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Cardiac Dysrhythmia Pneumonectomy* Clinical Correlates MichaelJ. Krowka, VictorF Trastek, PhilipE. Bernatz, and Prognostic M.D.;PeterC. M.D., following Pairolero, FC.C.P;W Significance M.D., Spencer FC.C.P.; Payne, M.D., FC.C.P.; Cardiac tachydysrhythmias occurred in 53 (22 percent) of 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 ‘J’he continuous consecutive 236 clinical course and F.C.C.P M.D., 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 postoperative pulmonary and interstitial edema. in following pneumonectomy may complications preoperative which have pulmonary poor corfunction onstrated tests, such as the forced vital capacity (FVC) and forced expired volume in one second (FEV1).’ Cardiac dysrhythmias are well-documented complications follow- terpreted ing pneumonectomy,4 236 patients studied is provided in the the numbers within parentheses represent involve certain relation to selected dysrhythmias mortality, and in selected have been associated with This retrospective analysis as undergoing pneumonectomy three-year occurrence period was undertaken of various postoperative preoperative pulmonary at the also records monectomy viewed. both of 244 at the Each before Clinic until Mayo patient and after AND consecutive a the to for patients dysrhythmias had Clinic METHODS who patients from routine pneumonectomy, 1982 through 12-lead underwent early and at any time pneu- 1985 were electrocardiograms re- taken, that the time upright consultants. postoperative of the patient’s in intensive record in intensive portable by radiologic and While was care, chest The events discharge develop or perihilar care dem- interpreted each by a patient had roentgenograms data during or death. following reported in- include all hospitalization up A description of the tabulation, where percentages: Sex over and to perioperative significance cardiac postoperative Each who edema monitoring in rhythm. consultant. preoperative significant of patients routine 5From the Department ofThoracic Diseases and Internal Medicine, Section of Thoracic and Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN. Manuscript received September II; revision accepted October 14. Reprint requests: Dr Krowka, 4500 San Pablo Road, Jacksonville, FL 32224 490 daily evaluated. MATERIALS The Mayo cardiologic these to correlate dysrhythmias function clinical data. The prognostic who developed postoperative was patients, electrocardiographic a change patients pulmonary Female Male Age Less than 50 yr Between 51 and 69 yr 70 yr or older (9 older than 80) Indications Primary lung cancer Metastatic disease Inflammatory disease Mesothelioma (malignant) Lymphoma/Av mal/broncholithiasis Operative notes Right pneumonectomy Left pneumonectomy Completion pneumonectomy Intrapericardial pneumonectomy Previous thoracic irradiation Surgical staging Ti T2 T3 NO Ni N2 Stage 1 Stage 2 Cardiac Dysrhythmia Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21558/ on 05/10/2017 tollowing 65 (28) 171 (72) 38 16 149 63 49 (21) 197 (83) 14 (6) 12 5) 94 4 (2 112 (47) 124(53) 28 (12 32 (14 9(4 183 (78 (11) (61 (28 (32) (32) (36 (12 (61) Pneumonectomy (Kmwka eta!) Stage 3 Reoperation within 72 hr 30-day mortality Intraoperative deaths Postoperative deaths The operative tient were developed Upon notes was was patient pH analyzer dioxide arterial tension recurrent oxygen or persistent ECGs beyond pressure if they 24 hours from (Pa02), again gas just were prior documented by patients showed as 12-lead atrial operative fibrillation (N =8) were excluded; resulted Patients in records from 236 patients for did not receive digitalis before surgery purpose of preventing Cardiac of the cent) tomy. In 236 patients 12 (28 percent) increases (>2 in and found levels mented marily of 43 of patterns ECGs. in the those 12 patients and In six of the subjects, of cardiac dysrhythmia, enzymes to the subsequent had docu- nine of the preceded and in the rhythm dismissed (rate to the devel- rhythmia. disturbance. a significant