high risk of postoperative respiratory complications, the substantial haemodynamic challenges posed are less well appreciated. This review highlights the influence of cardiovascular comorbidity on outcome, reviews the complex pathophysiological changes inherent in one-lung ventilation and lung resection, and examines their influence on cardiovascular complications and postoperative functional limitation. There is now good evidence for the presence of right ventricular dysfunction postoperatively, a finding that persists to at least 3 months. This dysfunction results from increased right ventricular afterload occurring both intraoperatively and persisting postoperatively. Although many patients adapt well, those with reduced right ventricular contractile reserve and reduced pulmonary vascular flow reserve might struggle. Postoperative right ventricular dysfunction has been implicated in the aetiology of postoperative atrial fibrillation and perioperative myocardial injury, both common cardiovascular complications which are increasingly being appreciated to have impact long into the postoperative period. In response to the physiological demands of critical illness or exercise, contractile reserve, flow reserve, or both can be overwhelmed resulting in acute decompensation or impaired long-term functional capacity. Aiding adaptation to the unique perioperative physiology seen in patients undergoing thoracic surgery could provide a novel therapeutic avenue to prevent cardiovascular complications and improve long-term functional capacity after surgery.

The Impact of Initial Postoperative Destination on Unplanned Critical Care Admissions After Lung Resection

OBJECTIVES

Despite an increasing proportion of patients undergoing lung resection being managed postoperatively in a ward-based environment, studies analyzing the impact of initial postoperative destination (IPD) on perioperative outcomes and unplanned critical care admission (UCCA) are lacking.

DESIGN

A single-center retrospective review.

SETTING

A cardiothoracic surgery center in the Northwest of England.

PARTICIPANTS

A total of 3,841 patients between 2012 and 2018.

INTERVENTIONS

All patients underwent lung resection. Patients were classified as either IPD ward or IPD critical care.

MEASUREMENTS AND MAIN RESULTS

Outcomes assessed included in-hospital and 90-day mortality and UCCA. Differences in mortality rates between groups were assessed using the chi-square test. Multivariate logistic regression analyses were performed to identify variables independently associated with 90-day mortality and UCCA. In total, 23.8% (n = 913) of patients went to critical care as their IPD. Overall in-hospital mortality was 1.6% (n = 62), and 90-day mortality was 2.9% (n = 112). The rate of UCCA was 10.5% (n = 404) and was significantly higher for IPD ward patients compared to IPD critical care patients (11.9% v 6.2%, p < 0.001). The 90-day mortality rates after UCCA were 5.2% (IPD ward) and 19.3% (IPD critical care) (p < 0.001). Advanced age, worse pulmonary function, IPD ward, and timing of surgery were all independently associated with UCCA.

CONCLUSIONS

Most patients undergoing lung resection can be managed safely postoperatively in a ward-based environment. Short-term mortality is higher after UCCA, with patients who experience readmission to critical care at the highest risk of death. Patients should receive additional monitoring immediately following discharge from critical care.

Outcome following unplanned critical care admission after lung resection

OBJECTIVES

Patients undergoing lung resection are at risk of perioperative complications, many of which necessitate unplanned critical care unit admission in the postoperative period. We sought to characterize this population, providing an up-to-date estimate of the incidence of unplanned critical care admission, and to assess critical care and hospital stay, resource use, mortality, and outcomes.

METHODS

A multicenter retrospective cohort study of patients undergoing lung resection in participating UK hospitals over 2 years. A comprehensive dataset was recorded for each critical care admission (defined as the need for intubation and mechanical ventilation and/or renal replacement therapy), in addition to a simplified dataset in all patients undergoing lung resection during the study period. Multivariable regression analysis was used to identify factors independently associated with critical care outcome.

RESULTS

A total of 11,208 patients underwent lung resection in 16 collaborating centers during the study period, and 253 patients (2.3%) required unplanned critical care admission with a median duration of stay of 13 (4-28) days. The predominant indication for admission was respiratory failure (68.1%), with 77.8% of patients admitted during the first 7 days following surgery. Eighty-seven (34.4%) died in critical care. On multivariable regression, only the diagnosis of right ventricular dysfunction and the need for both mechanical ventilation and renal-replacement therapy were independently associated with critical care survival; this model, however, had poor predictive value.

CONCLUSIONS

Although resource-intensive and subject to prolonged stay, following unplanned admission to critical care after lung resection outcomes are good for many patients; 65.6% of patients survived to hospital discharge, and 62.7% were discharged to their own home.

"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.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care

Introduction

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients.