ative medications reasons other than and were continued when the rhythm were rhythm preoper- that had been administered for the proposed pulmonary resection through the perioperative period disturbances occurred. The initial Table 1-Initial Cardiac Dysrhythmia Recurrent Rhythm Frequency Total Atrial fibrillation Supraventricular Atrial *N =53 tDrop in systolic blood pressure more arterial documented with atrial 25 per(37) were frequently than there was no clear of dysrhythmias blood gas abnormalities about the time of dys- hypoxemia (Pa02<Z60 only 15 percent disturbances, and factor. (8/53) mm the pH of the blood Furthermore, was not was no signifi- the TNM surgical monectomies, stage of lung cancer, completion previous thoracic irradiation, after between indication there Hg) with of those cant association rhythmia and or Persistent the development for pneumonectomy, of dysthe pneuor the Pneumonectomy* With Res olved Hypotensiont prior to Dismissal Associated with Mortality 20 (38) 37 (70) 13 (25) 20 (69) 14 (70) 23 (62) 9 (69) 12 (23) 4 (14) 4 (20) 7 (19) 4 (31) 7 (13) 5 (17) 2 (10) 7 (19) 0 . . . . . 0 data in 29 (55) tachycardia lkble hospital medication), and 70 percent 34 (64) tachycardia (22 percent). agof 53 (100) flutter Ventricular the with occurred Specifically, (two), (one) tachydysrhyth- and amiodatone, as four patients in whom from controlled and postoperative which could be six In six of the 53 patients developing tachydysrhythmia, either digoxin (three), 3-adrenergic blockers blockers the first six (55 percent) which included with combinations cant rhythm problems. In addition, association between the development of was associated or calcium-channel two the dys(50) of the ative interstitial pulmonary edema or perihilar pulmonary infiltrates (Table 2). Neither age nor preoperative pulmonary function had any predictive value in determining who would or who would not develop signifi- pri- remaining within patients recurrent Only of expected (p<O.OOl) in 53 percent (17) of 32 patients who underwent intrapericardial pneumonectomy and in 52 percent (30) of those 58 who developed postoper- fraction elevations onset 95 percent verapamil, In the Tachydysrhythmia per- were MB in systolic Hg). cent (13) died in the hospital, dismissed in normal sinus rhythm. documented change abnormalities, of the T-waves, compared opment occurred (22 phosphokinase of infarction, concentrations of the review. for the 53 were fibrillation pneumonec- patients, elevations had non-Q-wave in the configuration preoperative in underwent creatine with Three Q-wave who (three) this dysrhythmias. occurred of associated percent). patients postoperative tachydysrhythmia a drop ven- cardioversion was attempted, two attempts were successful, and two patients remained in a persistent rhythm abnormality. Of the 53 patients, 5 percent ECGs pre- with by 25 mm dysrhythmia Twenty-nine digitalis, quinidine, well as cardioversion. documentation. in this study had preoperative normal sinus rhythm. Patients per minute, associated mias despite maximal therapy gressive medical management RESULTS All which had 150 beats hypotension had an intraoperative (both survived), and or is shown atrial dysrhythmias than persistent surgery developed ventricular tachyHemodynamically, (defined of greater experienced carbon considered with dysrhythmia patients developed days after surgery. for as- and arterial rhythms were initial any blood reviewed of those pressure patients rhythmia an For obtained after (34) no patient developed pneumonectomy. (24) the blood venti- (Dss). were with those tests, voluntary IL 282 oximeter) In addition, For occurring percent tricular responses greater than and 38 percent (20) had relative which the arterial the dysrhythmia 45 percent pa- period. function capacity fibrillation and cardia following hospital occurred maximum cardiac dysrhythmia in Table 1. Sixty-four which patient’s discharge. dysrhythmia, and (PaCO2). to diffusing fullowing, of pH, the pulmonary FEy1, for each problems postoperative unit, prior FVC, a cardiac to, or immediately sessment of the record if complications steady-state developing unit or surgical care intervention and (IL 1302 intensive preoperative made (MVV), care medical to determine subsequent lation intensive or in the immediate the completing assessment levels surgery from reviewed required patients the to define during discharge record and reviewed (27) 8 (3) 26(11) 10(38 16 (62 are numbers of at least of patients; 25 mm numbers within parentheses are . percents. Hg. CHEST Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21558/ on 05/10/2017 I 91 / 4 / APRIL, 1987 491 Table 2-Clinical Correlate8 Dysrhythmias following Cardiac with With Parameter Preoperative N Dys- Dysrhythmia All patients 236 thoracic FEV<2.O FEV>2.O L L irradiation 53 (22) 183 6 58 90 17 41 This 22 68 center nectomy percent of predicted 46 12 34 percent of predicted 104 25 79 150 94 88 MVV Mean Dss Age<50 Age percent of predicted 94 yr 51-59 yr Age7O+yr Postoperative 17.7 but 6 32 149 31 118 49 16 33 lung cancer lung Inflammatory cancer 197 41 156 14 3 disease ii 12 5 Mesothelionia 7 9 3 6 Ti (malignant) surgical stage 21 5 16 T2 surgical stage 112 22 90 T3 surgical stage 50 12 38 from on to develop after The surgery. mia did occur more with interpericardial terstitial frequently dissections or perihilar pulmonary surgical stage 57 12 45 Our N2 surgical stage 15 Stage 2 112 22 90 Stage 3 51 12 39 Pa02<6OmmHg 53t 8(15) . pH<7.35 53t 6 (ii) . pH>7.45 53t 13 (25) . Completion Chest pneumonectomy wall resection Intrapericardial Interstitial or perihilar 30-day = 236. Table blood 19.80; §Chest x-ray 98.60; x21215 need data are numbers 8 4 9 32 lfl 15 58 3011 2811 26 13T 1311 20 numbers gas levels unless dysrhythmia within occurred. p<O.OOJ. rized between incidence in Table major film. p<O.OOl. The (26/236). 30-day There wall resections. mortality in the series were ten intraoperative was II percent deaths and 16 postoperative deaths. Table 3 summarizes data. Intraoperative deaths were not caused relevant by distur- bances in cardiac rhythm; hemorrhage was the major problem. Of the postoperative deaths, 81 percent (13/16) were associated with or preceded by tachydysrhythmias, and 69 percent persistent or recurrent (9/13) of those dysrhythmias. patients Nine series 4. assessing and had (31 per- cent) of 29 patients with recurrent or persistent tachydysrhythmia died during hospitalization. Twenty-five percent (13) of the 53 patients developing tachydysrhythmias died, compared to 7 percent (13/183) who died without dysrhythmias (p<O.OO1). Fifty-four per- of dysrhythmia from disturbances commonly), flutter. The to eliminate chest largest dysrhythmia 4 ranged rhythm (most atrial p<O.O0l. to complete the dysrhythmias in Table summarized the mortality in Keagy et al,2 in which they reported a similar 30-day mortality; however, they did not correlate the onset of rhythm disturbances to subsequent mortality. The not assessed represent cardiac with significant rhythm disturbances subsequently died, a higher percentage than the accepted mortality for pneumonectomy. Statistics on 30-day mortality were not available in any other study except that of 13 patients; data relationship 28 of was patients who underwent pneumonectomy. Of those series which correlated the incidence of dysrhythmia with subsequent mortality, 23 to 33 percent of patients are percentages. tArterial tx2 edemal mortality parentheses 2_ dissection in mortality edema. Ni 52 of morsinus than expected in those and postoperative in- 47 5 tachy- degree normal difference 11 16 referral or recurrent a greater maintained 58 20 a tertiary persistent experienced those who surgical stage 68 492 analysis NO 1 re- present that patients who underwent pneumodid not receive digitalis before surgery Previous studies concerning following pneumonectomy are Stage and were significant. Tachydysrhythmia, regardless of ventricular response, appeared to have no apparent association with preoperative pulmonary function, surgical indication, or TMN staging of lung cancer. Tachydysrhyth- correlates