Methods

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria.

Results

Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis.

Conclusions

These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Perioperative Factors for Predicting the Need for Postoperative Intensive Care after Major Lung Resection

Postoperative management after major lung surgery is critical. This study evaluates risk factors for predicting mandatory intensive care unit (ICU) admission immediately after major lung resection. We retrospectively reviewed patients for whom the surgeon requested an ICU bed before major lung resection surgery. Patients were classified into three groups. Univariable and multivariable logistic regression analyses were performed, and a clinical nomogram was constructed. Among 340 patients, 269, 50, and 21 were classified into the no need for ICU, mandatory ICU admission, and late-onset complication groups, respectively. Predictive postoperative diffusion capacity of the lung for carbon monoxide (47.2 (interquartile range (IQR) 43.3–65.7)% versus vs. 67.8 (57.1–79.7)%; p = 0.003, odds ratio (OR) 0.969, 95% confidence interval (CI) 0.95–0.99), intraoperative blood loss (400.00 (250.00–775.00) mL vs. 100.00 (50.00–250.00) mL; p = 0.040, OR 1.001, 95% CI 1.000–1.002), and open thoracotomy (p = 0.030, OR 2.794, 95% CI 1.11–7.07) were significant predictors for mandatory ICU admission. The risk estimation nomogram demonstrated good accuracy in estimating the risk of mandatory ICU admission (concordance index 83.53%). In order to predict the need for intensive care after major lung resection, preoperative and intraoperative factors need to be considered.

Association between anaesthetic technique and unplanned admission to intensive care after thoracic lung resection surgery: the second Association of Cardiothoracic Anaesthesia and Critical Care (ACTACC) National Audit

Unplanned intensive care admission is a devastating complication of lung resection and is associated with significantly increased mortality. We carried out a two-year retrospective national multicentre cohort study to investigate the influence of anaesthetic and analgesic technique on the need for unplanned postoperative intensive care admission. All patients undergoing lung resection surgery in 16 thoracic surgical centres in the UK in the calendar years 2013 and 2014 were included. We defined critical care admission as the unplanned need for either tracheal intubation and mechanical ventilation or renal replacement therapy, and sought an association between mode of anaesthesia (total intravenous anaesthesia vs. volatile) and analgesic technique (epidural vs. paravertebral) and need for intensive care admission. A total of 253 out of 11,208 patients undergoing lung resection in the study period had an unplanned admission to intensive care in the postoperative period, giving an incidence of intensive care unit admission of 2.3% (95%CI 2.0-2.6%). Patients who had an unplanned admission to intensive care unit had a higher mortality (29.00% vs. 0.03%, p < 0.001), and hospital length of stay was increased (26 vs. 6 days, p < 0.001). Across univariate, complete case and multiple imputation (multivariate) models, there was a strong and significant effect of both anaesthetic and analgesic technique on the need for intensive care admission. Patients receiving total intravenous anaesthesia (OR 0.50 (95%CI 0.34-0.70)), and patients receiving epidural analgesia (OR 0.56 (95%CI 0.41-0.78)) were less likely to have an unplanned admission to intensive care after thoracic surgery. This large retrospective study suggests a significant effect of both anaesthetic and analgesic technique on outcome in patients undergoing lung resection. We must emphasise that the observed association does not directly imply causation, and suggest that well-conducted, large-scale randomised controlled trials are required to address these fundamental questions.

Routine intensive monitoring but not routine intensive care unit-based management is necessary in video-assisted thoracoscopic surgery lobectomy for lung cancer

Background

Evidence for immediate postoperative intensive care unit (ICU) care is still lacking in the era of minimally invasive video-assisted thoracic surgery (VATS). We evaluated the safety and feasibility of general ward (GW) care after VATS lobectomy for lung cancer.

Methods

A total of 451 patients who underwent VATS lobectomy for lung cancer between June 2012 and August 2017 were retrospectively studied. The patients were divided into two groups (ICU 344 vs. GW 107). We compared the postoperative complications and mortality between the two groups after propensity score matching. Furthermore, we evaluated the clinical factors associated with complications, and stratified patients according to the risk for complications.