Metastatic went rhythms Diagnosis Primary hypotension, of dysrhythmia retrospective showed who dysrhythmias tality than 18.8 38 hypoxemia, or persistence to death. DIscuSsIoN 3 MVV<80 prolonged (78) 9 MVV>80 Mean currence prior correlates Previous (7/13) of death, Without rhythmia of dysrhythmias occurred within 96 hours of If dysrhythmia occurred prior to 72 to 96 hours cent death. Pneumonectomy* in patients summa- 9 to 29 percent, being atrial with the fibrillation supraventricular tachycardia, and data in these studies were reviewed ventricular the inclusion of patients with premature complexes or premature atrial complexes as part definition of the pneumonectomy. tremely uncommon occurred erative of cardiac in our study, Q-wave changes associated cardiac The enzymes. only study or even studies with non-Q-wave with that following were exand none the onset of periop- electrocardiographic elevated concentrations significantly lactic digitalization, that a decreased incidence prophylactic of rhythm mortality. dysrhythmia Ventricular tachycardias in the studies reviewed, addressed of Shields and of dysrhythmia of prophy- Ujiki,9 showed following digitalis but did not discuss the incidence disturbances as they related to subsequent Our study is different from the previous in that Cardiac most of our Dysrhythmia Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21558/ on 05/10/2017 patients following had Pneumonectocny continuous (Krowka eta!) Table Group 3-Clinical Data of Those Who Died within 30 Days following Postoperative and Case/Age Surgical (yr) Indication, Day Procedure cell typet or Stage Pneumonectomy* Recurrence of Dys- Hypo- rhythmiafDeath or tension Persistence Commentsf Intraoperative 1/66 L squamous T3N2 2/68 R adenocarcinoma Completion 3/39 R metastatic Wilms’ 4/80 squamous 6/54 L metastatic R squamous L large cell 7/74 R Lymphoma/BP 5/63 #{149} . . . . . . . Arterial . hemorrhage Hemorrhage Hemorrhage #{149} . . . . . . . Completion #{149} . #{149} . . . . . . Arterial Completion #{149} . . . . . . . . Hemorrhage Completion #{149} . . . . . . . . tumor SVC (diffuse) hemorrhage hemorrhage Arterial hemorrhage fistula 8/53 9/75 10/64 R adenocarcinoma R squamous R squamous Completion #{149} . . . . . . . . Hemorrhage T3NO #{149} . . . . . . . . Arterial (diffuse) T3N2 #{149} . . . . . . . . Hemorrhage hemorrhage Postoperative 1/73 L alveolar T2N 2182 R squamous T3N1; 3/52 R mesothelioma Pericardial 4/59 L squamous T2N2 2/4 Yes No Perioperative wall 3/6 No Yes Hypoxemia/pulmonary hypertension window 23/27 Yes Yes Cardiac 2/23 No Yes Hypoxemia; 1 chest resection Mi compression; tension; R mesothelioma 6/65 R squamous T2NO 24/28 7/74 R squamous T3N2 6/9 No No No No CO2 retention; Pneumonitis; 8/36 R AV malformation 6/6 Yes Yes Effusion; tension pneumothorax; None/6 9/73 L adenocarcinoma 3/20 Yes Yes Staphylococcal lobar T3N2 atrial aspiration sepsis; collapse ARDS pneumonitis; resection subendocardial R squamous 11/15 R metastatic 12/62 osteosarcoma R metastatic Completion None/15 . . . Yes None/lO . . 7/16 . . Yes . Stump T1N2 R squamous 6/9 No MI dehiscence Pulmonary . emboli Yes Hypoxemia; pulmonary No emboli Hypoxemia; ARDS; adenocarcinoma 13/84 hyper- BP fistulat 5/52 10/80 METS pulmonary pneumonitis 14/65 R squamous Completion; intra- 4/16 Yes No Hvpoxemia; 1/16 Yes Yes Stump sepsis pericardial 15/64 R metastatic breast dehiscence; sepsis; pulmonary hypertension 16/68 R squamous 7/21 Intrapericardial Yes Yes Hemothorax; reoperation; hypoxemia; = stump dehiscence 26. tBP, bronchopleural; added. and AV, arteriovenous ISVC, cava; Superior vena electrocardiographic unit after surgery, tection of cardiac MI, myocardial malformation; infarction; and ARDS, monitoring in the intensive care which certainly improved the dedysrhythmias, especially those which may have been asymptomatic. patients who were referred In addition, to our institution the types of for subse- quent pulmonary resection had had previous surgery, as well as other types of therapy chemotherapy and irradiation. Specifically, tion pneumonectomy was not though it did not correlate with rhythmia, METS, it appeared uncommon, the incidence to be associated with thoracic such as compleand alof dysa higher metastatic adult disease; respiratory none. distress no dysrhythmia occurred, postop day of death syndrome. 30-day mortality (see Table 3). Our 30-day mortality of II percent is similar to that reported in the series by Keagy et al.2 Compared to the recent Lung Cancer Study Group analysis from analyzing 569 pneumonectomies, 6.2 percent related with was cardiac In reviewing proposed causes have included flammation, reported, five participating a 30-day but those centers mortality data were of not cor- dysrhythmia.’#{176} those studies of dysrhythmia hypoxemia, preexisting presented in Table after pneumonectomy vagal cardiac CHEST / Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21558/ on 05/10/2017 irritation, disease, 91 / 4 / 4, atrial inpulmonary APRIL 1987 493 Table 4-Cardiac Dysrhythmias Pneumonectomy* following Dysrhythmias Incidence No. of Study Baily and Year Betts4 Currens et al6 Massie and Valle’ Cerney7 Associated Dysrhythmia, Pneumonectomies 1943 of with percent percent No 30-Day Mortality, Mortality, (cases) deaths percent reported (cases) 78 10 Unavailable 1943 43 21 23 (3/13) Unavailable 1947 120 34 33 (3/9) 30 (3/10) Unavailable 1957 9 29 19 Not discussed Unavailable Unavailable Mowry and Reynolds5 1964 Shields and Ujiki’ 1968 72 9t 6 Not discussed Unavailable 1983 58 28 Not discussed 12 (11/90) 1987 236 22 25 (13/53)1 11 181: Keagy et al’ Krowka et al *Includes tNo only atrial fibrillation prophylactically 1:Prophylactically §30-day (“auricular fibrillation”), atrial flutter, or supraventricular tachycardia, and ventricular tachycardias. digitalized. digitalized. mortality. hypertension, these and studies, first the right onset postoperative cardiac dilation. of dysrhythmia week. In most of was during Apparently, most the patients responded well or no medication. to combinations of digitalis, quinidine, There appeared to be an increased frequency age and, with tion of anesthesia-related could not demonstrate previous previous in at least study also addressed thoracic irradiation disturbances a relationship not significant a statistically our data. pulmonary In no study function bances. None one report, We A the association between and the frequency of following pneumonecwas suggested, it was nary fluid vascular overload tone of the and, hence, lung. remaining subclinical dysrhythmias fluid overload in some noted. This needs cases resulting in the further prospective study. The relationship of intrapericardial dissection cardiac has not dysrhythmia following pulmonary been addressed in the literature. tionship between pericardial disease of intrapericardial dissection as a cause may not be comparable. This finding studies needs additional confirmation. Finally, as previously documented,2 of the addressed or in hemodynamic or increased interstitial hypoxemia. with pulmo- infiltrates pneumonectomy edema after is intriguing. pneumonectomy has recently been discussed by Zeldin et al,’2 who reported the findings in ten patients. These investigators indicated that this phenomenon usually occurs within 48 hours after relatively hemodynamically surgery and can stable patient. appear to be right pneumonectomy administration of fluid in an amount capillary wedge occur in a Risk factors and interoperative greater than 2,000 pressures are not nec- documented,’4 we but could find no relationship between cardiac rhythm disturbances following pneumonectomy and preoperative pulmonary function. This finding was not unexpected and reinforces on the been and dysrhythmia the mechanism for dysrhythmia study has and resection The rela- could hypoxemia or preoperative be related to the rhythm distur- chest x-ray film after The entity of pulmonary Pulmonary precapillary in acute patients in that of dysrhythmia, especially acute association of cardiac dysrhythmia edema result in nonsurgical finding consequences (specifically, hypotension) in terms of the effect ofdysrhythmia. Our data did not suggest that hypoxemia is a major contributing factor to the development The or unaltered Based on our chest roentgenographic results, it would appear that certainly this entity is more common than realized and may indeed be responsible for an acute a ques- cause for dysrhythmia.3 an age-related association. cardiac rhythm tomy.