Results

Immediate complications (within 24 hours after surgery) occurred in 0.4%. Non-immediate complications occurred in 18.8%. There were no differences in the incidence of complications and mortality between the two groups, after propensity matching. However, the length of postoperative stay (12.6±10.0 vs. 10.3±4.1 days, P=0.041) was significantly higher in the ICU group than in the GW group. Multivariate regression analyses revealed that chronic obstructive pulmonary disease (COPD) [odds ratio (OR) =3.00, 95% confidence interval (CI): 1.51-5.97, P=0.002], non-stage I cancer (OR =2.54, 95% CI: 1.39-4.62, P=0.002), multi-port surgery (OR =3.75, 95% CI: 2.18-6.44, P<0.001), and age ≥60 years (OR =2.12, 95% CI: 1.03-4.37, P=0.042) were associated with complications. Immediate postoperative care in GW had no influence on complications.

Conclusions

Immediate postoperative care after VATS lobectomy for lung cancer in GW was safe and feasible without poor outcomes. Therefore, selective intensive monitoring for high risk groups may offer cost-saving and efficient use of ICU resources.

The right ventricular response to lung resection

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.

The Utility of Eccentricity Index as a Measure of the Right Ventricular Function in a Lung Resection Cohort

Context

Right ventricular (RV) dysfunction occurs after lung resection and is associated with postoperative morbidity. Noninvasive evaluation of the RV is challenging, particularly in the postoperative period. A reliable measure of RV function would have value in this population.

Aims

This study compares eccentricity index (EI) obtained by transthoracic echocardiography (TTE) with cardiovascular magnetic resonance (CMR) determined measures of RV function in a lung resection cohort. CMR is the reference method for noninvasive assessment of RV function.

Design and Setting

Prospective observational cohort study at a single tertiary hospital.

Materials and Methods

Twenty-eight patients scheduled for elective lung resection underwent contemporaneous TTE and CMR imaging preoperatively, on postoperative day (POD) 2 and at 2-month. Systolic and diastolic EI was measured offline from anonymized and randomized TTE and CMR images.

Statistical Analysis

Bland-Altman analysis was performed to determine agreement between EI^TTE and EI^CMR. Changes over time and comparison with CMR determined RV ejection fraction (RVEF^CMR) was assessed.

Results

Bland-Altman analysis showed a negligible mean difference between EI^TTE and EI^CMR, but limits of agreement were wide (SD 0.24 and 0.28). There were no significant changes in EI^TTE and EI^CMR over time (P > 0.35). We found no association between EI^TTE with RVEF^CMR at all-time points (P > 0.22). Systolic and diastolic EI^CMR on POD 2 demonstrated moderate association with RVEF^CMR (r = -0.54 and r = -0.59, P ≤ 0.01). At 2-month, only diastolic EI^CMR correlated with RVEF^CMR (r = -0.43, P = 0.03). There were no meaningful associations between EI^TTE and EI^CMR with TTE-derived RV systolic pressure (P > 0.31).

Conclusions

TTE determined EI is not useful as a noninvasive method of assessing RV function following lung resection.

The role of local anaesthetic techniques in ERAS protocols for thoracic surgery

The use of enhanced recovery after surgery (ERAS), as in other surgical specialties, is an emerging concept in cardio-thoracic surgery but there is still a lack of effective protocols to reduce the burden of surgery on the patient, shorten the period of postoperative recovery, and reduce the likelihood of chronic pain developing. The use of local anaesthetic (LA) techniques, such as thoracic epidural analgesia (TEA) and paravertebral blocks (PVB), as an adjunct to anaesthesia are considered key components, though there is little data for direct comparison of the techniques. This review aims to evaluate the role of LA techniques in a thoracic ERAS program through evidence from literature and considering aspects of clinical practice. We discuss how ERAS is adapting and evolving with the increasing use of video-assisted thoracoscopic surgery (VATS) is thoracic surgery. It also examines the advantages of multimodal, opioid-sparing analgesia in the post-operative period to minimise the inflammatory response and improve functional recovery. LA techniques within ERAS protocols have the potential to hasten recovery when managed appropriately and to their full potential.

Care of the Postoperative Pulmonary Resection Patient

Patients undergoing pulmonary resection all exhibit, to some degree, a level of pulmonary dysfunction. This is due to the physiologic stress of the procedure performed, the patient’s comorbidities, and preexisting cardiopulmonary reserve. Although prognostic factors for intensive care requirement exist, to date, there is no consensus for postoperative admission. Institutional practices vary across the country, with patients often admitted to intensive care for surveillance. Guidelines published from the American Thoracic Society in 1999 emphasize that admission to the ICU be reserved for those patients requiring care and monitoring for severe physiologic instability. Admissions following pulmonary resection are typically due to respiratory complications and are an independent predictor of mortality. The following chapter will review the indications for admission to the ICU and common issues encountered following pulmonary resection and conclude with a discussion of the management of patients undergoing pulmonary transplantation.