#{176}Although ml. nodal 11(26/236) the tion tests are the postoperative fact not that preoperative pulmonary func- useful parameters on which to base clinical course with reference to cardiac The and hemodynamic function.2’5 implications of this study focus on the increased mortality which occurred in patients that had nonventricular tachycardias after pneumonectomy. The role of digitalis tic medications or other rhythm-stabilizing prophylacis unclear. Whether or not prophylaxis would result in fewer mortality and morbidity in the literature. dysrhythmias has not Our been retrospective and subsequent well addressed study, although essarily elevated in these individuals. In fact, pulmonary arterial pressures may be falsely low following documenting rhythmias, pneumonectomy medications will favorably affect morbidity and mortality. Future studies should address the hypothesis that cardiac dysrhythmias after pneumonectomy are, creased output, based to balloon occlusion causing in- right ventricular afterload, reduced cardiac and decreased left atrial pressure. ‘ It appears, on other studies,14 that pulmonary capillary hydrostatic 494 due pressure can be raised in the setting of low in part, correlate the effects of postoperative does not imply that prophylactic volume-induced problems well hemodynamic to standard Cardiac Oysrhythmia following Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21558/ on 05/10/2017 which Pneumonectomy tachydyscardiac may not monitoring (Krowka eta!) techniques. Finally, medications the introduction calcium-channel (ie, noninvasive amiodarone), of newer blockers techniques cardiac plicating cardiac and 6 Currens Dop- (ie, a potential pulmonary importance. This type resection maybe of consideration, nary surgery White thoracic 7 Cerney CI. Massie E, 9 Shields Valle TW, rhythmias lung. Ann Intern Med 1964; Cardiac 1943; Cardiac Intern arrhythmias complicating 1947; total 26:231-39 Digitalization pulmonary complicating 34:105-10 arrhythmias Med fol- 229:360-64 arrhythmias 1957; Surg Ann CT. ED. Med of cardiac AR. Ujiki J N Engi for surgery. prevention Surg of Gynecol ar- Obstet 126:743-46 10 Ginsburg RJ, Hill LD, J, et lauras resection. Churchill J Thorac following 1968; for pulmo- of the prophylaxis surgery. pneumonectomy. medicasurrounding PD, surgery. The pulmonary 8 of clinical in conjunction with a prospective trial of rhythm-stabilizing tions, should help remove the mystique preoperative digitalization in the candidate JH, lowing pler echocardiography and exercise stress testing), and a combined cardiopulmonary approach to the patient with resectional 61:688-95 resections al. Eagan Modern in lung RI’, Thomas thirty day J Thorac cancer. P. Mountain operative CF. mortality Cardiovase Des- for surgical Surg 1983; 86: 654-58 REFERENCES 1 Kirsh MM, Rotman Complications H, pulmonary of 11 Behrenst DM, Orringer resection. Ann MB, Thorac Sloan Surg 12 BA, Shorlemeyer Cprrelation clinical Surg of course 1983; 3 Kohiman dictable 5 Mowry GF, pulmonary in patients after Starek PK, Wilcox function testing pneumonectomy. Ann BR. U, risks Ikins PM, of mortality Surg 1986; 1943; N EngI j Med FM, Reynolds after Cardiac RH. EW Oates RP. Random thoracotomy This 13 following pre- cancer. BA, rhythm pneumo- disturbances on pneumology Cedex, For (in the information, French contact Preoperative fur 1966; irradiation carcinoma in pa- of the lung. 51:30-5 D, Landtwing pulmonary Wittnich D, J Thorac edema. pressure” fluid in thoracic Willerson Peters RM. 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CHEST / 91 / 4 / Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21558/ on 05/10/2017 APRIL, 1987 495